Objective: To report a case where rivaroxaban was used in the management of an ovarian vein thrombosis and to briefly review the literature, pathophysiology, and clinical implications therein. Case Summary: A 30-year-old previously healthy woman was diagnosed with acute, spontaneous, left-ovarian vein thrombosis (OVT) with proximal extension into the renal vein. After initial catheter-directed thrombolysis with tPA, angioplasty of the left renal vein, and heparinoid treatment, rivaroxaban was begun for long-term anticoagulation. Three months after her index event she was symptom free, with complete resolution of her thrombosis and no adverse effects or bleeding complications from rivaroxaban. To our knowledge, this is the first report of OVT successfully treated with rivaroxaban. Discussion: OVT is a rare but potentially fatal cause of abdominal pain that may pose diagnostic and therapeutic dilemmas. Factor V Leiden (FVL) homozygosity, an uncommon but severe inherited thrombophilia, increases the risk of thrombosis by approximately 50- to 80-fold. This case report and accompanying literature review highlight important clinical pearls related to the diagnosis and management of OVT and inherited thrombophilias. Conclusions: This clinical vignette adds to the published literature suggesting that novel oral anticoagulants, such as rivaroxaban, may eventually emerge as an alternative to vitamin K antagonists for the treatment of extra-axial thromboses. Reporting these cases is important because their prevalence is low outside of specialized referral centers, and thus, dissemination of these experiences may help other providers in treating their patients.
Transformation of US health care from volume to value requires meaningful quantification of costs and outcomes at the level of individual patients.To measure the association of a value-driven outcomes tool that allocates costs of care and quality measures to individual patient encounters with cost reduction and health outcome optimization.Uncontrolled, pre-post, longitudinal, observational study measuring quality and outcomes relative to cost from 2012 to 2016 at University of Utah Health Care. Clinical improvement projects included total hip and knee joint replacement, hospitalist laboratory utilization, and management of sepsis.Physicians were given access to a tool with information about outcomes, costs (not charges), and variation and partnered with process improvement experts.Total and component inpatient and outpatient direct costs across departments; cost variability for Medicare severity diagnosis related groups measured as coefficient of variation (CV); and care costs and composite quality indexes.From July 1, 2014, to June 30, 2015, there were 1.7 million total patient visits, including 34 000 inpatient discharges. Professional costs accounted for 24.3% of total costs for inpatient episodes ($114.4 million of $470.4 million) and 41.9% of total costs for outpatient visits ($231.7 million of $553.1 million). For Medicare severity diagnosis related groups with the highest total direct costs, cost variability was highest for postoperative infection (CV = 1.71) and sepsis (CV = 1.37) and among the lowest for organ transplantation (CV ≤ 0.43). For total joint replacement, a composite quality index was 54% at baseline (n = 233 encounters) and 80% 1 year into the implementation (n = 188 encounters) (absolute change, 26%; 95% CI, 18%-35%; P < .001). Compared with the baseline year, mean direct costs were 7% lower in the implementation year (95% CI, 3%-11%; P < .001) and 11% lower in the postimplementation year (95% CI, 7%-14%; P < .001). The hospitalist laboratory testing mean cost per day was $138 (median [IQR], $113 [$79-160]; n = 2034 encounters) at baseline and $123 (median [IQR], $99 [$66-147]; n = 4276 encounters) in the evaluation period (mean difference, -$15; 95% CI, -$19 to -$11; P < .001), with no significant change in mean length of stay. For a pilot sepsis intervention, the mean time to anti-infective administration following fulfillment of systemic inflammatory response syndrome criteria in patients with infection was 7.8 hours (median [IQR], 3.4 [0.8-7.8] hours; n = 29 encounters) at baseline and 3.6 hours (median [IQR], 2.2 [1.0-4.5] hours; n = 76 encounters) in the evaluation period (mean difference, -4.1 hours; 95% CI, -9.9 to -1.0 hours; P = .02).Implementation of a multifaceted value-driven outcomes tool to identify high variability in costs and outcomes in a large single health care system was associated with reduced costs and improved quality for 3 selected clinical projects. There may be benefit for individual physicians to understand actual care costs (not charges) and outcomes achieved for individual patients with defined clinical conditions.
Introduction The modified early warning score (mEWS) has been used to identify decompensating patients in critical care settings, potentially leading to better outcomes and safer, more cost-effective patient care. We examined whether the admission or maximum mEWS of neurosurgical patients was associated with outcomes and total patient costs across neurosurgical procedures. Methods This retrospective cohort study included all patients hospitalized at a quaternary care hospital for neurosurgery procedures during 2019. mEWS were automatically generated during a patient's hospitalization from data available in the electronic medical record. Primary and secondary outcome measures were the first mEWS at admission, maximum mEWS during hospitalization, length of stay (LOS), discharge disposition, mortality, cost of hospitalization, and patient biomarkers (i.e., white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and procalcitonin). Results In 1,408 patients evaluated, a mean first mEWS of 0.5 ± 0.9 (median: 0) and maximum mEWS of 2.6 ± 1.4 (median: 2) were observed. The maximum mEWS was achieved on average one day (median = 0 days) after admission and correlated with other biomarkers (p < 0.0001). Scores correlated with continuous outcomes (i.e., LOS and cost) distinctly based on disease types. Multivariate analysis showed that the maximum mEWS was associated with longer stay (OR = 1.8; 95% CI = 1.6-1.96, p = 0.0001), worse disposition (OR = 0.82, 95% CI = 0.71-0.95, p = 0.0001), higher mortality (OR = 1.7; 95% CI = 1.3-2.1, p = 0.0001), and greater cost (OR = 1.2, 95% CI = 1.1-1.3, p = 0.001). Machine learning algorithms suggested that logistic regression, naïve Bayes, and neural networks were most predictive of outcomes. Conclusion mEWS was associated with outcomes in neurosurgical patients and may be clinically useful. The composite score could be integrated with other clinical factors and was associated with LOS, discharge disposition, mortality, and patient cost. mEWS also could be used early during a patient's admission to stratify risk. Increase in mEWS scores correlated with the outcome to a different degree in distinct patient/disease types. These results show the potential of the mEWS to predict outcomes in neurosurgical patients and suggest that it could be incorporated into clinical decision-making and/or monitoring of neurosurgical patients during admission. However, further studies and refinement of mEWS are needed to better integrate it into patient care.
