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Williamson TK, Martinez VH, Aziz AW, Kotzur T, Verlinsky L, Buttacavoli FA. Aspirin in prevention of venous thromboembolism following hip fracture surgery: A systematic review and meta-analysis. J Orthop 2024; 58:75-81. [PMID: 39070114 PMCID: PMC11269802 DOI: 10.1016/j.jor.2024.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/30/2024] Open
Abstract
Background Many orthopaedic surgeons routinely prescribe aspirin (ASA) as prophylaxis for venous thromboembolism (VTE) following hip fracture surgery (HFS). The purpose of this study is to assess the effectiveness of aspirin to other agents in preventing VTE and mortality following hip fracture surgery. Methods Following PRISMA guidelines, we performed a search for HFS studies from 1998 to 2023 reporting comparisons between aspirin and other chemoprophylaxis methods for VTE (DVT - deep vein thrombosis; PE - pulmonary embolism). SPSS Meta-analysis function was used to calculate Mean Effect Size Estimate (MESE) and 95 % Confidence Intervals for each outcome. Reverse Fragility Index (RFI) and Fragility Quotient (FQ) were calculated for each study. Results Of the 847 articles screened, 4 studies with 5 comparisons met the search criteria to be included for analysis. A total of 1194 participants were included in these studies. There was a decreased risk of mortality seen with use of aspirin compared to other agents (MESE = 0.86, 95 % CI: [0.07-1.66]; p=.03). There was no increased risk of DVT or PE with use of aspirin (both p>.4). The overall RFI and FQ for all 19 outcomes were 12 (IQR: 6.5-15) and 0.080 (IQR: 0.027-0.110), respectively. Ten studies (52.6 %) reported a loss-to-follow-up (LTF) greater than the overall RFI. Conclusions Aspirin demonstrates similar protective effects on prevention of VTE compared to other agents and may have significant protective effects on overall mortality following surgical intervention for hip fractures. However, the current evidence concerning its use in this arena is less than robust, with more than half of the studied outcomes considered statistically fragile.
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Affiliation(s)
- Tyler K. Williamson
- Department of Orthopaedic Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Victor H. Martinez
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX, USA
| | - Adam W. Aziz
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX, USA
| | - Travis Kotzur
- Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Luke Verlinsky
- Department of Orthopaedic Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Frank A. Buttacavoli
- Department of Orthopaedic Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
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Furdock R, Alejo A, Hoffa M, Vergon A, Romeo NM, Vallier HA. Improving Patient Recall Following Operative Orthopaedic Trauma. J Bone Joint Surg Am 2024:00004623-990000000-01186. [PMID: 39190689 DOI: 10.2106/jbjs.23.01366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
BACKGROUND Orthopaedic trauma patients may experience poor recall regarding their injury and treatment, impairing postoperative outcomes. We sought to evaluate the impact of a standardized postoperative educational protocol on patient recall, adherence to the treatment plan, and satisfaction. METHODS Two hundred and twenty adult, English-speaking patients with surgically treated lower-extremity fractures were prospectively included. One hundred and ten patients in the educational intervention cohort met with a non-physician study member after surgery but before hospital discharge. They were given a written questionnaire evaluating knowledge of key aspects of their injury and treatment plan. For incorrectly answered questions, the study team member told the patient the correct answer (e.g., "No, you broke your tibia."). Immediately after, the patient was verbally asked the question again (e.g., "Which bone did you break?"), repeating the process until the answer was correct. The 110 patients in the control cohort did not receive this "teach-back" protocol. During their first postoperative appointment, all 220 patients completed a follow-up questionnaire assessing recall, adherence to the treatment plan, and satisfaction. RESULTS The control cohort correctly answered 64% of recall-oriented questions versus 89% in the intervention cohort (p < 0.001). Eighty-two percent of control patients versus 89% patients in the intervention cohort adhered to postoperative weight-bearing restrictions (p = 0.09). Eighty-four percent of controls adhered to their deep venous thrombosis prophylaxis regimen versus 99% of the intervention cohort (p < 0.001). On a 5-point Likert scale, controls