Alan D Cook1, Brian W Gross2, Turner M Osler3, Katelyn J Rittenhouse4, Eric H Bradburn2, Steven R Shackford5, Frederick B Rogers2. 1. Trauma Research Program, Chandler Regional Medical Center, Chandler, Arizona. 2. Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania. 3. Department of Surgery, University of Vermont College of Medicine, Burlington. 4. University of North Carolina at Chapel Hill School of Medicine. 5. Trauma Service, Scripps Mercy Hospital, San Diego, California.
Abstract
IMPORTANCE: Vena cava filter (VCF) placement for pulmonary embolism (PE) prophylaxis in trauma is controversial. Limited research exists detailing trends in VCF use and occurrence of PE over time. OBJECTIVE: To analyze state and nationwide temporal trends in VCF placement and PE occurrence from 2003 to 2015 using available data sets. DESIGN, SETTING, AND PARTICIPANTS: A retrospective trauma cohort study was conducted using data from the Pennsylvania Trauma Outcome Study (PTOS) (461 974 patients from 2003 to 2015), the National Trauma Data Bank (NTDB) (5 755 095 patients from 2003 to 2014), and the National (Nationwide) Inpatient Sample (NIS) (24 449 476 patients from 2003 to 2013) databases. MAIN OUTCOMES AND MEASURES: Temporal trends in VCF placement and PE rates, filter type (prophylactic or therapeutic), and established predictors of PE (obesity, pregnancy, cancer, deep vein thrombosis, major procedure, spinal cord paralysis, venous injury, lower extremity fracture, pelvic fracture, central line, intracranial hemorrhage, and blood transfusion). Prophylactic filters were defined as VCFs placed before or without an existing PE, while therapeutic filters were defined as VCFs placed after a PE. RESULTS: Of the 461 974 patients in PTOS, the mean (SD) age was 47.2 (26.4) and 61.6% (284 621) were men; of the 5 755 095 patients in NTDB, the mean age (SD) was 42.0 (24.3) and 63.7% (3 666 504) were men; and of the 24 449 476 patients in NIS, the mean (SD) age was 58.0 (25.2) and 49.7% (12 160 231) were men. Of patients receiving a filter (11 405 in the PTOS, 71 029 in the NTDB, and 189 957 in the NIS), most were prophylactic VCFs (93.6% in the PTOS, 93.5% in the NTDB, and 93.3% in the NIS). Unadjusted and adjusted temporal trends for the PTOS and NTDB showed initial increases in filter placement followed by significant declines (unadjusted reductions in VCF placement rates, 76.8% in the PTOS and 53.3% in the NTDB). The NIS demonstrated a similar unadjusted trend, with a slight increase and modest decline (22.2%) in VCF placement rates over time; however, adjusted trends showed a slight but significant increase in filter rates. Adjusted PE rates for the PTOS and NTDB showed significant initial increases followed by slight decreases, with limited variation during the declining filter use periods. The NIS showed an initial increase in PE rates followed by a period of stagnation. CONCLUSIONS AND RELEVANCE: Despite a precipitous decline of VCF use in trauma, PE rates remained unchanged during this period. Taking this association into consideration, VCFs may have limited utility in influencing rates of PE. More judicious identification of at-risk patients is warranted to determine individuals who would most benefit from a VCF.
IMPORTANCE: Vena cava filter (VCF) placement for pulmonary embolism (PE) prophylaxis in trauma is controversial. Limited research exists detailing trends in VCF use and occurrence of PE over time. OBJECTIVE: To analyze state and nationwide temporal trends in VCF placement and PE occurrence from 2003 to 2015 using available data sets. DESIGN, SETTING, AND PARTICIPANTS: A retrospective trauma cohort study was conducted using data from the Pennsylvania Trauma Outcome Study (PTOS) (461 974 patients from 2003 to 2015), the National Trauma Data Bank (NTDB) (5 755 095 patients from 2003 to 2014), and the National (Nationwide) Inpatient Sample (NIS) (24 449 476 patients from 2003 to 2013) databases. MAIN OUTCOMES AND MEASURES: Temporal trends in VCF placement and PE rates, filter type (prophylactic or therapeutic), and established predictors of PE (obesity, pregnancy, cancer, deep vein thrombosis, major procedure, spinal cord paralysis, venous injury, lower extremity fracture, pelvic fracture, central line, intracranial hemorrhage, and blood transfusion). Prophylactic filters were defined as VCFs placed before or without an existing PE, while therapeutic filters were defined as VCFs placed after a PE. RESULTS: Of the 461 974 patients in PTOS, the mean (SD) age was 47.2 (26.4) and 61.6% (284 621) were men; of the 5 755 095 patients in NTDB, the mean age (SD) was 42.0 (24.3) and 63.7% (3 666 504) were men; and of the 24 449 476 patients in NIS, the mean (SD) age was 58.0 (25.2) and 49.7% (12 160 231) were men. Of patients receiving a filter (11 405 in the PTOS, 71 029 in the NTDB, and 189 957 in the NIS), most were prophylactic VCFs (93.6% in the PTOS, 93.5% in the NTDB, and 93.3% in the NIS). Unadjusted and adjusted temporal trends for the PTOS and NTDB showed initial increases in filter placement followed by significant declines (unadjusted reductions in VCF placement rates, 76.8% in the PTOS and 53.3% in the NTDB). The NIS demonstrated a similar unadjusted trend, with a slight increase and modest decline (22.2%) in VCF placement rates over time; however, adjusted trends showed a slight but significant increase in filter rates. Adjusted PE rates for the PTOS and NTDB showed significant initial increases followed by slight decreases, with limited variation during the declining filter use periods. The NIS showed an initial increase in PE rates followed by a period of stagnation. CONCLUSIONS AND RELEVANCE: Despite a precipitous decline of VCF use in trauma, PE rates remained unchanged during this period. Taking this association into consideration, VCFs may have limited utility in influencing rates of PE. More judicious identification of at-risk patients is warranted to determine individuals who would most benefit from a VCF.
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