Effects of changing guidelines on prescribing aspirin for primary prevention of cardiovascular events.

OBJECTIVE: The use of low-dose aspirin for primary prevention of cardiovascular events in patients at elevated risk for cardiovascular disease (CVD) is increasingly being questioned. Aspirin may not benefit this population and may increase the risk of major bleeding events. Data support aspirin use in patients with known CVD. METHODS: This is a secondary analysis of de-identified electronic health record (EHR) data from 131,050 individuals with known CVD or elevated risk for CVD as determined by diagnostic, demographic, and clinical data collected from 33 primary care practices in 11 different clinical organizations across 6 states. The percentage of the population of each cohort with aspirin recorded on their medication list, created through risk base analysis, was observed across 4 time periods. RESULTS: From 2007 to 2011, aspirin usage reflected in the EHR increased for the entire population and for each individual high-risk diagnosis. The percentage of the population initiating aspirin therapy for primary prevention within a year of diagnosis of CVD risk factors or CVD "equivalency" increased between 2007 and 2011. Among those with a new diagnosis of CVD, aspirin usage also steadily increased over the 4-year period, indicating no negative impact from new negative primary prevention studies. CONCLUSIONS: Primary care clinicians have a central role in providing evidence-based preventive services and should integrate revised information into their practice to improve outcomes. Even with new evidence against the use of aspirin for primary prevention, it is difficult to change beliefs about the effectiveness and safety of aspirin, as reflected in the behavior of physicians and patients.

Validation of rules to predict emergent surgical intervention in pediatric trauma patients.

BACKGROUND: Trauma centers use guidelines to determine when a trauma surgeon is needed in the emergency department (ED) on patient arrival. A decision rule from Loma Linda University identified patients with penetrating injury and tachycardia as requiring emergent surgical intervention. Our goal was to validate this rule and to compare it with the American College of Surgeons' Major Resuscitation Criteria (MRC). STUDY DESIGN: We used data from 1993 through 2010 from 2 level 1 trauma centers in Denver, CO. Patient demographics, injury severity, times of ED arrival and surgical intervention, and all variables of the Loma Linda Rule and the MRC were obtained. The outcome, emergent intervention (defined as requiring operative intervention by a trauma surgeon within 1 hour of arrival to the ED or performance of cricothyroidotomy or thoracotomy in the ED), was confirmed using standardized abstraction. Sensitivities, specificities, and 95% confidence intervals were calculated. RESULTS: There were 8,078 patients included, and 47 (0.6%) required emergent intervention. Of the 47 patients, the median age was 11 years (interquartile range [IQR] 7 to 14 years), 70% were male, 30% had penetrating mechanisms, and the median Injury Severity Score (ISS) was 25 (IQR 9 to 41). At the 2 institutions, the Loma Linda Rule had a sensitivity and specificity of 69% (95% CI 45% to 94%) and 76% (95% CI 69% to 83%), respectively, and the MRC had a sensitivity and specificity of 80% (95% CI 70% to 92%) and 81% (95% CI 77% to 85%), respectively. CONCLUSIONS: Emergent surgical intervention is rare in the pediatric trauma population. Although precision of predictive accuracies of the Loma Linda Rule and MRC were limited by small numbers of outcomes, neither set of criteria appears to be sufficiently accurate to recommend their routine use.