Is there adequate provision of venous thrombo-embolism prophylaxis following hip arthroplasty? An audit and international survey

Abstract

INTRODUCTIONThe peak incidence of venous thrombo-embolism (VTE) occurs 3 weeks following hip arthroplasty surgery and current guidelines proposing VTE prophylaxis continuing for 4 weeks after surgery. This study first compares the duration of treatment and satisfaction between patients prescribed low molecular weight heparin (LMWH) and rivaroxaban, a new oral Factor Xa inhibitor, following elective hip arthroplasty; and second, surveys the duration of LMWH use in other units. SUBJECTS AND METHODS An international survey detailing the use of LMWH was performed. A prospective audit was performed of 100 hip replacements, with 50 prescribed 40 mg once daily of subcutaneous enoxaparin and subsequently 50 patients prescribed 10 mg once daily of oral rivaroxaban. The duration of treatment, patient satisfaction and complications for both cohorts was quantified and compared against published evidence-based guidelines. RESULTS The survey demonstrated that four out of 39 (10.2%) units that routinely prescribe LMWH do so for at least 4 weeks following surgery. The audit demonstrated that rivaroxaban afforded a superior mean duration of postoperative VTE prophylaxis (35 days vs 5.4 days; P < 0.05) and superior patient satisfaction. There was no difference in the incidence of bleeding, wound infection or thrombotic complications. CONCLUSIONS This study demonstrates that patients are exposed to an increased VTE risk following hip replacement surgery due to the inadequate prescription of LMWH. This is poor clinical practice, contrary to current evidence-based guidelines and has potential medicolegal implications. The prescription of rivaroxaban affords a superior patient compliance compared with subcutaneous LMWH, thus ensuring that patients receive VTE prophylaxis for the current recommend period of time.

Thromboprophylaxis following hip and knee arthroplasty

“…182,197 Patient compliance and a lack of time to refer to protocols in practice were also identified as potential barriers to protocol uptake.…”

A multi-perspective cost-effectiveness analysis comparing rivaroxaban with enoxaparin sodium for thromboprophylaxis after total hip and knee replacement in the German healthcare setting

“…Furthermore, we did not consider intangible costs such as patients’ greater satisfaction with the oral administration of rivaroxaban resulting in better drug compliance [42]. As increased compliance would also decrease the number of post-operative VTE complications, our model may even underestimate cost savings with rivaroxaban prophylaxis.…”

A 12 month review of a modified protocol using low dose Dabigatran Etexilate in postoperative thromboembolic prophylaxis in joint replacement surgery

“…Previously numerous anticoagulant regimes ceased on discharge of the patient, around day 5 post operatively [5,13,14]. One of the NICE recommended anticoagulants was Dabigatran Etexilate (Boehringer Ingelheim), which is an oral direct thrombin inhibitor.…”

“…Patient compliance is greater [4,5], and one can postulate the VTE prophylactic effect for ones patient population will be greater if they are actually taking the medicine.…”

“…We were keen on the advantages of an oral anticoagulant post hip or knee arthroplasty in terms of patient compliance [4,5], and avoiding the need for self administered injection in the community. Dabigatran Etexilate (hereafter termed Dabigatran) has been tested in large clinical trials and has been shown to have equivalent effectiveness to subcutaneous Enoxaparin, and to be similar in terms of safety and side effect profile [6-9].…”