were less satisfied with their overall orthopaedic care compared with patients in the intervention cohort (mean of 4.38 ± 0.84 versus 4.54 ± 0.63 points; p = 0.02), although this difference was less than the minimal clinically relevant difference of 10% that was defined at study onset. On propensity score-weighted multivariable analysis, receipt of the postoperative educational intervention was the only modifiable factor associated with improvement in patient recall (26% improvement [95% confidence interval, 20% to 31%]; p < 0.001). CONCLUSIONS Some orthopaedic trauma patients' nonadherence to surgeon recommendations and dissatisfaction with care may be mitigated by postoperative education. This standardized postoperative educational protocol improves orthopaedic trauma patients' recall, adherence to their treatment plan, and satisfaction in a manner requiring minimal time. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ryan Furdock
- Department of Orthopaedics, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Andrew Alejo
- Northeast Ohio Medical University, Rootstown, Ohio
| | - Matthew Hoffa
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Anna Vergon
- Department of Orthopaedics, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Nicholas M Romeo
- Department of Orthopaedics, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Ghazi FG, Schenker ML, Smith RN, Spencer CC, Mlaver E. Patient-reported barriers for adherence to prophylactic enoxaparin after orthopedic trauma surgery. Injury 2024; 55:111650. [PMID: 38878384 DOI: 10.1016/j.injury.2024.111650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/29/2024] [Indexed: 07/26/2024]
Abstract
INTRODUCTION Venous thromboembolism following orthopedic trauma surgery remains prevalent despite prophylaxis being a standard of care. Enoxaparin injection is a commonly utilized prophylaxis regimen among high-risk patients. Patient-reported rates of nonadherence and barriers to enoxaparin use are not described in the literature. A better understanding of these barriers and their impact on adherence to post-discharge prophylaxis regimens may shed light on persistent outcomes gaps. MATERIALS AND METHODS Semi-structured interviews were administered to adult patients prescribed prophylactic enoxaparin and presenting to orthopedic surgery outpatient clinic at an urban level 1 trauma center for a post-operative appointment following traumatic injury from April to July 2023. Patients self-reported their age, gender, race, and mobility. Inductive thematic analysis with three-reviewer consensus identified common barriers among responses. Adherence rates were calculated by dividing patients' estimated number of missed doses over total prescribed doses at the point of inquiry. RESULTS We identified 154 eligible patients through chart review, and 50 enrolled and interviewed. Participants had a mean age of 37 years. Of 50 participants, 20 identified as female; 25 identified as Black or African American, 16 as White, 5 as Hispanic, 2 as Asian, and 2 as multiracial. Twenty-one participants were non-ambulatory at time of interview. Mean and median patient-reported adherence were 64.5 % (SD 35.5) and 70.5 % (IQR 33-100) respectively. Five patients reported complete nonadherence, while 17 patients reported perfect adherence. Every participant reporting complete nonadherence identified as Black or African American, as compared to 8 out of 17 reporting perfect adherence. Despite acknowledging a twice-daily prescription, 17 patients reported once-daily rather than twice-daily use. Inductive thematic analysis revealed the following six barriers to prophylaxis adherence (number of participants reporting): Inconvenience (18 patients), Pain (16), Fear (12), Acquisition (7), Bruising (7), and Mechanism (7). Altogether, 40 patients endorsed at least one barrier to adherence. DISCUSSION & CONCLUSIONS Most patients face barriers to adherence with post-discharge prophylactic enoxaparin, and the resultant rates of adherence are low. This may contribute to persistent outcomes gaps in the orthopedic trauma population despite prophylaxis standards. Changes in prescribing patterns and patient engagement techniques may improve post-operative thromboembolic outcomes.
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Affiliation(s)
| | - Mara L Schenker
- Emory University, School of Medicine Department of Orthopedic Surgery, USA; Grady Memorial Hospital, USA
| | - Randi N Smith
- Emory University, School of Medicine Department of Surgery, USA; Grady Memorial Hospital, USA
| | - Corey C Spencer
- Emory University, School of Medicine Department of Orthopedic Surgery, USA
| | - Eli Mlaver
- Emory University, School of Medicine Department of Surgery, USA.
