Pulmonary embolism and deep venous thrombosis in hospitalized adults with chronic obstructive pulmonary disease.

BACKGROUND: Hospitalized patients with exacerbations of chronic obstructive pulmonary disease (COPD), when routinely evaluated for pulmonary embolism (PE), show PE in 25-29% of cases. We assessed the rate of diagnosis of PE and deep venous thrombosis (DVT) in hospitalized patients with COPD and the influence of age on relative risk compared with hospitalized patients who do not have COPD. METHODS: A retrospective evaluation of data in hospitalized adults with and without COPD from the National Hospital Discharge Survey. RESULTS: From 1979 to 2003, 58,392,000 adults 20 years of age and older, were hospitalized with COPD in the United States. Among these patients, PE was diagnosed in 381,000 (0.65%) and DVT in 632,000 (1.08%). The relative risk of PE in adults hospitalized with COPD was 1.92 and for DVT it was 1.30. Relative risks were age dependent. Among those aged 20-39 years with COPD, the relative risk of PE was 5.34. Among patients aged 40-59 years, the relative risk of PE decreased to 2.02, and among patients aged 60-79 years the relative risk of PE was 1.23. CONCLUSION: These data, when compared with the rate of diagnosis of PE in hospitalized patients with exacerbations of COPD, all of whom were evaluated for PE, indicate that PE in patients with COPD is generally underdiagnosed. In young adults, other risk factors in combination with COPD are uncommon, so the contribution of COPD to the risk of PE becomes more apparent than in older patients.

Deep venous thrombosis and pulmonary embolism in hospitalized patients with sickle cell disease.

BACKGROUND: As would be expected with a hypercoagulable state, pulmonary embolism (PE) occurs in sickle cell disease (SCD). Its frequency, however, is undetermined, largely because of difficulties in distinguishing it from thrombosis in situ. The prevalence of deep venous thrombosis (DVT) is also undetermined in patients with SCD. Knowing the prevalence of DVT would be an important step in the overall assessment of the risk of PE in these patients. METHODS: Data from the National Hospital Discharge Survey were assessed. RESULTS: In patients

Incidence of venous thromboembolism in patients hospitalized with cancer.

BACKGROUND: There are sparse data on the frequency of venous thromboembolism in patients with various types of cancer. We sought to determine the incidence and relative risk of venous thromboembolism, pulmonary embolism, and deep venous thrombosis in patients with malignancies. SUBJECTS AND METHODS: The number of patients discharged with a diagnostic code for 19 types of malignancies, pulmonary embolism or deep venous thrombosis from 1979 through 1999 was obtained from the National Hospital Discharge Survey. Patients studied were men and women of all ages and races. RESULTS: In patients with any of the 19 malignancies studied, 827,000 of 40,787,000 (2.0%) had venous thromboembolism, which was twice the incidence in patients without these malignancies, 6,854,000 of 662,309,000 (1.0 %). The highest incidence of venous thromboembolism was in patients with carcinoma of the pancreas, 51,000 of 1,176,000 (4.3%), and the lowest incidences were in patients with carcinoma of the bladder and carcinoma of the lip, oral cavity or pharynx. The overall incidences of pulmonary embolism and deep venous thrombosis were also twice the rates in noncancer patients. Incidences with cancer were not age dependent. The incidence of venous thromboembolism in patients with cancer began to increase in the late 1980s. CONCLUSION: Patients with cancer had twice the incidence of venous thromboembolism, pulmonary embolism and deep venous thrombosis as patients without cancer. The incidence of venous thromboembolism, pulmonary embolism and deep venous thrombosis associated with cancer differed according to the type of cancer, was comparable in elderly and younger patients, and increased in the late 1980s and 1990s.

Pulmonary embolism as a cause of death in patients who died with cancer.

Little is known about the frequency of death from pulmonary embolism in patients who die with cancer. We investigated this on the basis of data from death certificates, as listed by the United States Bureau of the Census in the period 1980-1998. Among patients with cancer who died over the 19-year period of study, pulmonary embolism was the listed cause of death in 0.21% (95% confidence interval, [CI] 0.21-0.22%). The frequency of death from pulmonary embolism in patients who died with cancer decreased from 0.39% in 1980 to 0.15% in 1998. Adjustment of the data for the frailty of the diagnosis of fatal pulmonary embolism based on death certificates indicated a likely range of 0.60% to 1.05% for the frequency of death from pulmonary embolism among patients who died with cancer in the period 1980-1998. In conclusion, with modern diagnostic, prophylactic, and therapeutic methods, death from pulmonary embolism in patients who died with cancer was 1% or less.

Venous thromboembolic disease: comparison of the diagnostic process in blacks and whites.

