Margaret Shyu

All Publications

• Equivalent thrombotic risk with Warfarin, Dabigatran, or Enoxaparin after failure of initial direct oral anticoagulation (DOAC) therapy. Journal of thrombosis and thrombolysis Shyu, M., Liu, A., Srikureja, A., Gregorian, A., Srisuwananukorn, A., Tremblay, D., Naymagon, L. 2024

  Abstract

  The direct oral anticoagulants (DOACs) are now commonly regarded as first line anticoagulants in most cases of venous thromboembolism (VTE). However, the optimal choice of subsequent anticoagulant in instances of first line DOAC failure is unclear.To describe and compare outcomes with second line anticoagulants used after DOAC failure.Patients seen at an urban hospital system for an episode of acute VTE initially treated with either apixaban or rivaroxaban who experienced a subsequent recurrent thrombosis while on anticoagulation (1st recurrent thrombosis) were included.In total, 166 patients after apixaban or rivaroxaban failure were included. Following DOAC failure (1st recurrent thrombosis), the subsequent anticoagulant was warfarin in 60 patients (36%), dabigatran in 42 patients (25%), and enoxaparin in 64 patients (39%). Enoxaparin was preferentially prescribed in patients with a malignancy-associated etiology for 1st recurrent thrombosis (p < 0.01). The median follow-up time in our cohort was 16 months. There was no difference in 2nd recurrent thrombosis-free survival (p = 0.72) or risk for major bleeding event (p = 0.30) among patients treated with dabigatran, warfarin, or enoxaparin.In this retrospective analysis of patients failing first line DOAC therapy, rates of 2nd recurrent thrombosis and bleeding did not differ among subsequently chosen anticoagulants. Our study provides evidence that the optimal 2nd anticoagulant is not clear, and the choice of 2nd anticoagulant should continue to balance patient preference, cost, and provider experience.

  View details for DOI 10.1007/s11239-024-02978-z

  View details for PubMedID 38643437

  View details for PubMedCentralID 7903232

• Analysis of Female Participant Representation in Registered Oncology Clinical Trials in the United States from 2008 to 2020. The oncologist Perera, N. D., Bellomo, T. R., Schmidt, W. M., Litt, H. K., Shyu, M., Stavins, M. A., Wang, M. M., Bell, A., Saleki, M., Wolf, K. I., Ionescu, R., Tao, J. J., Ji, S., O'Keefe, R. M., Pun, M., Takasugi, J. M., Steinberg, J. R., Go, R. S., Turner, B. E., Mahipal, A. 2023; 28 (6): 510-519

  Abstract

  Female underrepresentation in oncology clinical trials can result in outcome disparities. We evaluated female participant representation in US oncology trials by intervention type, cancer site, and funding.Data were extracted from the publicly available Aggregate Analysis of ClinicalTrials.gov database. Initially, 270,172 studies were identified. Following the exclusion of trials using Medical Subject Heading terms, manual review, those with incomplete status, non-US location, sex-specific organ cancers, or lacking participant sex data, 1650 trials consisting of 240,776 participants remained. The primary outcome was participation to prevalence ratio (PPR): percent females among trial participants divided by percent females in the disease population per US Surveillance, Epidemiology, and End Results Program data. PPRs of 0.8-1.2 reflect proportional female representation.Females represented 46.9% of participants (95% CI, 45.4-48.4); mean PPR for all trials was 0.912. Females were underrepresented in surgical (PPR 0.74) and other invasive (PPR 0.69) oncology trials. Among cancer sites, females were underrepresented in bladder (odds ratio [OR] 0.48, 95% CI 0.26-0.91, P = .02), head/neck (OR 0.44, 95% CI 0.29-0.68, P < .01), stomach (OR 0.40, 95% CI 0.23-0.70, P < .01), and esophageal (OR 0.40 95% CI 0.22-0.74, P < .01) trials. Hematologic (OR 1.78, 95% CI 1.09-1.82, P < .01) and pancreatic (OR 2.18, 95% CI 1.46-3.26, P < .01) trials had higher odds of proportional female representation. Industry-funded trials had greater odds of proportional female representation (OR 1.41, 95% CI 1.09-1.82, P = .01) than US government and academic-funded trials.Stakeholders should look to hematologic, pancreatic, and industry-funded cancer trials as exemplars of female participant representation and consider female representation when interpreting trial results.

