Major bleeding after hospitalization for deep-venous thrombosis.

PURPOSE Most studies of oral anticoagulant-related bleeding have analyzed the incidence of adverse outcomes among patients with a variety of different conditions and without any comparison with a control group. We determined the incidence, time course, and risk factors associated with major bleeding after hospital discharge among patients with deep-vein thrombosis, and estimated the excess risk of bleeding associated with oral anticoagulant therapy. METHODS A total of 22,000 adults were hospitalized in California for 3 or more days with a diagnosis of deep-venous thrombosis between January 1, 1992, and September 30, 1994. We determined the risk factors associated with readmission for bleeding. We compared the incidence of readmission for bleeding with comparison cohorts of patients with pneumonia or cellulitis who were matched for age, gender, race, and length of hospital stay. RESULTS Of 21,250 patients with deep-venous thrombosis who were discharged without bleeding, 1.4% were readmitted for bleeding within 91 days; the rate was 2.7 times greater in the first 30 days than in the next 61 days. Risk factors for bleeding included hospitalization with gastrointestinal bleeding during the previous 18 months (relative hazard [RH] = 2.6, 95% confidence interval [CI]: 1.6 to 4.1), hospitalization with an alcohol-related diagnosis during the previous 18 months (RH = 2.6, 95% CI: 1.4 to 4.8), chronic renal disease (RH = 2.4, 95% CI: 1.4 to 4.2), female gender (RH = 1.7, 95% CI: 1.3 to 2.2), presence of a malignancy (RH = 1.6, 95% CI: 1.2 to 2.2), nonwhite race (RH = 1.6, 95% CI: 1.2 to 2.1), and age over 65 years (RH = 1.3, 95% CI: 1.0 to 1.7). Significantly more women (n = 40) had intracranial bleeding than men (n = 18, P = 0.02). In the comparison cohorts, the incidence of readmission for bleeding within 3 months of discharge was 0.7%, and the relative risk (RR) of readmission was greater in those with deep-venous thrombosis than in those with cellulitis (RR = 2.0, 95% CI: 1.6 to 2.5) or pneumonia (RR = 2.0, 95% CI: 1.7 to 2.5). CONCLUSIONS The incidence of rehospitalization for bleeding was greatest in the first 30 days after discharge, and was approximately twice that seen in patients hospitalized for cellulitis or pneumonia. Further studies are needed to determine why women and nonwhite patients are at increased risk for anticoagulant-related bleeding.

[1]  P. Patton.  Risk factors for complications of chronic anticoagulation , 1994 .

[2]  P. Bossuyt,et al.  Replacing Inpatient Care by Outpatient Care in the Treatment of Deep Venous Thrombosis – An Economic Evaluation , 1998, Thrombosis and Haemostasis.

[3]  M. Prins,et al.  Low-molecular-weight heparin in the treatment of patients with venous thromboembolism. , 1997, The New England journal of medicine.

[4]  E Meux,et al.  Encrypting personal identifiers. , 1994, Health services research.

[5]  Donald Martin,et al.  Risk Factors for Complications of Chronic Anticoagulation: A Multicenter Study , 1993, Annals of Internal Medicine.

[6]  R. Beyth,et al.  Prospective evaluation of an index for predicting the risk of major bleeding in outpatients treated with warfarin. , 1998, The American journal of medicine.

[7]  Vittorio Pengo,et al.  Bleeding complications of oral anticoagulant treatment: an inception-cohort, prospective collaborative study (ISCOAT) , 1996, The Lancet.

[8]  D. W. Barritt,et al.  Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. , 1960, Lancet.

[9]  Jeffrey S. Ginsberg,et al.  Management of venous thromboembolism. , 1996, The New England journal of medicine.

[10]  N. E. Breslow.  Statistical Methods in Cancer Research , 1986 .

[11]  R. White,et al.  Incidence of Idiopathic Deep Venous Thrombosis and Secondary Thromboembolism among Ethnic Groups in California , 1998, Annals of Internal Medicine.

[12]  B. Gersh,et al.  Bleeding and thromboembolism during anticoagulant therapy: a population-based study in Rochester, Minnesota. , 1995, Mayo Clinic proceedings.

[13]  M. Peyman.  The significance of haemorrhage during the treatment of patients with the coumarin anticoagulants. , 2009, Acta medica Scandinavica. Supplementum.

[14]  J. Gurwitz,et al.  Age-related risks of long-term oral anticoagulant therapy. , 1988, Archives of internal medicine.

[15]  P. Romano,et al.  Length of hospital stay for treatment of deep venous thrombosis and the incidence of recurrent thromboembolism. , 1998, Archives of internal medicine.

[16]  J. Forfar.  A 7-year analysis of haemorrhage in patients on long-term anticoagulant treatment. , 1979, British heart journal.

[17]  R. Beyth,et al.  Anticoagulant-related bleeding: clinical epidemiology, prediction, and prevention. , 1993, The American journal of medicine.

[18]  G. Bots,et al.  The risk of intracerebral hemorrhage during oral anticoagulant treatment: A population study , 1984, Annals of neurology.

[19]  S. Fihn,et al.  The Risk for and Severity of Bleeding Complications in Elderly Patients Treated with Warfarin , 1996, Annals of Internal Medicine.

[20]  D. Petitti,et al.  Prothrombin time ratio and other factors associated with bleeding in patients treated with warfarin. , 1989, Journal of clinical epidemiology.

[21]  J. Jollis,et al.  A comparison of administrative versus clinical data: coronary artery bypass surgery as an example. Ischemic Heart Disease Patient Outcomes Research Team. , 1994, Journal of clinical epidemiology.

[22]  J. Hirsh,et al.  A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. , 1996, The New England journal of medicine.

[23]  G. Simonneau,et al.  A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. The THESEE Study Group. Tinzaparine ou Heparine Standard: Evaluations dans l'Embolie Pulmonaire. , 1997, The New England journal of medicine.

[24]  P. Bossuyt,et al.  Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tasman Study Group. , 1996, The New England journal of medicine.

[25]  L. Goldman,et al.  The bleeding severity index: validation and comparison to other methods for classifying bleeding complications of medical therapy. , 1989, Journal of clinical epidemiology.

[26]  Subcutaneous low-molecular-weight heparin compared with continuous intravenous heparin in the treatment of proximal-vein thrombosis. , 1992 .

[27]  L Goldman,et al.  Major bleeding in outpatients treated with warfarin: incidence and prediction by factors known at the start of outpatient therapy. , 1989, The American journal of medicine.

[28]  D. Petitti,et al.  Duration of warfarin anticoagulant therapy and the probabilities of recurrent thromboembolism and hemorrhage. , 1986, The American journal of medicine.

[29]  E. Hylek,et al.  Risk Factors for Intracranial Hemorrhage in Outpatients Taking Warfarin , 1994, Annals of Internal Medicine.

[30]  J. Hirsh,et al.  Hemorrhagic Complications of Anticoagulant Therapy , 1986, Seminars in thrombosis and hemostasis.

[31]  J. Roos,et al.  The cause of bleeding during anticoagulant treatment. , 2009, Acta medica Scandinavica.

[32]  H. Büller,et al.  A comparison of real-time compression ultrasonography with impedance plethysmography for the diagnosis of deep-vein thrombosis in symptomatic outpatients. , 1993, The New England journal of medicine.

[33]  C HISCOCK,et al.  EPIDEMICS OF TYPHOID FEVER. , 1964, Lancet.