- Email: [email protected]
Declining National Annual IVC Filter Utilization
demonstrated superiority over chest radiography for evaluation of pneumothorax identification in multiple studies.2 For 4 years, we have employed this expanded approach in the office setting. Using a 2- to 4-mHz phased-array probe on a Z.One Ultra system (Zonare/Mindray), scanning is performed along three longitudinal planes in the seated patient: paraspinal, subscapular, and midaxillary lines. Prior to thoracentesis, each intercostal space along these lines is examined for the presence of pleural effusion, lung sliding, and B lines in both the lung of interest and the contralateral lung. Postthoracentesis, this examination is repeated in the lung of interest, and short video clips from the most apical interspace along each line are recorded as confirmation of sliding lung or the presence of B lines. To enhance detection of pleural movement, M mode or a 6- to 8mHz linear probe is occasionally employed. When there is absence of lung sliding or B lines at the onset and/or at the completion of the procedure, patients are sent for chest radiography. In addition, the residual pleural effusion size is noted and recorded for future comparison. The benefits of this new practice style are numerous. The use of chest radiography has decreased by 81%, resulting in enhanced patient safety and faster office throughput. Initially, time expenditure at the bedside was increased. However, once the skills are acquired, an additional 2 to 3 minutes of additional time is spent scanning and recording images. For billing purposes, the images are recorded and our documentation has been enhanced to include ultrasound findings and interpretation. One hundred and four outpatients have been studied by this technique with no adverse events. Only one patient studied was found to have an asymptomatic small inferior pneumothorax detected on routine CT scan completed 2 days later for cancer follow-up. While the literature suggests no chest radiography is necessary, community practice routinely includes imaging. In this new era of office-based ultrasoundguided thoracentesis, using tools already available, the clinician can efficiently evaluate for pneumothorax and eliminate the community practice of a postthoracentesis chest radiograph. Amali Jayasinghe, MD Downey, CA
1402 Correspondence
AFFILIATIONS: From the Division of Pulmonary and Critical Care, Department of Medicine, Kaiser Permanente. FINANCIAL/NONFINANCIAL DISCLOSURES: None declared. CORRESPONDENCE TO: Amali Jayasinghe, MD, Division of Pulmonary and Critical Care, Department of Medicine, Kaiser Permanente, Ste 120C, 9449 E. Imperial Hwy, Downey, CA 90242; e-mail: [email protected] Copyright Ó 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2017.02.034
References 1. Aleman C, Alegre J, Armadans L, et al. The value of chest roentgenography in the diagnosis of pneumothorax after thoracentesis. Am J Med. 1999;107(4):340-343. 2. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax. a systematic review and meta-analysis. Chest. 2012;141(3):703-708.
Declining National Annual IVC Filter Utilization An Analysis on the Impact of Societal and Governmental Communications To the Editor:
Until recently, the annual rate of inferior vena cava (IVC) filter placements has been increasing.1 The potential inappropriate utilization of IVC filters and its negative consequences have been discussed and highlighted by a US Food and Drug Administration (FDA)-issued advisory in 2010. We analyzed national annual IVC filter placement trends over the past 2 decades to assess for differences in placement rates following updates to societal guidelines, legal events, and governmental communications. Hospital discharges from 1993 through 2014 were retrospectively analyzed using data from the Healthcare Cost and Utilization Project - National Inpatient Sample; yearly percentage change of filter placements were graphed and plotted with release dates for societal guidelines, legal events, and governmental communications issued over this time span. Legal events included the consolidation of IVC filter lawsuits into multidistrict litigations against C.R. Bard and Cook Medical.2,3 An inflection point from positive to negative use was identified in 2010, correlating with the year in which the FDA advisory was released. We found that, from 1993 to 2010, the number of annual IVC filters placed increased from 28,330 to 129,614 (358% increase) at a compounded annual increase of 9.4% and maximum single-year increase of
[
151#6 CHEST JUNE 2017
]
140,000
SIR Guidelines
Figure 1 – Number of IVC filters placed per year. *Consolidation of IVC filter lawsuits into MDLs against C. R. Bard and Cook Medical by the US Judicial Panel on Multidistrict Litigation. ACCP ¼ American College of Clinical Pharmacy; AHA ¼ American Heart Association; EAST ¼ Eastern Association for the Surgery of Trauma; FDA ¼ Food and Drug Administration; IVC ¼ inferior vena cava; MDL ¼ multidistrict litigation.
