S. J. Layne2, E. A. Bailey1, R. R. Kelz1, C. M. Vollmer1 1University Of Pennsylvania,Center For Surgery And Health Economics, Department Of Surgery,Philadelphia, PA, USA 2Perelman School Of Medicine At The University Of Pennsylvania,Philadelphia, PA, USA
Introduction: National guidelines recommend that physicians prescribe 4 weeks of extended venous thromboembolism (VTE) prophylaxis to high-risk patients who have undergone major abdominal or pelvic surgery for cancer. Despite growing evidence in support of these guidelines, recent studies continue to find low rates of adherence. While factors contributing to low adherence have not been directly evaluated, many barriers have been suggested including high cost, inadequate insurance coverage, and physician perceptions and prescribing patterns. This study evaluates the results of a local quality improvement (QI) initiative to increase appropriate use of extended VTE prophylaxis and the subsequent out of pocket (OOP) cost to patients.
Methods: We performed a retrospective cohort study of all high-risk patients (Caprini score >=5) who underwent surgery for cancer on our hepatobiliary surgery service between February and June 2016. This period encompassed 2 months before and 3 months after initiation of a formal extended prophylaxis protocol (EPP) in April 2016. We used the Wilcoxon test to compare the percentage of eligible patients who were appropriately prescribed extended prophylaxis at discharge before and after this intervention. The incidence of DVT, PE and bleeding events were compared before and after initiation of the EPP. Descriptive statistics were performed to assess the OOP cost to patients.
Results: 63 high-risk patients underwent abdominal surgery for cancer during the study period. 52 patients remained in the final study cohort. Prior to the QI intervention, 3 out of 20 eligible patients (15.0%) received extended prophylaxis at discharge. In the post-intervention period, 78% of patients (25/32) were prescribed extended prophylaxis representing a significant increase in adherence to the guidelines (p<0.001) (Figure 1). In both pre- and post-intervention groups, no DVT, PE, or bleeding events occurred after discharge. The median OOP cost required for patients to fill their lovenox prescription was $20 although reported costs ranged from $0-$565 (IQR [$10,$101]. Only 1 patient in the post-intervention period refused extended prophylaxis due to prohibitively high OOP cost.
Conclusion: Adherence to extended VTE prophylaxis guidelines improved from 15% to 78% during the study. We were unable to show an overall reduction in VTE events due to our small sample size. Out of pocket cost to the patient for extended prophylaxis was relatively low and did not pose a significant patient-driven barrier.
