A. Mukkamala1, J. R. Montgomery1, A. De Roo1, S. E. Regenbogen1 1University Of Michigan,Surgery, Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA
Introduction: Since 2012, the American College of Chest Physicians (ACCP) has recommended 4 weeks of pharmacologic prophylaxis against venous thromboembolism (VTE) after abdominopelvic cancer surgery. Additionally, there is growing expert consensus favoring extended prophylaxis after surgery for inflammatory bowel disease (IBD). National studies have revealed very low uptake of prophylaxis before adoption of the ACCP guideline, but it remains unclear to what extent it has been adopted in standard practice in recent years. We sought to understand responsiveness to guidelines versus expert opinion by evaluating adherence to extended VTE prophylaxis after colectomy in a statewide registry.
Methods: We identified all patients in the Michigan Surgical Quality Collaborative (MSQC) registry who underwent elective colon or rectal resection between October 2015 (when MSQC first began recording post-discharge VTE prophylaxis) and February 2018. MSQC is an audited and validated, statewide population-based surgical registry including all major acute care hospitals in the state. We used descriptive statistics and chi-square tests to compare annual statewide utilization trends for extended VTE prophylaxis with low molecular weight heparin by operative year and by diagnosis among all patients without documented exclusions.
Results: Of 5722 eligible patients, 373 (6.5%) received extended VTE prophylaxis after discharge. Use of extended prophylaxis was similar between patients with cancer (282/1945, 14.5%) and IBD (31/242, 12.8%), but was significantly increased when compared with patients with other indications (60/3051, 1.97%, p<0.001). Overall use during the study period significantly increased among cancer patients from 8.2% in 2015 to 9.0% in 2016 to 18.6% in 2017-18 (p=0.001). Use among IBD patients also significantly increased from 0% to 6.6% to 17.1% (p=0.03). Use among patients with other diagnoses was rare and did not vary over the study period (1.5 to 2.4%, p=0.50). Annual trends are shown in Figure 1.
Conclusion: Use of extended VTE prophylaxis after discharge is increasing, but remains uncommon in spite of guidelines recommending its use for colorectal cancer surgery and expert consensus supporting its use in IBD. Efforts to improve dissemination of guidelines and recommendations may require quality implementation initiatives accompanied by payment incentives to improve adherence.
