Advertisement

Annals of Surgical Oncology

, Volume 23, Issue 5, pp 1431–1439 | Cite as

Variation in Hospital Thromboprophylaxis Practices for Abdominal Cancer Surgery

  • Robert W. Krell
  • Christopher P. ScallyEmail author
  • Sandra L. Wong
  • Zaid M. Abdelsattar
  • Nancy J. O. Birkmeyer
  • Kelsey Fegan
  • Joanne Todd
  • Peter K. Henke
  • Darrell A. Campbell
  • Samantha Hendren
Healthcare Policy and Outcomes

Abstract

Introduction

Venous thromboembolism remains a prominent cause of morbidity and mortality following cancer surgery. Although evidence-based guidelines recommend major cancer surgery thromboprophylaxis starts before incision and continues at least 7–10 days postoperatively, the extent to which the guidelines are followed is unknown. We assessed variation in thromboprophylaxis practices for abdominal cancer surgery in a regional surgical collaborative.

Methods

We studied abdominal resections for primary gastrointestinal, hepatopancreatobiliary (HPB), and neuroendocrine malignancies in the Michigan Surgical Quality Collaborative from July 2012 to September 2013 (N = 2967 patients in 52 hospitals). We obtained detailed perioperative and postoperative pharmacologic and mechanical thromboprophylaxis information for patients without documented exemptions (e.g., active bleeding, allergy), and compared differences in procedure mix and operative complexity across hospitals based on their perioperative thromboprophylaxis rates. Additionally, we surveyed hospitals to identify variations in perioperative practice and barriers to prophylaxis administration.

Results

Overall, 40.4 % of eligible patients had perioperative pharmacologic thromboprophylaxis for abdominal cancer surgery, and 25.3 % of the highest-risk patients had evidence of inadequate postoperative prophylaxis (under-prophylaxis, either by dose or duration). Hospital perioperative thromboprophylaxis rates ranged from 0 to 96.1 %, and postoperative thromboprophylaxis rates ranged from 73.9 to 100 %. Epidural use was not independently associated with hospital pharmacologic thromboprophylaxis rates.

Conclusions

Fewer than half of patients undergoing abdominal cancer surgery receive perioperative thromboprophylaxis, and there is wide variation in hospital thromboprophylaxis utilization despite strong evidence-based guidelines supporting its use.

Keywords

Pharmacologic Prophylaxis Pharmacologic Thromboprophylaxis Postoperative Prophylaxis Preoperative Prophylaxis Cancer Surgery Patient 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

Robert W. Krell and Christopher P. Scally receive support from the National Institutes of Health grant 5T32CA009672. The funding organizations had no role in the concept or design of the study, the collection, analysis or interpretation of the data, or the drafting or review of the manuscript.

Conflicts of interest

Robert W. Krell received payment from BCBSM for data entry unrelated to the submitted work. Christopher P. Scally, Sandra L. Wong, Zaid M. Abdelsattar, Nancy J.O. Birkmeyer, Kelsey Fegan, Joanne Todd, Peter K. Henke, Darrell A. Campbell, and Samantha Hendren have no conflicts of interest to disclose.