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O'Hara NN, Frey KP, Stein DM, Levy JF, Slobogean GP, Castillo R, Firoozabadi R, Karunakar MA, Gary JL, Obremskey WT, Seymour RB, Cuschieri J, Mullins CD, O'Toole RV. Effect of Aspirin Versus Low-Molecular-Weight Heparin Thromboprophylaxis on Medication Satisfaction and Out-of-Pocket Costs: A Secondary Analysis of a Randomized Clinical Trial. J Bone Joint Surg Am 2024; 106:590-599. [PMID: 38381842 PMCID: PMC10980176 DOI: 10.2106/jbjs.23.00824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Current guidelines recommend low-molecular-weight heparin for thromboprophylaxis after orthopaedic trauma. However, recent evidence suggests that aspirin is similar in efficacy and safety. To understand patients' experiences with these medications, we compared patients' satisfaction and out-of-pocket costs after thromboprophylaxis with aspirin versus low-molecular-weight heparin. METHODS This study was a secondary analysis of the PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT) trial, conducted at 21 trauma centers in the U.S. and Canada. We included adult patients with an operatively treated extremity fracture or a pelvic or acetabular fracture. Patients were randomly assigned to receive 30 mg of low-molecular-weight heparin (enoxaparin) twice daily or 81 mg of aspirin twice daily for thromboprophylaxis. The duration of the thromboprophylaxis, including post-discharge prescription, was based on hospital protocols. The study outcomes included patient satisfaction with and out-of-pocket costs for their thromboprophylactic medication measured on ordinal scales. RESULTS The trial enrolled 12,211 patients (mean age and standard deviation [SD], 45 ± 18 years; 62% male), 9725 of whom completed the question regarding their satisfaction with the medication and 6723 of whom reported their out-of-pocket costs. The odds of greater satisfaction were 2.6 times higher for patients assigned to aspirin than those assigned to low-molecular-weight heparin (odds ratio [OR]: 2.59; 95% confidence interval [CI]: 2.39 to 2.80; p < 0.001). Overall, the odds of incurring any out-of-pocket costs for thromboprophylaxis medication were 51% higher for patients assigned to aspirin compared with low-molecular-weight heparin (OR: 1.51; 95% CI: 1.37 to 1.66; p < 0.001). However, patients assigned to aspirin had substantially lower odds of out-of-pocket costs of at least $25 (OR: 0.15; 95% CI: 0.12 to 0.18; p < 0.001). CONCLUSIONS Use of aspirin substantially improved patients' satisfaction with their medication after orthopaedic trauma. While aspirin use increased the odds of incurring any out-of-pocket costs, it protected against costs of ≥$25, potentially improving health equity for thromboprophylaxis. LEVEL OF EVIDENCE Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nathan N O'Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Katherine P Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Deborah M Stein
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gerard P Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Renan Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Madhav A Karunakar
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Joseph Cuschieri
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - C Daniel Mullins
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
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5
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Costantini TW, Bulger E, Price MA, Haut ER. Research priorities in venous thromboembolism after trauma: Secondary analysis of the National Trauma Research Action Plan. J Trauma Acute Care Surg 2023; 95:762-769. [PMID: 37322589 DOI: 10.1097/ta.0000000000004074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a significant cause of morbidity and mortality during recovery from injury and can result in significant health care costs. Despite advances in the past several decades in our approach to VTE prophylaxis after injury, opportunities exist to improve the delivery and implementation of optimal VTE prophylaxis. Here, we aim to identify consensus research questions related to VTE across all National Trauma Research Action Plan (NTRAP) Delphi expert panels to further guide the research agenda aimed at preventing VTE after injury. METHODS This is a secondary analysis of consensus-based research priorities that were collected using a Delphi methodology by 11 unique NTRAP panels that were charged with unique topic areas across the spectrum of injury care. The database of questions was queried for the keywords "VTE," "venous thromboembo," and "DVT" and then grouped into relevant topic areas. RESULTS There were 86 VTE-related research questions identified across 9 NTRAP panels. Eighty-five questions reached consensus with 24 rated high priority; 60, medium priority; and 1, low priority. Questions related to the timing of VTE prophylaxis (n = 17) were most common, followed by questions related to risk factors for the development of VTE (n = 16), the effects of tranexamic acid on VTE (n = 11), the approach to dosing of pharmacologic prophylaxis (n = 8), and the pharmacologic prophylactic medication choice for optimal VTE prophylaxis (n = 6). CONCLUSION National Trauma Research Action Plan panelists identified 85 consensus-based research questions that should drive dedicated extramural research funding opportunities to support quality studies aimed at optimizing VTE prophylaxis after injury. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Todd W Costantini
