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• W2087755429 abstract "The thought-provoking study by Nanchal et al1Nanchal R Kumar G Taneja A from the Milwaukee Initiative in Critical Care Outcomes Research (MICCOR) Group of Investigators et al.Pulmonary embolism: the weekend effect.Chest. 2012; 142: 690-696Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar in CHEST (September 2012) shows that patients admitted to the hospital with a principal diagnosis of pulmonary embolism (PE) during weekends have a significantly higher risk of in-hospital death than those admitted on weekdays (OR, 1.17; 95% CI, 1.11-1.22). The authors suggest that delayed access to inferior vena cava (IVC) filters during weekends might explain this finding. We believe that alternative interpretations merit consideration. As the authors rightly point out, weekend admissions represent only 21% of all admissions, instead of 28.5% (two out of seven). A simple and plausible interpretation for this finding is a selection bias: Some patients with the least severe clinical forms of PE delay the diagnostic workup (and eventual admission) up to the next working day, whereas patients with severe PEs cannot and do not. The significantly higher rate of severe PEs among weekend admissions (2.8% vs 2.3%, P < .05) supports this interpretation. Interestingly, if such a bias does exist, Mondays should be associated with the highest absolute number of admissions and the lowest death rate of the week, which could be called a “Monday effect.” Could the authors provide this information? The authors also suggest that delayed IVC filter placements could explain a higher death rate. However, it is far from established that filters, let alone the “timeliness” of filter placement, have an impact on mortality.2Decousus H Leizorovicz A Parent F et al.A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group.N Engl J Med. 1998; 338: 409-415Crossref PubMed Scopus (1536) Google Scholar, 3Monreal M Falgá C Valdés M RIETE Investigators et al.Fatal pulmonary embolism and fatal bleeding in cancer patients with venous thromboembolism: findings from the RIETE registry.J Thromb Haemost. 2006; 4: 1950-1956Crossref PubMed Scopus (178) Google Scholar, 4Kearon C Akl EA Comerota AJ et al.Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. 2010; 141: e419S-e494SGoogle Scholar, 5Spencer FA Bates SM Goldberg RJ et al.A population-based study of inferior vena cava filters in patients with acute venous thromboembolism.Arch Intern Med. 2010; 170: 1456-1462Crossref PubMed Scopus (87) Google Scholar Furthermore, as compared with European studies, the overall filter placement rate in this study (13.6%) is disturbingly high. In the Computerized Registry of Patients With VTE (RIETE), a mainly European database, only 2% of patients with VTE received an IVC filter as part of their initial treatment.3Monreal M Falgá C Valdés M RIETE Investigators et al.Fatal pulmonary embolism and fatal bleeding in cancer patients with venous thromboembolism: findings from the RIETE registry.J Thromb Haemost. 2006; 4: 1950-1956Crossref PubMed Scopus (178) Google Scholar The only two recommended indications for filter placement in patients with PE (ie, contraindications to curative anticoagulation and PE despite adequate anticoagulation)4Kearon C Akl EA Comerota AJ et al.Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. 2010; 141: e419S-e494SGoogle Scholar are unlikely to be more frequent in the United States than in Europe. Therefore, in the study by Nanchal et al,1Nanchal R Kumar G Taneja A from the Milwaukee Initiative in Critical Care Outcomes Research (MICCOR) Group of Investigators et al.Pulmonary embolism: the weekend effect.Chest. 2012; 142: 690-696Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar if a substantial proportion of the indications for filter placement in the population were questionable (eg, IVC filters in addition to anticoagulants4Kearon C Akl EA Comerota AJ et al.Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. 2010; 141: e419S-e494SGoogle Scholar), the prognostic impact of delayed placements would appear even more questionable. The increased mortality rate reported by Nanchal et al1Nanchal R Kumar G Taneja A from the Milwaukee Initiative in Critical Care Outcomes Research (MICCOR) Group of Investigators et al.Pulmonary embolism: the weekend effect.Chest. 2012; 142: 690-696Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar among weekend admissions for PE may represent real excess deaths. But more convincing arguments are needed to rule out a mere selection bias. And without precise information regarding the indications for filter placement and concurrent anticoagulant use, the timing of IVC filter insertions cannot be regarded as a reliable marker of the quality of care in patients with PE. Pulmonary Embolism: ResponseCHESTVol. 142Issue 4PreviewWe appreciate the interest demonstrated by Dr Girard and his colleagues in our work.1 We agree that we cannot completely rule out a selection bias as a mechanism of our findings and have acknowledged this in the “Limitations” section of our article. Despite robustly adjusting for severity of illness in our multivariable regression model, we cannot exclude residual confounding. The “Monday Effect,” or deferred care for relatively minor pulmonary embolism (PE), as suggested by Dr Girard and colleagues, is an interesting concept and deserves further study. Full-Text PDF" @default.
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• W2087755429 title "Pulmonary Embolism" @default.
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• W2087755429 doi "https://doi.org/10.1378/chest.12-1262" @default.
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