References

  1. 1.
    Auer RA, Scheer AS, McSparron JI, et al. Postoperative venous thromboembolism predicts survival in cancer patients. Ann Surg. 2012;255(5):963-970.CrossRefPubMedGoogle Scholar
  2. 2.
    Kakkar AK, Haas S, Wolf H, Encke A. Evaluation of perioperative fatal pulmonary embolism and death in cancer surgical patients: the MC-4 cancer substudy. Thromb Haemost. 2005;94(4):867-871.PubMedGoogle Scholar
  3. 3.
    Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med. 1988;318(18):1162-1173.CrossRefPubMedGoogle Scholar
  4. 4.
    Mismetti P, Laporte S, Darmon JY, Buchmuller A, Decousus H. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery. Br J Surg. 2001;88(7):913-930.CrossRefPubMedGoogle Scholar
  5. 5.
    Farge D, Debourdeau P, Beckers M, et al. International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. J Thromb Haemost. 2013;11(1):56-70.CrossRefPubMedGoogle Scholar
  6. 6.
    Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(17):2189-2204.CrossRefPubMedGoogle Scholar
  7. 7.
    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(9610):387-394.CrossRefPubMedGoogle Scholar
  8. 8.
    Merkow RP, Bilimoria KY, McCarter MD, et al. Post-discharge venous thromboembolism after cancer surgery: extending the case for extended prophylaxis. Ann Surg. 2011;254(1):131-137.CrossRefPubMedGoogle Scholar
  9. 9.
    Schleyer AM, Schreuder AB, Jarman KM, Logerfo JP, Goss JR. Adherence to guideline-directed venous thromboembolism prophylaxis among medical and surgical inpatients at 33 academic medical centers in the United States. Am J Med Qual. 2011;26(3):174-180.CrossRefPubMedGoogle Scholar
  10. 10.
    Merkow RP, Bilimoria KY, Sohn MW, et al. Adherence with postdischarge venous thromboembolism chemoprophylaxis recommendations after colorectal cancer surgery among elderly Medicare beneficiaries. Ann Surg. 2014;260(1):103-108.CrossRefPubMedGoogle Scholar
  11. 11.
    Michigan Surgical Quality Collaborative. Available at: http://www.msqc.org. Accessed 8 Sep 2014.
  12. 12.
    Campbell DA Jr, Englesbe MJ, Kubus JJ, et al. Accelerating the pace of surgical quality improvement: the power of hospital collaboration. Arch Surg. 2010;145(10):985-991.CrossRefPubMedGoogle Scholar
  13. 13.
    Pannucci CJ, Laird S, Dimick JB, Campbell DA, Henke PK. A validated risk model to predict 90-day VTE events in postsurgical patients. Chest. 2014;145(3):567-573.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e195S-226S.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Kahn SR, Morrison DR, Cohen JM, et al. Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism. Cochrane Database Syst Reviews. 2013. doi: 10.1002/14651858.CD008201.pub2 Google Scholar
  16. 16.
    Tapson VF, Hyers TM, Waldo AL, et al. Antithrombotic therapy practices in US hospitals in an era of practice guidelines. Arch Intern Med. 2005;165(13):1458-1464.CrossRefPubMedGoogle Scholar
  17. 17.
    Yu HT, Dylan ML, Lin J, Dubois RW. Hospitals’ compliance with prophylaxis guidelines for venous thromboembolism. Am J Health Syst Pharm. 2007;64(1):69-76.CrossRefPubMedGoogle Scholar
  18. 18.
    Hammond J, Kozma C, Hart JC, et al. Rates of venous thromboembolism among patients with major surgery for cancer. Ann Surg Oncol. 2011;18(12):3240-3247.CrossRefPubMedGoogle Scholar
  19. 19.
    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(13):975-980.CrossRefPubMedGoogle Scholar
  20. 20.
    Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458-1465.CrossRefPubMedGoogle Scholar
  21. 21.
    Bilimoria KY, Chung J, Ju MH, et al. Evaluation of surveillance bias and the validity of the venous thromboembolism quality measure. JAMA. 2013;310(14):1482-1489.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2015

Authors and Affiliations

  • Robert W. Krell
    • 1
    • 2
  • Christopher P. Scally
    • 1
    • 2
    Email author
  • Sandra L. Wong
    • 1
    • 2
  • Zaid M. Abdelsattar
    • 1
    • 2
  • Nancy J. O. Birkmeyer
    • 1
    • 2
  • Kelsey Fegan
    • 1
    • 2
  • Joanne Todd
    • 1
    • 2
  • Peter K. Henke
    • 1
    • 2
  • Darrell A. Campbell
    • 1
    • 2
  • Samantha Hendren
    • 1
    • 2
  1. 1.University of Michigan Health SystemAnn ArborUSA
  2. 2.Center for Healthcare Outcomes and Policy (CHOP)Ann ArborUSA

Personalised recommendations