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Rahul Nanchal, MD, FCCP; Gagan Kumar, MD; Jeff Whittle, MD, MPH; From the Milwaukee Initiative in Critical Care Outcomes Research (MICCOR) Group of Investigators
Author and Funding Information

From the Department of Medicine, Division of Pulmonary and Critical Care Medicine (Drs Nanchal and Kumar), and the Division of General Internal Medicine (Dr Whittle), Medical College of Wisconsin; and the Primary Care Division (Dr Whittle), Clement J. Zablocki VA Medical Center.

Correspondence to: Rahul Nanchal, MD, FCCP, Department of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226; e-mail: rnanchal@mcw.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(4):1074. doi:10.1378/chest.12-1408
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To the Editor:

We 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. Unfortunately, our data sources do not allow us to make such a determination. The National Inpatient Sample has a variable that indicates whether the admission was on a weekday or weekend but not for specific days of the week. However, it is unlikely that this phenomenon is solely responsible for our findings. Delaying care for a potential life-threatening disease, by up to >2 days in some cases, would lead to an increase in severity of illness and by extension mortality on weekdays in at least some such people. This would bias our results toward finding no differences in mortality between weekends and weekdays.

In our article, we did not mean to suggest that delays in inferior vena cava filter placement might be the direct cause of observed differences in mortality; indeed, we agree with Dr Girard and colleagues that they are unlikely to be a reliable marker of quality of care in acute PE. Rather, we suggest that differences in timeliness of placement may be a surrogate for delays in other processes of care that possibly affect mortality, for example, delays in achievement of anticoagulation targets or impediments in diagnosis via belated performance of CT scan angiography. The proportion of people receiving inferior vena cava filters in our study is consistent with other investigations in the United States.2 We cannot, however, determine the appropriateness of the indication for such placement. Differences in findings of the Computerized Registry of Patients With VTE (RIETE) and our study may partly arise from the fact that RIETE includes patients with VTE, whereas we restricted our attention to people with PE only.

Nanchal R, Kumar G, Taneja A, et al;; from the Milwaukee Initiative in Critical Care Outcomes Research (MICCOR) Group of Investigators from the Milwaukee Initiative in Critical Care Outcomes Research (MICCOR) Group of Investigators. Pulmonary embolism: the weekend effect. Chest. 2012;142(3):690-696. [PubMed] [CrossRef]
 
Spencer 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(16):1456-1462.
 

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Nanchal R, Kumar G, Taneja A, et al;; from the Milwaukee Initiative in Critical Care Outcomes Research (MICCOR) Group of Investigators from the Milwaukee Initiative in Critical Care Outcomes Research (MICCOR) Group of Investigators. Pulmonary embolism: the weekend effect. Chest. 2012;142(3):690-696. [PubMed] [CrossRef]
 
Spencer 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(16):1456-1462.
 
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