Division of General Internal Medicine, Department of Internal Medicine, University of Utah, Salt Lake City.
Division of Health System Innovation & Research, Department of Population Health Science, University of Utah, Salt Lake City.
JAMA Netw Open. 2021 Jun 1;4(6):e2111788. doi: 10.1001/jamanetworkopen.2021.11788.
Venous thromboembolism (VTE) is a common complication of COVID-19. It is not well understood how hospitals have managed VTE prevention and the effect of prevention strategies on mortality.
To characterize frequency, variation across hospitals, and change over time in VTE prophylaxis and treatment-dose anticoagulation in patients hospitalized for COVID-19, as well as the association of anticoagulation strategies with in-hospital and 60-day mortality.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study of adults hospitalized with COVID-19 used a pseudorandom sample from 30 US hospitals in the state of Michigan participating in a collaborative quality initiative. Data analyzed were from patients hospitalized between March 7, 2020, and June 17, 2020. Data were analyzed through March 2021.
Nonadherence to VTE prophylaxis (defined as missing ≥2 days of VTE prophylaxis) and receipt of treatment-dose or prophylactic-dose anticoagulants vs no anticoagulation during hospitalization.
The effect of nonadherence and anticoagulation strategies on in-hospital and 60-day mortality was assessed using multinomial logit models with inverse probability of treatment weighting.
Of a total 1351 patients with COVID-19 included (median [IQR] age, 64 [52-75] years; 47.7% women, 48.9% Black patients), only 18 (1.3%) had a confirmed VTE, and 219 (16.2%) received treatment-dose anticoagulation. Use of treatment-dose anticoagulation without imaging ranged from 0% to 29% across hospitals and increased over time (adjusted odds ratio [aOR], 1.46; 95% CI, 1.31-1.61 per week). Of 1127 patients who ever received anticoagulation, 392 (34.8%) missed 2 or more days of prophylaxis. Missed prophylaxis varied from 11% to 61% across hospitals and decreased markedly over time (aOR, 0.89; 95% CI, 0.82-0.97 per week). VTE nonadherence was associated with higher 60-day (adjusted hazard ratio [aHR], 1.31; 95% CI, 1.03-1.67) but not in-hospital mortality (aHR, 0.97; 95% CI, 0.91-1.03). Receiving any dose of anticoagulation (vs no anticoagulation) was associated with lower in-hospital mortality (only prophylactic dose: aHR, 0.36; 95% CI, 0.26-0.52; any treatment dose: aHR, 0.38; 95% CI, 0.25-0.58). However, only the prophylactic dose of anticoagulation remained associated with lower mortality at 60 days (prophylactic dose: aHR, 0.71; 95% CI, 0.51-0.90; treatment dose: aHR, 0.92; 95% CI, 0.63-1.35).
This large, multicenter cohort of patients hospitalized with COVID-19, found evidence of rapid dissemination and implementation of anticoagulation strategies, including use of treatment-dose anticoagulation. As only prophylactic-dose anticoagulation was associated with lower 60-day mortality, prophylactic dosing strategies may be optimal for patients hospitalized with COVID-19.
静脉血栓栓塞症（VTE）是 COVID-19 的常见并发症。医院如何管理 VTE 预防以及预防策略对死亡率的影响尚不清楚。
描述 COVID-19 住院患者中 VTE 预防和治疗剂量抗凝的频率、医院间差异以及随时间的变化，并评估抗凝策略与住院期间和 60 天死亡率的关联。
设计、地点和参与者：这项对美国密歇根州 30 家医院参与合作质量倡议的 COVID-19 住院患者的队列研究使用了来自医院的随机样本。分析的数据来自 2020 年 3 月 7 日至 2020 年 6 月 17 日期间住院的患者。数据分析于 2021 年 3 月进行。
未遵守 VTE 预防（定义为漏用 VTE 预防药物≥2 天）和接受治疗剂量或预防剂量抗凝剂与住院期间未接受抗凝治疗。
使用逆概率治疗加权的多项逻辑回归模型评估不遵守治疗和抗凝策略对住院期间和 60 天死亡率的影响。
在纳入的 1351 例 COVID-19 患者中（中位数[IQR]年龄为 64[52-75]岁；47.7%为女性，48.9%为黑人患者），只有 18 例（1.3%）确诊 VTE，219 例（16.2%）接受了治疗剂量抗凝。在医院间，无影像学检查的治疗剂量抗凝的使用率从 0%到 29%不等，并随时间增加（调整后的优势比[aOR]，每增加一周为 1.46；95%CI，1.31-1.61）。在接受过抗凝治疗的 1127 例患者中，有 392 例（34.8%）漏用了 2 天或以上的预防药物。漏用预防药物的情况在医院间差异从 11%到 61%不等，并随时间明显下降（aOR，每增加一周为 0.89；95%CI，0.82-0.97）。VTE 不遵守治疗与 60 天死亡率升高相关（调整后的危险比[aHR]，1.31；95%CI，1.03-1.67），但与住院期间死亡率无关（aHR，0.97；95%CI，0.91-1.03）。接受任何剂量的抗凝治疗（与未接受抗凝治疗相比）与住院期间死亡率降低相关（仅预防剂量：aHR，0.36；95%CI，0.26-0.52；任何治疗剂量：aHR，0.38；95%CI，0.25-0.58）。然而，只有预防剂量的抗凝治疗与 60 天死亡率降低相关（预防剂量：aHR，0.71；95%CI，0.51-0.90；治疗剂量：aHR，0.92；95%CI，0.63-1.35）。
这项针对 COVID-19 住院患者的大型多中心队列研究发现了抗凝策略快速传播和实施的证据，包括使用治疗剂量抗凝。由于只有预防剂量的抗凝与 60 天死亡率降低相关，因此对 COVID-19 住院患者可能采用预防剂量抗凝策略更优。
