Real-world practices to prevent venous thromboembolism with pharmacological prophylaxis in US orthopedic surgery patients: an analysis of an integrated healthcare database

Abstract

Major orthopedic surgery patients are at high risk of venous thromboembolism (VTE) in-hospital and post-discharge. This study assessed real-world inpatient and outpatient thromboprophylaxis practices following knee or hip arthroplasty. Patients from the Henry Ford Health System aged ≥18 years undergoing knee and hip arthroplasty (January 1997-June 2007) were identified using Current Procedural Terminology codes from administrative databases. Patients with <18 months of continuous enrollment in the system's health maintenance organization or with a current diagnosis of atrial fibrillation were excluded. Both inpatient and outpatient pharmacological prophylaxis was assessed. The analysis included 1393 (58.5%) patients following knee arthroplasty and 989 (41.5%) following hip arthroplasty. Average length of hospitalization was 4.9 days over the study period, although the median stay decreased from 5 days in 1997 to 3 days in 2007. Of patients included, 72.7% received pharmacological prophylaxis only in the inpatient setting following knee arthroplasty and 73.9% following hip arthroplasty. Both inpatient and outpatient pharmacological prophylaxis was received by 12.5% of knee and 12.3% of hip arthroplasty patients. Total length of pharmacological prophylaxis fluctuated between 2 to 4 days between 1997 and 2005, but increased to 11.5 ± 9.0 days in 2007. Although the duration of prophylaxis has recently increased, considerable numbers of hip and knee arthroplasty patients only receive prophylaxis for part of the time period recommended by guidelines. Further efforts are required to ensure the recommended duration of thromboprophylaxis is prescribed to all patients and continued outpatient VTE prophylaxis is provided.

Thromboprophylaxis after major orthopedic surgery: Improving compliance with clinical practice guidelines

“…Rates of compliance to CPGs recommendations are typically described between 40 and 54% [5,16,18]. However, in a study carried out by Merli et al, adherence to CPG was reported to be around 12% [19]. Compliance to CPGs.…”

“…This program included: 1. Definition of performance indicators, 2. establishment of a baseline of the rate of compliance (February 2012), 3. implementation of improvement strategies [17][18][19], and 4. systematic monitoring of performance indicators (February 2012 to August 2014).…”

Inpatient and Outpatient Occurrence of Deep Vein Thrombosis and Pulmonary Embolism and Thromboprophylaxis Following Selected At-Risk Surgeries

“…These results are consistent with a recent study by Merli et aI., in which an increase in the lengthof prophylaxis duration was observedover the years from 2 to 4 days between 1997 and 2005 and to 115 (9.0)days in 2007. 20 The 8th edition of the ACCP guidelines recommends continuing thromboprophylaxisfor up to 35 daysin patients undergoing hipreplacement or hip fracture surgery, as wellas those undergoing knee replacement surgery.' In a meta-analysis,extended-duration thromboprophylaxis of 30-42 days was associated with significant reduction in the likelihood of symptomatic DVTIPE compared withstandard-duration thromboprophylaxis in patientsundergoing elective totalhip or knee replacement (OR 0.38; 95% CI 0.24 to 0.61),without an increased riskof major bleeding," Furthermore, extended-duration thromboprophylaxis has been found to be cost-effective, because increased pharmacy costs wereoffset by reductions in DVTIPE eventsand theassociated costs of'hospitalization.…”

Primary Joint Arthroplasty Surgery: Is the Risk of Major Bleeding Higher in Elderly Patients? A Retrospective Cohort Study

“…The use prophylactic anticoagulant agents is one of the most effective strategies to prevent the onset of venous thromboembolism following major orthopedic surgery (1)(2)(3)(4). However, thromboprophylaxis has been associated with an increased risk of major bleeding, intracranial bleeding and fatal bleeding (5-7).…”