Paper Chase 1 - Discharged with Rivaroxavan

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Nurses Edition Commentary

Mizuho Morrison, DO, Lisa Chavez, RN, and Kathy Garvin, RN

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Joshua Michael, MD -

I want Xa's to work. I want them to show non-inferiority across all measures. Unfortunately The Rocket AF trial that came out yesterday in the Journal of the American College of Cardiology throws a wet towel on this. Death rates were the same (And very low) in both groups, but rivaroxaban caused significant GI bleeding compared to warfarin with a NNH of 100 patient-years of treatment (or 100 patients for 1 year). Bummer.

Clay S. -

I have seen a couple of articles suggesting that overall cost of factor Xa for course of treatment is likely not higher than for LMW-heparain/warfarin. Lovenox is still expensive and patients still need repeat visits for INR checks and those costs add up when compared to factor Xa.

Michael M., MD -

Suggestion for Sanjay and Mike in the area of imaging decision and shared decision making (sorry this is out of context but it was how I was told to drop something in the suggestion box) :

AJEM December 2015
"Can physician and patient gestalt lead to a shared decision to reduce
unnecessary radiography in extremity trauma?"
Michael Mouw, MD, MPAff

Study Objective: To study the predictive value of patient and physician gestalt regarding the presence or absence of fracture or dislocation in minor extremity trauma.
Methods: This was a prospective observational study of patients presenting to an urban teaching hospital emergency department with minor extremity trauma, but without obvious deformity. Subjects were enrolled after radiography had been ordered by a physician. Exclusion criteria included arrival by ambulance, torso injury, and unreliable clinical examination. A questionnaire assessed patient’s and physician’s pretest prediction of abnormality (fracture or dislocation,) and the outcome was radiologist finding of an abnormality. Chi-squared analysis was done to evaluate the predictive value of patient and physician gestalt for radiographic abnormality.
Results: 191 subjects with 195 injuries were analyzed. Fifty-four (27.7%) were found to have abnormalities. There were 14 cases where the patient predicted there was “definitely not” an abnormality. All 14 had no abnormality, for an NPV of 100%. There were 87 cases where an attending emergency physician predicted <10% likelihood of abnormality - of these there were 5 (6%) abnormal x-rays. Multivariate regression analysis found that pain scores did not predict the presence of abnormality but that patients with abnormalities presented sooner after their injury than patients without.
Conclusions: In patients estimated to have a fracture risk of <10%, only 6% had fractures. When patients felt there was “definitely not” a fracture, there were no fractures. These results suggest that patient and physician gestalt should be studied further as variables for inclusion in future imaging decision rules.

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