BACKGROUND: There has been concern that a disproportionate use of some health services exists among races. Whether this applies to patients with pulmonary embolism (PE) or deep venous thrombosis (DVT) has not been determined. OBJECTIVE: To assess if there is a racial disparity in the application of diagnostic tests for PE or DVT, or in reaching a diagnosis or using medical facilities. DESIGN: A study of cross-sectional samples of hospitalizations during 21 years using data from the National Hospital Discharge Survey. SETTING: Noninstitutional hospitals in 50 states and the District of Columbia from January 1, 1979, through December 31, 1999. PATIENTS: The National Hospital Discharge Survey abstracts demographic and medical information from the medical records of inpatients. For 1979 through 1999, the number of patients sampled ranged annually from 181 000 to 307 000. Measurements The number of sampled patients with DVT and with PE and the number of diagnostic tests performed were determined from the International Classification of Diseases, Ninth Revision, Clinical Modification codes at discharge. A multistage estimation procedure gave an estimate of values for the entire United States. RESULTS: The age-adjusted rates of diagnosis of PE and of DVT per 100 000 population were not lower in blacks than in whites. Rates of use of radioisotopic lung scans, venous ultrasonography of the lower extremities, and contrast venography were comparable between races. The durations of hospitalization for patients with a primary discharge diagnosis of PE and of DVT were also comparable. CONCLUSIONS: There is nothing to suggest that diagnostic tests are being withheld, and there is no evidence of a failure to reach a diagnosis in blacks with thromboembolic disease.

Venous thromboembolic disease: comparison of the diagnostic process in men and women.

BACKGROUND: There has been concern that women may be limited to fewer major diagnostic tests than men. Whether this applies to patients with pulmonary embolism (PE) or deep venous thrombosis (DVT) has not been determined. OBJECTIVE: To assess whether there is a sex disparity in the application of diagnostic tests for PE or DVT, in reaching a diagnosis, or in using medical facilities. DESIGN: A study of cross-sectional samples of hospitalizations from 21 separate years using data from the National Hospital Discharge Survey. SETTING: Noninstitutional hospitals in the 50 states and the District of Columbia from 1979 through 1999. PATIENTS: The National Hospital Discharge Survey abstracts demographic and medical information from the medical records of inpatients. For 1979 through 1999, the number of patients sampled ranged from 181000 to 307000.Measurements The number of sampled patients with DVT and with PE and the number of diagnostic tests performed were determined from the International Classification of Diseases, Ninth Revision, Clinical Modification codes at discharge. A multistage estimation procedure gave an estimation of values for the entire United States. RESULTS: Age-adjusted rates of the diagnosis of PE per 100000 population and of DVT per 100000 population were not lower in women. Rates of the use of ventilation-perfusion lung scans, venous ultrasonography of the lower extremities, and contrast venography were not lower in women. Durations of hospitalization for PE or DVT were comparable in men and women. CONCLUSION: Data from the National Hospital Discharge Survey do not support a sex bias in the diagnosis of PE or DVT, the use of diagnostic tests, or the duration of hospitalization for PE or DVT.

Tracking the uptake of evidence: two decades of hospital practice trends for diagnosing deep vein thrombosis and pulmonary embolism.

BACKGROUND: Advances in clinical research methods have led to prospective randomized controlled (level 1) clinical studies evaluating diagnostic modalities resulting in a paradigm shift in the literature for diagnosing deep vein thrombosis (DVT) and pulmonary embolism (PE). To assess whether these advances correlate with clinical practice, we analyzed 21-year trends in diagnostic testing for patients with venous thromboembolism. METHODS: We used discharge data from the National Hospital Discharge Survey (1979-1999) to determine DVT and PE cases annually. Procedure fields were screened to determine patients who had DVT or PE or who underwent venography, arteriography of the pulmonary arteries, pulmonary scintigraphy, or DVT ultrasonic scanning. Searching EMBASE, MEDLINE, and the American Thoracic Society guidelines, a literature-based time line of level 1 studies was derived and juxtaposed against trends and procedure use. RESULTS: Improved diagnostic tests resulted in diagnostic changes in patients with suspected venous thromboembolism. These observed changes correlated over time in subsequent years with level 1 studies. Diagnostic DVT approaches showed an initial marked increased use of venography followed by a rapid decline that coincided with increased use of Doppler ultrasonography. Diagnostic approaches to PE were characterized by initial marked increases in lung scanning followed by a rapid decline as use of ultrasonography considerably increased and pulmonary angiography modestly increased. CONCLUSIONS: Diagnostic approaches to DVT and PE have changed markedly during the past 2 decades, in temporal harmony with the evolving literature. Change in clinical practice occurs over years, and long-term follow-up is required to capture this change.