Need to improve thromboprophylaxis across the continuum of care for surgical patients
Prophylaxis for venous thromboembolism (VTE) is underused following major surgery and frequently stopped at hospital discharge despite short stays and high VTE risk for several weeks postsurgery. We evaluated inpatient and postdischarge prophylaxis in patients who underwent major abdominal or orthopedic surgery.
Patient records were assessed for anticoagulant use by cross-matching data from the Premier’s Perspective™ discharge database with the i3/Ingenix LabRx outpatient and inpatient database from January 2005 to December 2007. Abdominal or orthopedic surgery patients at risk of VTE according to the 2004 American College of Chest Physicians guidelines and with no contraindications to anticoagulation were included.
A total of 14,009 eligible surgical discharges were analyzed. Only 27.9% of the 10,698 abdominal surgery patients received anticoagulation in hospital. Most inpatients received unfractionated heparin (12.3% of the total abdominal surgery population) or enoxaparin (11.8%). Of the 3311 orthopedic surgery patients, 91.1% received in-hospital anticoagulation. Similar proportions of patients received enoxaparin (32.1%), warfarin (31.1%), or other agents (28.0%). Only 1.2% of abdominal surgery patients had an anticoagulant prescription filled 30 days postdischarge. Although orthopedic surgery outpatients had higher anticoagulation rates, only 54.4% had filled a prescription 30 days postdischarge with 31.1% receiving warfarin, 18.5% receiving enoxaparin, and 4.8% receiving other anticoagulants. The higher prophylaxis rate in orthopedic patients may reflect the high VTE risk in orthopedic surgery patients and increased awareness among orthopedic surgeons.
This real-world study highlights the underuse of thromboprophylaxis in hospitalized surgical patients, especially following abdominal surgery. Furthermore, a considerable proportion of these patients do not receive postdischarge anticoagulation despite guideline recommendations. Further efforts are needed to improve anticoagulant use, particularly in the outpatient setting.
- Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 suppl.):381S–453S. CrossRef
- Anderson FA Jr, Zayaruzny M, Heit JA, Fidan D, Cohen AT. Estimated annual numbers of US acute-care hospital patients at risk for venous thromboembolism. Am J Hematol. 2007;82:777–782. CrossRef
- US Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. September 15, 2008. Available at: www. surgeongeneral.gov/topics/deepvein/calltoaction/call-to-action-on-dvt-2008.pdf. Accessed: February 23, 2010.
- Centers for Medicare and Medicaid Services. Reporting Hospital Quality Data for Annual Payment Update. Available at: www.cms.hhs.gov/HospitalQualityInits/08_HospitalRHQDAPU.asp. Accessed February 23, 2010.
- HCUP NIS Related Reports. Healthcare Cost and Utilization Project (HCUP). September 2008. Agency for Healthcare Research and Quality, Rockville, MD. Available at: www.hcup-us.ahrq. gov/db/nation/nis/nisrelatedreports.jsp. Accessed February 23, 2010.
- Anderson FA Jr., Hirsh J, White K, Fitzgerald RH Jr.; Hip and Knee Registry Investigators. Temporal trends in prevention of venous thromboembolism following primary total hip or knee arthroplasty 1996–2001: findings from the Hip and Knee Registry. Chest. 2003;124:349S–356S. CrossRef
- Spyropoulos AC, Hussein M, Lin J, Battleman D. Rates of symptomatic venous thromboembolism in US surgical patients: a retrospective administrative database study. J Thromb Thrombolysis. 2009;28:458–464. CrossRef
- Eriksson BI, Lassen MR; PENTasaccharide in HIp-FRActure Surgery Plus Investigators. Duration of prophylaxis against venous thromboembolism with fondaparinux after hip fracture surgery: a multicenter, randomized, placebo-controlled, double-blind study. Arch Intern Med. 2003;163:1337–1342. CrossRef
- Dahl OE, Gudmundsen TE, Haukeland L. Late occurring clinical deep vein thrombosis in joint operated patients. Acta Orthop Scand. 2000;71:47–50. CrossRef
- White RH, Romano PS, Zhou H, Rodrigo J, Bargar W. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med. 1998;158:1525–1531. CrossRef
- Planes A, Vochelle N, Darmon JY, Fagola M, Bellaud M, Huet Y. Risk of deep-venous thrombosis after hospital discharge in patients undergoing total hip replacement: double-blind randomised comparison of enoxaparin versus placebo. Lancet. 1996;348:224–228. CrossRef
- Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet. 2008;371:387–394. CrossRef
- Yu HT, Dylan ML, Lin J, Dubois RW. Hospitals’ compliance with prophylaxis guidelines for venous thromboembolism. Am J Health Syst Pharm. 2007;64:69–76. CrossRef
- Amin AN, Stemkowski S, Lin J, Yang G. Preventing venous thromboembolism in US hospitals: are surgical patients receiving appropriate prophylaxis? Thromb Haemost. 2008;99:796–797.