  View details for DOI 10.1093/oncolo/oyad009

  View details for PubMedID 36848266

  View details for PubMedCentralID PMC10243778

• Critical Lessons From High-Value Oncology Practices JAMA ONCOLOGY Blayney, D. W., Simon, M. K., Podtschaske, B., Ramsey, S., Shyu, M., Lindquist, C., Milstein, A. 2018; 4 (2): 164–71

  Abstract

  Cancer care is expensive. Cancer care provided by practice organizations varies in total spending incurred by patients and payers during treatment episodes and in quality of care, and this unnecessary variation contributes to the high cost.To use the variation in total spending and quality of care to assess oncology practice attributes distinguishing "high value" that may be tested and adopted by others to produce similar results."Positive deviance" was used in this exploratory mixed-methods (quantitative and qualitative) analysis of interview results. To quantify value, oncology practices located near the US Pacific Northwest and Midwest with low mean insurer-allowed spending were identified. Among those, practices with high quality were selected. A team then conducted site visits to interview practice personnel from June 2, 2015, through October 3, 2015, and to probe for attributes of high-value care. A qualitative analysis of their interview results was performed, and a panel of experienced oncologists was convened to review attributes occurring uniquely or frequently in low-spending practices for their contribution to value improvement and ease of implementation. Four positive deviant (ie, low-spending) oncology practices and 3 oncology practices that ranked near the middle of the spending distribution were studied.Thematic saturation in a qualitative analysis of high-value care attributes.From the 7 oncology practices studied, 13 attributes within the following 5 themes emerged: treatment planning and goal setting, services supporting the patient journey, technical support and physical layout, care team organization and function, and external context. Five attributes (ie, conservative use of imaging, early discussion of treatment limitations and consequences, single point of contact, maximal use of registered nurses for interventions, and a multicomponent health care system) most sharply distinguished the high-value practice sites. The expert oncologist panel judged 3 attributes (ie, early and normalized palliative care, ambulatory rapid response, and early discussion of treatment limitations and consequences) to carry the highest immediate potential for lowering spending without compromising the quality of care.Oncology practice attributes warranting further testing were identified that may lower total spending for high-quality oncology care.

  View details for PubMedID 29145584

  View details for PubMedCentralID PMC5838576

• Decreased patency of transjugular intrahepatic portosystemic shunts performed for splanchnic vein thrombosis in patients with myeloproliferative neoplasms. Thrombosis research Shyu, M., Winters, A., Naymagon, L., Patel, R., Schiano, T. D., Tremblay, D. 2024; 234: 32-35

  View details for DOI 10.1016/j.thromres.2023.12.013

  View details for PubMedID 38154200

• An interdisciplinary student-led multifaceted intervention addressing overuse of broad-spectrum antibiotics for patients with penicillin allergies. Antimicrobial resistance and infection control Banashefski, B., Henson, P., David, N., Kok, H. T., Beerkens, F. J., Shyu, M., Linker, A. S., Tsega, S., Dunn, A., Fuller, R. 2023; 12 (1): 34