- From the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (T.W.C.), UC San Diego School of Medicine, San Diego, California; Division of Trauma, Burns, and Critical Care, Department of Surgery (E.B.), University of Washington, Seattle, Washington; Harborview Medical Center (E.B.), Seattle, Washington; Coalition for National Trauma Research (M.A.P.), San Antonio, Texas; Division of Acute Care Surgery, Department of Surgery (E.R.H.), Department of Anesthesiology and Critical Care Medicine (E.R.H.), and Department of Emergency Medicine (E.R.H.), The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality (E.R.H.), Johns Hopkins Medicine, Baltimore, Maryland; and Department of Health Policy and Management (E.R.H.), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Evaluating patient recall following operative orthopaedic trauma. Injury 2023:S0020-1383(23)00269-3. [PMID: 36931966 DOI: 10.1016/j.injury.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Orthopedic trauma patients may have poor recall of their injuries and treatment. This may lead to poor adherence to instructions. The purposes of this project were to quantify recall about injury and treatment information, and to assess adherence to postoperative instructions and satisfaction with care. METHODS A prospective cohort of 110 consecutive adult orthopaedic trauma patients treated for acute injury at a Level 1 trauma center were included. All had undergone surgical treatment of fractures of the pelvis or lower extremity. A brief survey to assess patient recall about injury and treatment knowledge, adherence to weightbearing and DVT recommendations and to evaluate patient satisfaction was administered during the first post-hospital clinic visit. RESULTS Patients correctly answered 64% of recall-oriented questions. 82% and 83% of patients, respectively, reported adherence to their weightbearing restrictions and their DVT prophylaxis regimen, while 66% of patients reported adherence to both. Forty-two percent of non-adherent patients could not remember their weightbearing restrictions, while 78% of non-adherent patients could not remember their DVT prophylaxis regimen. Average patient satisfaction was 4.3 (range 1-5), with 15% of patients indicating neutral sentiment or dissatisfaction with their care. CONCLUSION Orthopaedic trauma patients have poor recall, which likely reduces postoperative adherence and may impair patient satisfaction. A postoperative educational protocol focused on improving patient recall may be useful. LEVEL OF EVIDENCE Level 4, prognostic.
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7
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Dhillon NK, Haut ER, Price MA, Costantini TW, Teichman AL, Cotton BA, Ley EJ. Novel therapeutic medications for venous thromboembolism prevention in trauma patients: Findings from the Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma. J Trauma Acute Care Surg 2023; 94:479-483. [PMID: 36729880 PMCID: PMC9974825 DOI: 10.1097/ta.0000000000003853] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
ABSTRACT Trauma patients are at high risk for venous thromboembolism (VTE). Despite evidence-based guidelines and concerted efforts in trauma centers to implement optimal chemoprophylaxis strategies, VTE remains a frequent diagnosis in trauma patients. Current chemoprophylaxis strategies largely focus on the subcutaneous injection of low-molecular-weight heparin, which is administered twice daily. Novel approaches to pharmacologic VTE prophylaxis have the potential to reduce VTE rates by improving patient compliance through oral administration or through their ability to target alternative pathways that mediate thrombosis. While novel pharmacologic VTE prophylaxis strategies have been studied in nontrauma patients, there is a paucity of literature in trauma patients where the risk of thrombosis versus hemorrhage must be carefully considered. As a component of the 2022 Consensus Conference to Implement Optimal VTE Prophylaxis in Trauma, this review provides an update of the novel chemoprophylaxis agents for potential use in trauma patients. Here, we will consider the relative risks and benefits related to the use of these drugs, evaluate the current literature in nontrauma patients, and consider future directions that could potentially improve posttrauma VTE prophylaxis.