AHA Guidelines
No. of IVC Filters Placed
120,000 FDA Advisory Initial ACCP Updated Guidelines ACCP
EAST Guidelines
100,000 80,000
Guidelines
60,000 Consolidation of IVCF lawsuits into MDLs *
40,000 20,000
19
9 19 3 9 19 4 9 19 5 9 19 6 9 19 7 9 19 8 99 20 0 20 0 01 20 0 20 2 0 20 3 04 20 0 20 5 0 20 6 07 20 0 20 8 09 20 1 20 0 11 20 1 20 2 13 20 14
0
Year
25.8% (range, 1.7% to 25.8%). Filter use increased following societal guideline updates from the Eastern Association for the Surgery of Trauma in 2002, TABLE 1
Society of Interventional Radiology in 2006, and American College of Clinical Pharmacy (ACCP) in 2008. After peaking in 2010, however, annual filter use
] Geographic Rates of IVC Filters Placements, PE, DVT, and IVC Filters per 100 DVTs/PEs
Region
2010
2011
2012
2013
>2010 Change (%)
Average Yearly Change (%)
Compounded Rate (%)
IVC filter Northeast
31,044
24,004
24,970
22,455
-27.67
-9.22
-10.23
Midwest
27,364
25,575
24,170
22,135
-19.11
-6.37
-6.82
South
51,128
48,940
45,115
40,770
-20.26
-6.75
-7.27
West
20,077
19,708
17,640
16,105
-19.78
-6.59
-7.08
Northeast
61,088
60,021
61,025
61,490
0.66
0.22
0.22
Midwest
77,740
83,070
80,855
80,255
3.24
1.08
1.07
119,068
123,734
124,755
124,805
4.82
1.61
1.58
60,607
64,897
61,965
61,165
0.92
0.31
0.31
Northeast
73,759
69,991
78,300
74,550
1.07
0.36
0.36
Midwest
93,771
99,300
95,715
91,000
-2.96
-0.99
-0.99
145,311
149,494
144,825
143,550
-1.21
-0.40
-0.41
68,463
68,712
67,100
63,965
-6.57
-2.19
-2.24
PE
South West DVT
South West IVC filter per 100 DVT and PE diagnosis Northeast
23.0
18.5
17.9
16.5
-28.30
-9.43
-10.50
Midwest
16.0
14.0
13.7
12.9
-18.99
-6.33
-6.78
South
19.3
17.9
16.7
15.2
-21.44
-7.15
-7.73
West
15.6
14.8
13.7
12.9
-17.26
-5.75
-6.12
IVC ¼ inferior vena cava; PE ¼ pulmonary embolism.
journal.publications.chestnet.org
1403
declined to 96,005 in 2014, a -25.9% decline or 6.7% compounded yearly decrease (range, -5.4% to -9.3%) (Fig 1). This occurred despite stable and increased rates of DVT and pulmonary embolism diagnosed in this period. The FDA advisory regarding filter use in 2010, updates to American Heart Association in 2011 and ACCP in 2012 societal guidelines, and the consolidation of IVC filter lawsuits into multidistrict litigations in 2014 occurred during this period. Interrupted time series analysis of filter placements demonstrated a significant difference in trends between the pre-2010 and post-2010 periods (P ¼ .0002) that were significant across subgroups of age, gender, and other studied variables. Decreased use was observed across all geographic regions of the United States (Table 1). Since 2010, annual IVC filter use has declined by compound and overall rates of -6.7% and -25.9%, respectively. In evaluating the events that occurred since 2010, it remains likely that the FDA advisory, incorporation of legal cases into multidistrict litigations, and updated American Heart Association and ACCP guidelines recommending only therapeutic placements have contributed to temper the number of filters placed annually in the United States. Osman Ahmed, MD Ketan Patel, MD, FCCP Mikin V. Patel, MD Amanjit S. Baadh, MD Sreekumar Madassery, MD Ulku Cenk Turba, MD Chicago, IL Thomas J. Ward, MD Orlando, FL AFFILIATIONS: From the Department of Radiology (Drs Ahmed, K. Patel, Baadh, Madassery, and Turba), Section of Interventional Radiology, Rush University Medical Center; Department of Radiology (Dr M. V. Patel), University of Chicago Medicine; and the Department of Radiology (Dr Ward), Section of Interventional Radiology, University of Central Florida