  Abstract

  Though 15% of hospitalized patients have a documented penicillin (PCN) allergy, fewer than 1% have an IgE-mediated reaction that necessitates avoidance of β-lactam antibiotics.Our interdisciplinary team of medical and nursing students led and executed a two-pronged quality improvement intervention to reduce prescribing of non-β-lactam antibiotics (NBLs) for patients with reported PCN allergies. To the best of our knowledge, this is the first multidisciplinary student-led intervention aimed at educating providers on low-risk penicillin allergy and encouraging best antibiotic prescribing practices.The intervention took place from June 2021 to February 2022. We developed and provided clinician education modules, including peer-to-peer information sharing and in-person small group discussions, as well as clinical decision support (CDS) strategies through the electronic medical record (EMR). The target population was attendings, residents, nurse practitioners, and physician assistants on the hospital medicine service at a large urban academic tertiary care center. We followed the SQUIRE 2.0 guidelines for reporting on quality improvement.Primary outcome measures included number of NBL prescriptions and use of nonspecific descriptors (e.g., "other" or "unknown") for PCN allergy reaction type, and were compared with a pre-intervention period.The percent of β-lactam prescriptions for patients with a PCN allergy after the intervention increased from 19 to 23% (p = 0.006). For patients with a low severity PCN allergy, the percent of β-lactam prescriptions increased from 20 to 28% (p = 0.001). There was a significant decrease in nonspecific PCN allergy reaction type from 23% in the pre-intervention period to 20% post-intervention (p = 0.012).An intervention focused on educating prescribers and CDS strategies delivered through the EMR increased appropriate β-lactam prescribing for patients with a documented low-risk PCN allergy and reduced the use of nonspecific PCN allergy reaction type in EMR documentation.

  View details for DOI 10.1186/s13756-023-01232-0

  View details for PubMedID 37061722

  View details for PubMedCentralID PMC10105531

• Analysing Monday discharges to identify lost opportunities for weekend discharge. Internal medicine journal Shyu, M., Golec, S., Anderson, J., Linker, A. S., Nguyen, V. T., Raucher, B., Dunn, A. 2023; 53 (4): 625-628

  Abstract

  Lower rates of hospital discharge occur on weekends compared with weekdays. The authors performed a retrospective chart review of Monday discharges from the Hospital Medicine service at an academic hospital over a 3-month period to identify reasons for delayed discharge despite medical stability. Of 202 eligible patients, 81 (40%) had documentation indicating stability for earlier discharge. Common causes included bed availability or insurance authorisation at a skilled nursing facility, home care services and patient/family disagreement with discharge.

  View details for DOI 10.1111/imj.16062

  View details for PubMedID 37186364

• Interventions to reduce repetitive ordering of low-value inpatient laboratory tests: a systematic review. BMJ open quality Yeshoua, B., Bowman, C., Dullea, J., Ditkowsky, J., Shyu, M., Lam, H., Zhao, W., Shin, J. Y., Dunn, A., Tsega, S., S Linker, A., Shah, M. 2023; 12 (1)

  Abstract

  Over-ordering of daily laboratory tests adversely affects patient care through hospital-acquired anaemia, patient discomfort, burden on front-line staff and unnecessary downstream testing. This remains a prevalent issue despite the 2013 Choosing Wisely recommendation to minimise unnecessary daily labs. We conducted a systematic review of the literature to identify interventions targeting unnecessary laboratory testing.We systematically searched MEDLINE, EMBASE, Cochrane Central and SCOPUS databases to identify interventions focused on reducing daily complete blood count, complete metabolic panel and basic metabolic panel labs. We defined interventions as 'effective' if a statistically significant reduction was attained and 'highly effective' if a reduction of ≥25% was attained.The search yielded 5646 studies with 41 articles that met inclusion criteria. We grouped interventions into one or more categories: audit and feedback, cost display, education, electronic medical record (EMR) change, and policy change. Most interventions lasted less than a year and used a multipronged approach. All five strategies were effective in most studies with EMR change being the most commonly used independent strategy. EMR change and policy change were the strategies most frequently reported as effective. EMR change was the strategy most frequently reported as highly effective.Our analysis identified five categories of interventions targeting daily laboratory testing. All categories were effective in most studies, with EMR change being most frequently highly effective.CRD42021254076.

  View details for DOI 10.1136/bmjoq-2022-002128

  View details for PubMedID 36958791

  View details for PubMedCentralID PMC10040017