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Affiliation(s)
- Navpreet K Dhillon
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery; Department of Anesthesiology and Critical Care Medicine; Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, and Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine, San Diego, CA
| | - Amanda L Teichman
- Division of Acute Care Surgery, Rutgers-Robert Wood Johnson School of Medicine, New Brunswick, NJ
| | - Bryan A Cotton
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School, Memorial Hermann Hospital, Houston, TX
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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Sidhu V, Naylor JM, Adie S, Bastiras D, Buchbinder R, Ackerman I, Harris IA. Post-discharge patient-reported non-adherence to aspirin compared to enoxaparin for venous thromboembolism prophylaxis after hip or knee arthroplasty. ANZ J Surg 2023; 93:989-994. [PMID: 36661408 DOI: 10.1111/ans.18284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/15/2022] [Accepted: 01/08/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Aspirin and enoxaparin are commonly used for venous thromboembolism (VTE) prophylaxis following total hip arthroplasty (THA) or total knee arthroplasty (TKA). The purpose of this study was to compare non-adherence after discharge to aspirin or enoxaparin following THA or TKA. METHODS A subset of participants in the CRISTAL study were selected for participation. Additional inclusion criteria were no preoperative anticoagulant use and discharge from hospital before the prophylaxis period ended. The first four consecutive patients from each arm at each participating hospital were planned to be recruited (planned sample size n = 248). A patient-reported adherence questionnaire was completed by telephone at 36-41 days after THA and at 15-20 days after TKA. The primary outcome was non-adherence. Secondary outcomes were number of missed doses and the reasons for non-adherence. RESULTS There were 178 participants included from 15 sites, less than planned explained by early stopping of trial recruitment. There was no significant between-group difference in patient-reported non-adherence: 24% (17/71) for aspirin, 30% (32/107) for enoxaparin, odds ratio = 1.4 (95% CI 0.7-2.9). The mean number of missed doses was 2.5 for aspirin and 3.4 for enoxaparin (mean difference = 0.9 doses, 95% CI -1.2 to 3.1). For aspirin, the most commonly reported reason for non-adherence was forgotten doses and for enoxaparin it was clinician-recommended change. CONCLUSIONS Rates of non-adherence and the number of missing doses were similar for patients regardless of drug prescribed. The most common reasons for non-adherence were unrelated to the mode of administration.
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Affiliation(s)
- Verinder Sidhu
- School of Clinical Medicine, UNSW Medicine & Health, South West Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia.,Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Justine M Naylor
- School of Clinical Medicine, UNSW Medicine & Health, South West Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia.,Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Sam Adie
- School of Clinical Medicine, UNSW Medicine & Health, St George & Sutherland Clinical Campuses, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia.,St George and Sutherland Centre for Clinical Orthopaedic Research, Sydney, New South Wales, Australia
| | - Durga Bastiras
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Victoria, Australia
| | - Ilana Ackerman
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Victoria, Australia
| | - Ian A Harris
- School of Clinical Medicine, UNSW Medicine & Health, South West Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia.,Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,Institute of Musculoskeletal Health, School of Public Health, Faculty of Medicine, The University of Sydney, Sydney, New South Wales, Australia
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A Prospective Randomized Controlled Trial Comparing Enoxaparin & Rivaroxaban for Venous Thromboembolism Prophylaxis in Orthopaedic Trauma. J Orthop Trauma 2022; 36:615-622. [PMID: 36399673 DOI: 10.1097/bot.0000000000002454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether there is a difference in orthopaedic trauma patient medication satisfaction and adherence using an oral versus subcutaneous injectable anticoagulant for venous thromboembolism chemoprophylaxis. DESIGN Randomized controlled trial. SETTING Single academic Level 1 trauma center. PARTICIPANTS One hundred twenty adult orthopaedic trauma patients with operative pelvic or lower extremity fractures were randomized and completed the study. INTERVENTION Three weeks of either the service standard 40 mg once daily enoxaparin versus trial medication 10 mg once daily rivaroxaban postoperatively. MAIN OUTCOME MEASURES Patient satisfaction as measured by the Treatment Satisfaction Questionnaire for Medication (TSQM-9). Medication adherence as measured