College of Medicine, Florida Hospital. FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: A. S. B. is a speaker and advisory board member for Penumbra and Medtronic/Covidien and speaker for Cook, W.L. Gore, Guerbet, and CR Bard. O. A. is a speaker for Cook and shareholder of Penumbra. None declared (K. P., M. V. P., S. M., U. C. T., T. J. W.). CORRESPONDENCE TO: Osman Ahmed, MD, Rush University Medical Center, 1725 W Harrison St, Ste 450, Chicago, IL 60612; e-mail: [email protected] Copyright Ó 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2017.03.038
1404 Correspondence
References 1. Antevil JL, Sise MJ, Sack DI, et al. Retrievable vena cava filters for preventing pulmonary embolism in trauma patients: a cautionary tale. J Trauma. 2006;60(1):35-40. 2. IN RE COOK MEDICAL, INC., IVC FILTERS MARKETING, 53F. Supp.3d (J.P.M.L 2014). 3. IN RE BARD IVC FILTERS PRODUCTS LIBABILITY LITIGATION (J.P.M.L 2015).
Palliative Care, Spiritual Care, and Clinical Ethics Widely Available, but Underused To the Editor:
With expansion of hospital-based care come increasingly complex needs inviting palliative care (PC), clinical ethics (CE), and spiritual care (SC) collaboration. Commonly encountered situations include withdrawal of life-sustaining therapies, surrogate decision-making, provider conflict, and spiritual/ religious distress, all of which overlap among PC, CE, and SC domains of expertise. Nevertheless, although hospitals commonly use these three clinical services, little guidance exists regarding which service to consult, how they might best collaborate, and their effect on quality benchmarks.1-4 To learn more about consultation preferences in critical care settings, we conducted an institutional review board–approved 22-question online survey to members of the American College of Chest Physicians in August 2015. The survey presented three cases in critical care settings and elicited responses regarding consultation needs preferences. The survey yielded 72 responses (6% response rate, 100% completion rate). Respondents (88% physicians, 83% intensivists, 63% male) reported high availability of PC (81%), CE (74%), and SC (79%) at their institutions. Despite high availability of all these services, only 14% of respondents reported “routinely” or “often” consulting CE, compared with 72% for PC and 63% for SC. In hypothetical cases, most respondents expressed preference to consult PC for a patient with stage IV lung cancer admitted to their ICU for hypoxemic respiratory failure (case 1) or for a patient with an estimated prognosis of weeks who wants “everything done” (case 2) (Fig 1). For a mechanically ventilated patient with multisystem organ failure and no available surrogate decision-maker, 40.3% of respondents would consult CE first (case 3),
[
151#6 CHEST JUNE 2017
]
1402 Correspondence
AFFILIATIONS: From the Division of Pulmonary and Critical Care, Department of Medicine, Kaiser Permanente. FINANCIAL/NONFINANCIAL DISCLOSURES: None declared. CORRESPONDENCE TO: Amali Jayasinghe, MD, Division of Pulmonary and Critical Care, Department of Medicine, Kaiser Permanente, Ste 120C, 9449 E. Imperial Hwy, Downey, CA 90242; e-mail: [email protected] Copyright Ó 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2017.02.034
References 1. Aleman C, Alegre J, Armadans L, et al. The value of chest roentgenography in the diagnosis of pneumothorax after thoracentesis. Am J Med. 1999;107(4):340-343. 2. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax. a systematic review and meta-analysis. Chest. 2012;141(3):703-708.
