Utilization of 4T score to determine the pretest probability of heparin-induced thrombocytopenia in a community hospital in upstate New York

Background: Thrombocytopenia is common in hospitalized patients. Heparin-induced thrombocytopenia (HIT) is a life-threatening condition which can lead to extensive thrombosis. Diagnosis of HIT relies on clinical suspicion determined by 4T score and immunoassays through testing for anti-PF4/heparin antibodies. Clinical practice guidelines published by the American Society of Hematology in 2013 recommended use of the 4T score before ordering the immunoassays as a measure of pretest probability. The purpose of this study was to evaluate the utilization of 4T score before ordering anti-PF4/heparin antibodies at Unity Hospital. Methods: We did a retrospective chart review for patients who are 18 years or older, admitted to Unity Hospital between July 1, 2013, and December 31, 2014, and had anti-PF4/heparin antibodies ordered. Subjects who had prior history of HIT or had end-stage renal disease on hemodialysis were excluded. After calculating 4T score retrospectively, we calculated the proportion of patients who had 4T score documented prior to ELISA testing and proportion of ELISA tests, which were not indicated due to a 4T score less than or equal to 3 using Minitab 16. Results: Review of 123 patients, with an average age of 69.4 years, showed that testing was indicated in 18 patients. Six subjects had positive results, and testing was indicated in all of them. 4T score was documented in three patients. This quality improvement study showed that 4T score documentation rate at Unity Hospital is 2.4%. Anti-PF4/heparin antibody testing was indicated in 14.6%. This test is being overused in thrombocytopenia work up at Unity Hospital, costing $9,345. The topic was reviewed for residents. A prompt and calculator for 4T score were added to electronic medical records before ordering the test as a step to improve high value care

Utilization of 4T score to determine the pretest probability of heparin-induced thrombocytopenia in a community hospital in upstate New York

BACKGROUND: Thrombocytopenia is common in hospitalized patients. Heparin-induced thrombocytopenia (HIT) is a life-threatening condition which can lead to extensive thrombosis. Diagnosis of HIT relies on clinical suspicion determined by 4T score and immunoassays through testing for anti-PF4/heparin antibodies. Clinical practice guidelines published by the American Society of Hematology in 2013 recommended use of the 4T score before ordering the immunoassays as a measure of pretest probability. The purpose of this study was to evaluate the utilization of 4T score before ordering anti-PF4/heparin antibodies at Unity Hospital. METHODS: We did a retrospective chart review for patients who are 18 years or older, admitted to Unity Hospital between July 1, 2013, and December 31, 2014, and had anti-PF4/heparin antibodies ordered. Subjects who had prior history of HIT or had end-stage renal disease on hemodialysis were excluded. After calculating 4T score retrospectively, we calculated the proportion of patients who had 4T score documented prior to ELISA testing and proportion of ELISA tests, which were not indicated due to a 4T score less than or equal to 3 using Minitab 16. RESULTS: Review of 123 patients, with an average age of 69.4 years, showed that testing was indicated in 18 patients. Six subjects had positive results, and testing was indicated in all of them. 4T score was documented in three patients. This quality improvement study showed that 4T score documentation rate at Unity Hospital is 2.4%. Anti-PF4/heparin antibody testing was indicated in 14.6%. This test is being overused in thrombocytopenia work up at Unity Hospital, costing $9,345. The topic was reviewed for residents. A prompt and calculator for 4T score were added to electronic medical records before ordering the test as a step to improve high value care

Impact of education and electronic decision support tool on the practice of heparin-induced thrombocytopenia testing: An experience of a teaching community hospital

Heparin Induced Thrombocytopenia (HIT) is a potentially life-threatening disorder caused by antibodies directed against complex of heparin and platelets factor-4 (PF-4) [ 1 ]. HIT occurs in 1 in 5000 hospitalized patients and 1–3% of patients after cardiac surgery, with the incidence being highest with the use of unfractionated heparin [ 2 ]. Hospitalized patients can develop thrombocytopenia due to a variety of causes and determining HIT as the cause of thrombocytopenia is crucial because of potential of thrombotic complications which affects 50% of the patients [ 2 ]. American Society of Hematology (ASH) recommends utilization of 4Ts score based on clinical and simple laboratory data to identify patients with high likelihood of HIT and to prevent unnecessary additional testing [ 3 ]. Low probability of HIT as determined by 4Ts score of 3 or less carries a negative predictive value of 99.8% and additional testing can safely be deferred, as HIT is unlikely and heparin can be continued safely [ 4 ]. HIT is diagnosed at our institution by testing anti-PF4/heparin antibodies by Enzyme-linked Immunosorbent Assay (ELISA; Instrumentation Laboratory, ACL TOP 500, Bedford, Massachusetts) for suspected cases. Positive results are confirmed by Serotonin Release Assay (SRA) which is sent out to Mayo Clinic, Rochester, Minnesota. Anti-PF4/heparin antibodies ELISA is an expensive test and replacement of heparin with non-heparin parenteral anticoagulants adds greatly to the heath expenditure. A study found an extra cost of $39,616 per patient suspected of having HIT in US with most of it coming from prolonged hospital stay and use of non-heparin anticoagulants [ 5 ]. In an earlier retrospective study, we found that we were overusing ELISA HIT testing for thrombocytopenia patients at Unity Hospital [ 6 ]. Therefore, we held educational sessions regarding the usefulness of 4Ts scoring and incorporated a 4 T score calculator into our Electronic Health Record (EHR) to encourage providers to order ELISA testing only when it is deemed appropriate by the Electronic Decision Support Tool (EDST). The objective of this study to evaluate the effect of education and EDST on the appropriateness of HIT testing

Lung cancer in the very elderly: incidence, presentation, and diagnostic decision-making. A retrospective analysis at a teaching community hospital

Background and objectives: Lung cancer presentation and decision-making in the very elderly patient population, 80 years of age and older, was studied given the projected increase in cancer incidence in the very elderly and yet only limited management guidelines. Design and setting: A 10-year experience at the Unity Health System of Rochester, NY, was reviewed using tumor registry data for the entire lung cancer population plus focused medical record review of very elderly patients. A questionnaire survey on the clinical approach to lung cancer in the elderly was distributed to medical staff involved in their care.Participants, measurements, and results: Of 997 patients, approximately 100 cases each year, the very elderly comprised 18% of patients from year 1998 through 2002, and 23% from year 2003 through 2007. One-third of the very elderly were diagnosed with lung cancer on clinical grounds without tissue confirmation. The majority of this group had cardio-pulmonary symptoms and an advanced clinical stage. The very elderly had no tissue sampling as per their own decision in 12 of 44 of cases, per family decision in 28 of 44, and per physician and other input in 4 of 44. Physicians stated that patient wishes and health-related factors, more so than socio-economic factors, were primary concerns for management decision-making. Conclusions: The number of very elderly lung cancer patients in this community setting has been significant and appears to be increasing. These patients were more likely to have an incomplete diagnostic work-up, with patient and family wishes being the major factor in medical decision-making. The physician approach to these patients emphasized patient autonomy and medical factors