How reliable is perioperative anticoagulant management? Determining guideline compliance and practice variation by a retrospective patient record review

Abstract

ObjectivesSurgery in patients on anticoagulants requires careful monitoring and risk assessment to prevent harm. Required interruptions of anticoagulants and deciding whether to use bridging anticoagulation add further complexity. This process, known as perioperative anticoagulant management (PAM), is optimised by using guidelines. Optimal PAM prevents thromboembolic and bleeding complications. The purpose of this study was to assess the reliability of PAM practice in Dutch hospitals. Additionally, the variations between hospitals and different bridging dosages were studied.DesignA multicentre retrospective patient record review.Setting and participantsRecords from 268 patients using vitamin-K antagonist (VKA) anticoagulants who underwent surgery in a representative random sample of 13 Dutch hospitals were reviewed, 259 were analysed.Primary and secondary outcome measuresOur primary outcome measure was the reliability of PAM expressed as the percentage of patients receiving guideline compliant care. Seven PAM steps were included. Secondary outcome measures included different bridging dosages used and an analysis of practice variation on the hospital level.ResultsPreoperative compliance was lowest for timely VKA interruptions: 58.8% (95% CI 50.0% to 67.7%) and highest for timely preoperative assessments: 81% (95% CI 75.0% to 86.5%). Postoperative compliance was lowest for timely VKA restarts: 39.9% (95% CI 33.1% to 46.7%) and highest for the decision to apply bridging: 68.5% (95% CI 62.3% to 74.8%). Variation in compliance between hospitals was present for the timely preoperative assessment (range 41%–100%), international normalised ratio testing (range 21%–94%) and postoperative bridging (range 20%–88%). Subtherapeutic bridging was used in 50.5% of patients and increased with patients’ weight.ConclusionsUnsatisfying compliance for most PAM steps, reflect suboptimal reliability of PAM. Furthermore, the hospital performance varied. This increases the risk for adverse events, warranting quality improvement. The development of process measures can help but will be complicated by the availability of a strong supporting evidence base and integrated care delivery regarding PAM.

Potential for a Virtual Care Model in the Perioperative Management of Anticoagulant Therapy: A 5-Year Retrospective Clinic Review

“…However, the makeup of patients in this clinic appears representative in terms of clinical indications for anticoagulation (i.e., AF > VTE > MHV) as other anticoagulation clinic settings. 19 20 Moreover, the surgeries/procedures patients underwent, with the majority being low-/moderate-bleed-risk surgeries/procedures, are consistent with that observed in studies involving unselected patients who are receiving a DOAC or VKA. 5 7 8 Third, we may have underestimated the proportion of patients who require heparin bridging as this was limited to warfarin-treated patients with an MHV and we did not include warfarin-treated patients with AF or VTE.…”

“…It is possible that a virtual model of care would be less applicable, for example in clinics that assess predominantly patients with a MHV in whom heparin bridging may be more widely used. However, the make-up of patients in this clinic appears representative in terms of clinical indications for anticoagulation (i.e., AF > VTE > MHV) as other anticoagulation clinic settings 19,20 . Moreover, the surgeries/procedures patients underwent, with the majority being low/moderate-bleed-risk, is consistent with that observed in studies involving unselected patients who are receiving a DOAC or VKA 5,7,8 .…”

Compliance to perioperative anticoagulation protocols in elderly patients undergoing elective orthopedic procedures: a retrospective observational cohort study on 548 patients

“…Previous studies on noncompliance with perioperative anticoagulation management guidelines have shown poor compliance, similar to the results found in our study [ 19 – 22 ]. Moesker et al described guidelines compliance of 40–81%, depending on the step of the perioperative anticoagulation management [ 21 , 22 ]. Contrary to our study, they found that the incidence of guidelines noncompliance was highest in the postoperative steps when VKA therapy was reinitiated.…”

Physicians' adherence to evidence‐based guidelines as a major predictor of anticoagulant‐related medication error incidence and severity

“…This finding was confirmed with our ordinal logistic regression analysis (Table 5) that predicted a positive association of more than 24‐fold between physicians' non‐adherence to evidence‐based guidelines and the medication error severity compared to the full or partial adherence group. While no studies investigated physician adherence to guidelines as a predictor of the incidence and severity of medication errors, Moesker et al 29 concluded that physician adherence to perioperative anticoagulant management guidelines is “suboptimal”, which leads to increased risk of adverse events inflicted upon patients, and recommended further procedures to increase physician compliance. Haque and his colleagues 30 reported a necessity to help healthcare providers adhere to direct oral anticoagulant guidelines through prescribing aid tools.…”