Declining National Annual IVC Filter Utilization An Analysis on the Impact of Societal and Governmental Communications To the Editor:
Until recently, the annual rate of inferior vena cava (IVC) filter placements has been increasing.1 The potential inappropriate utilization of IVC filters and its negative consequences have been discussed and highlighted by a US Food and Drug Administration (FDA)-issued advisory in 2010. We analyzed national annual IVC filter placement trends over the past 2 decades to assess for differences in placement rates following updates to societal guidelines, legal events, and governmental communications. Hospital discharges from 1993 through 2014 were retrospectively analyzed using data from the Healthcare Cost and Utilization Project - National Inpatient Sample; yearly percentage change of filter placements were graphed and plotted with release dates for societal guidelines, legal events, and governmental communications issued over this time span. Legal events included the consolidation of IVC filter lawsuits into multidistrict litigations against C.R. Bard and Cook Medical.2,3 An inflection point from positive to negative use was identified in 2010, correlating with the year in which the FDA advisory was released. We found that, from 1993 to 2010, the number of annual IVC filters placed increased from 28,330 to 129,614 (358% increase) at a compounded annual increase of 9.4% and maximum single-year increase of
[
151#6 CHEST JUNE 2017
]
140,000
SIR Guidelines
Figure 1 – Number of IVC filters placed per year. *Consolidation of IVC filter lawsuits into MDLs against C. R. Bard and Cook Medical by the US Judicial Panel on Multidistrict Litigation. ACCP ¼ American College of Clinical Pharmacy; AHA ¼ American Heart Association; EAST ¼ Eastern Association for the Surgery of Trauma; FDA ¼ Food and Drug Administration; IVC ¼ inferior vena cava; MDL ¼ multidistrict litigation.
AHA Guidelines
No. of IVC Filters Placed
120,000 FDA Advisory Initial ACCP Updated Guidelines ACCP
EAST Guidelines
100,000 80,000
Guidelines
60,000 Consolidation of IVCF lawsuits into MDLs *
40,000 20,000
19
9 19 3 9 19 4 9 19 5 9 19 6 9 19 7 9 19 8 99 20 0 20 0 01 20 0 20 2 0 20 3 04 20 0 20 5 0 20 6 07 20 0 20 8 09 20 1 20 0 11 20 1 20 2 13 20 14
0
Year
25.8% (range, 1.7% to 25.8%). Filter use increased following societal guideline updates from the Eastern Association for the Surgery of Trauma in 2002, TABLE 1
Society of Interventional Radiology in 2006, and American College of Clinical Pharmacy (ACCP) in 2008. After peaking in 2010, however, annual filter use
] Geographic Rates of IVC Filters Placements, PE, DVT, and IVC Filters per 100 DVTs/PEs
Region
2010
2011
2012
2013
>2010 Change (%)
Average Yearly Change (%)
Compounded Rate (%)
IVC filter Northeast
31,044
24,004
24,970
22,455
-27.67
-9.22
-10.23
Midwest
27,364
25,575
24,170
22,135
-19.11
-6.37
-6.82
South
51,128
48,940
45,115
40,770
-20.26
-6.75
-7.27
West
20,077
19,708
17,640
16,105
-19.78
-6.59
-7.08
Northeast
61,088
60,021
61,025
61,490
0.66
0.22
0.22
Midwest
77,740
83,070
80,855
80,255
3.24
1.08
1.07
119,068
123,734
124,755
124,805
4.82
1.61
1.58
60,607
64,897
61,965
61,165
0.92
0.31
0.31
Northeast
73,759
69,991
78,300
74,550
1.07
0.36
0.36
Midwest
93,771
99,300
95,715
91,000
-2.96
-0.99
-0.99
145,311
149,494
144,825
143,550
-1.21
-0.40
-0.41
68,463
68,712
67,100
63,965
-6.57
-2.19
-2.24
PE
South West DVT
South West IVC filter per 100 DVT and PE diagnosis Northeast
23.0
18.5
17.9
16.5
-28.30
-9.43
-10.50
Midwest
16.0
14.0
13.7
12.9
-18.99
-6.33
-6.78
South
19.3
17.9
16.7
15.2
-21.44
-7.15
-7.73
West
15.6
14.8
13.7
12.9
-17.26
-5.75
-6.12
IVC ¼ inferior vena cava; PE ¼ pulmonary embolism.