- Amin A, Stemkowski S, Lin J, Yang G. Appropriate thromboprophylaxis in hospitalized cancer patients. Clin Adv Hematol Oncol. 2008;6:910–920.
- Amin A, Spyropoulos AC, Dobesh P, et al. Are hospitals delivering appropriate VTE prevention? The venous thromboembolism study to assess the rate of thromboprophylaxis (VTE start). J Thromb Thrombolysis. 2010;29:326–339. CrossRef
- Tapson VF, Decousus H, Pini M, et al. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest. 2007;132:936–945. CrossRef
- Rahme E, Dasgupta K, Burman M, et al. Postdischarge thromboprophylaxis and mortality risk after hip- or knee-replacement surgery. CMAJ. 2008;178:1545–1554.
- Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 suppl.):338S–400S. CrossRef
- Spencer FA, Lessard D, Emery C, Reed G, Goldberg RJ. Venous thromboembolism in the outpatient setting. Arch Intern Med. 2007;167:1471–1475. CrossRef
- Lassen MR, Borris LC, Anderson BS, et al. Efficacy and safety of prolonged thromboprophylaxis with low molecular weight heparin (dalteparin) after total hip arthroplasty — the Danish Prolonged Prophylaxis (DaPP) Study. Thromb Res. 1998;89:281–287. CrossRef
- Dahl OE, Andreassen G, Aspelin T, et al. Prolonged thromboprophylaxis following hip replacement surgery — results of a double-blind, prospective, randomised, placebo-controlled study with dalteparin (Fragmin). Thromb Haemost. 1997;77:26–31.
- Bergqvist D, Benoni G, Björgell O, et al. Low-molecular-weight heparin (enoxaparin) as prophylaxis against venous thromboembolism after total hip replacement. N Engl J Med. 1996;335:696–700. CrossRef
- Hull RD, Pineo GF, Stein PD, et al. Extended out-ofhospital low-molecular-weight heparin prophylaxis against deep venous thrombosis in patients after elective hip arthroplasty: a systematic review. Ann Intern Med. 2001;135:858–869.
- Eikelboom JW, Quinlan DJ, Douketis JD. Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomized trials. Lancet. 2001;358:9–15. CrossRef
- Rasmussen MS, Jorgensen LN, Wille-Jørgensen P, et al. Prolonged prophylaxis with dalteparin to prevent late thromboembolic complications in patients undergoing major abdominal surgery: a multicenter randomized open-label study. J Thromb Haemost. 2006;4:2384–2390. CrossRef
- Rasmussen MS, Jørgensen LN, Wille-Jørgensen P. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev. 2009;(1):CD004318.
- Bergqvist D, Agnelli G, Cohen AT, et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med. 2002;346:975–980. CrossRef
- Huo MH, Muntz J. Extended thromboprophylaxis with low-molecular-weight heparins after hospital discharge in high-risk surgical and medical patients: a review. Clin Ther. 2009;31:1129–1141. CrossRef
- Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 suppl.):160S–198S. CrossRef
- Schuringa P, Yen D. Home prophylactic warfarin anticoagulation program after hip and knee arthroplasty. Can J Surg. 1999;42:360–362.
- Hirsh J, Bauer KA, Donati MB, et al. Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 suppl.):141S–159S. CrossRef
- Colorado Foundation for Medical Care. Surgical Care Improvement Project (SCIP). Available at: www.cfmc.org/hospital/hospital_scip.htm. Accessed February 23, 2010.
- National Quality Forum. NQF-Endorsed® Standards. Available at: www.qualityforum.org/Measures_List.aspx. Accessed February 23, 2010.
- The Joint Commission. Performance Measurement Initiatives. Venous Thromboembolism (VTE) Core Measures Set. Last updated 4/2009. Available at: www. jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/VTE.htm. Accessed February 23, 2010.
- Need to improve thromboprophylaxis across the continuum of care for surgical patients
Advances in Therapy
Volume 27, Issue 2 , pp 81-93
- Cover Date
- Print ISSN
- Online ISSN
- Springer Healthcare Communications
- Additional Links
- abdominal surgery
- orthopedic surgery
- venous thromboembolism
- Industry Sectors