journal.publications.chestnet.org
1403
declined to 96,005 in 2014, a -25.9% decline or 6.7% compounded yearly decrease (range, -5.4% to -9.3%) (Fig 1). This occurred despite stable and increased rates of DVT and pulmonary embolism diagnosed in this period. The FDA advisory regarding filter use in 2010, updates to American Heart Association in 2011 and ACCP in 2012 societal guidelines, and the consolidation of IVC filter lawsuits into multidistrict litigations in 2014 occurred during this period. Interrupted time series analysis of filter placements demonstrated a significant difference in trends between the pre-2010 and post-2010 periods (P ¼ .0002) that were significant across subgroups of age, gender, and other studied variables. Decreased use was observed across all geographic regions of the United States (Table 1). Since 2010, annual IVC filter use has declined by compound and overall rates of -6.7% and -25.9%, respectively. In evaluating the events that occurred since 2010, it remains likely that the FDA advisory, incorporation of legal cases into multidistrict litigations, and updated American Heart Association and ACCP guidelines recommending only therapeutic placements have contributed to temper the number of filters placed annually in the United States. Osman Ahmed, MD Ketan Patel, MD, FCCP Mikin V. Patel, MD Amanjit S. Baadh, MD Sreekumar Madassery, MD Ulku Cenk Turba, MD Chicago, IL Thomas J. Ward, MD Orlando, FL AFFILIATIONS: From the Department of Radiology (Drs Ahmed, K. Patel, Baadh, Madassery, and Turba), Section of Interventional Radiology, Rush University Medical Center; Department of Radiology (Dr M. V. Patel), University of Chicago Medicine; and the Department of Radiology (Dr Ward), Section of Interventional Radiology, University of Central Florida College of Medicine, Florida Hospital. FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: A. S. B. is a speaker and advisory board member for Penumbra and Medtronic/Covidien and speaker for Cook, W.L. Gore, Guerbet, and CR Bard. O. A. is a speaker for Cook and shareholder of Penumbra. None declared (K. P., M. V. P., S. M., U. C. T., T. J. W.). CORRESPONDENCE TO: Osman Ahmed, MD, Rush University Medical Center, 1725 W Harrison St, Ste 450, Chicago, IL 60612; e-mail: [email protected] Copyright Ó 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2017.03.038
1404 Correspondence
References 1. Antevil JL, Sise MJ, Sack DI, et al. Retrievable vena cava filters for preventing pulmonary embolism in trauma patients: a cautionary tale. J Trauma. 2006;60(1):35-40. 2. IN RE COOK MEDICAL, INC., IVC FILTERS MARKETING, 53F. Supp.3d (J.P.M.L 2014). 3. IN RE BARD IVC FILTERS PRODUCTS LIBABILITY LITIGATION (J.P.M.L 2015).
Palliative Care, Spiritual Care, and Clinical Ethics Widely Available, but Underused To the Editor:
With expansion of hospital-based care come increasingly complex needs inviting palliative care (PC), clinical ethics (CE), and spiritual care (SC) collaboration. Commonly encountered situations include withdrawal of life-sustaining therapies, surrogate decision-making, provider conflict, and spiritual/ religious distress, all of which overlap among PC, CE, and SC domains of expertise. Nevertheless, although hospitals commonly use these three clinical services, little guidance exists regarding which service to consult, how they might best collaborate, and their effect on quality benchmarks.1-4 To learn more about consultation preferences in critical care settings, we conducted an institutional review board–approved 22-question online survey to members of the American College of Chest Physicians in August 2015. The survey presented three cases in critical care settings and elicited responses regarding consultation needs preferences. The survey yielded 72 responses (6% response rate, 100% completion rate). Respondents (88% physicians, 83% intensivists, 63% male) reported high availability of PC (81%), CE (74%), and SC (79%) at their institutions. Despite high availability of all these services, only 14% of respondents reported “routinely” or “often” consulting CE, compared with 72% for PC and 63% for SC. In hypothetical cases, most respondents expressed preference to consult PC for a patient with stage IV lung cancer admitted to their ICU for hypoxemic respiratory failure (case 1) or for a patient with an estimated prognosis of weeks who wants “everything done” (case 2) (Fig 1). For a mechanically ventilated patient with multisystem organ failure and no available surrogate decision-maker, 40.3% of respondents would consult CE first (case 3),
[
151#6 CHEST JUNE 2017
]