by the Morisky Medication Adherence Scale (MMAS-8). RESULTS Medication adherence was similar in both groups. Medication satisfaction was significantly higher in the oral rivaroxaban group based on the TSQM-9 and patient-reported data. Secondary outcomes found no significant difference in the incidence of bleeding events or clinically relevant venous thromboembolism. The enoxaparin group experienced more adverse medication-related events. The rivaroxaban medication regimen costs 7.5-10× less out of pocket for uninsured patients. CONCLUSION The results of this randomized controlled trial demonstrate that patients with surgical orthopaedic trauma prefer an oral anticoagulant for postoperative venous thromboembolism chemoprophylaxis and suggest that rivaroxaban may be a viable option. Furthermore, large-scale studies are needed to confirm safety and efficacy for rivaroxaban in this population as a potential alternative to enoxaparin and aspirin. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Howard TA, Judd CS, Snowden GT, Lambert RJ, Clement ND. Incidence and risk factors associated with venous thromboembolism following primary total hip arthroplasty in low-risk patients when using aspirin for prophylaxis. Hip Int 2022; 32:562-567. [PMID: 33594900 DOI: 10.1177/1120700021994530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIMS The primary aim was to assess the incidence of venous thromboembolism (VTE) following total hip replacements (THR) in a low-risk patient group when using 150 mg aspirin as the pharmacological component of VTE prophylaxis on discharge. The secondary aim was to identify factors associated with an increased risk of a VTE event in this low-risk group. PATIENTS AND METHODS Retrospective review of a consecutive cohort of patients undergoing THR during a 63-month period. Patient demographics, socio-economic status, ASA grade, type of anaesthetic, length of surgery and BMI were recorded. A diagnosis of VTE was assigned to symptomatic patients with positive imaging for a deep vein thrombosis (DVT) and/or a pulmonary embolism (PE) within 8 weeks of surgery. Multivariate logistic regression modeling was used to identify factors associated with VTE after THR. RESULTS 3880 patients underwent THR during the study period, of which 2740 (71%) were low risk and prescribed aspirin for VTE prophylaxis. There were 34 VTE events, of which 15 were DVTs and 18 were PEs, with 1 patient diagnosed with both. The incidence of VTE was 1.2%, with no VTE-related deaths. Patients incurring a VTE postoperatively were more likely to be male (odds ratio [OR] 2.06, p = 0.022), of older age (OR 0.43, p = 0.047) and were more likely to be socially deprived (OR 0.32, p = 0.006). There was no significant difference with patients given low-molecular-weight heparin (LMWH) as an inpatient prior to discharge on aspirin (p = 0.806), nor any difference with the type of anaesthetic used during surgery (p = 0.719). CONCLUSIONS Aspirin is a relatively safe and effective choice for VTE prophylaxis in low-risk patients undergoing THR. Male sex and age >70 years were twice as likely to sustain a VTE and patients from the most deprived socio-economic background are 3 times as likely.
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Affiliation(s)
- Thomas A Howard
- Department of Trauma and Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Caitlin S Judd
- Division of Medical and Radiological Sciences - Orthopaedics, The University of Edinburgh, Edinburgh, UK
| | - Gordon T Snowden
- Department of Trauma and Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Robert J Lambert
- Department of Trauma and Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nick D Clement
- Department of Trauma and Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, UK
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Cost-Effectiveness of Aspirin for Extended Venous Thromboembolism Prophylaxis After Major Surgery for Inflammatory Bowel Disease. J Gastrointest Surg 2022; 26:1275-1285. [PMID: 35277799 DOI: 10.1007/s11605-022-05287-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/26/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE Venous thromboembolism extended prophylaxis after inflammatory bowel disease surgery remains controversial. The purpose of this study was to evaluate if adopting an aspirin-based prophylaxis strategy may address current cost-effectiveness limitations. METHODS A decision analysis model was used to compare costs and outcomes of a reference case patient undergoing inflammatory bowel disease-associated colorectal surgery considered for post-discharge thromboembolism prophylaxis. Low-dose aspirin was compared to an enoxaparin regimen as well as no prophylaxis. Source estimates were obtained from aggregated existing literature. Secondary analysis included out-of-pocket costs. A 10,000-simulation Monte Carlo probabilistic sensitivity analysis accounted for uncertainty in model estimates. RESULTS An enoxaparin-based regimen compared to aspirin demonstrated an unfavorable incremental cost-effectiveness ratio of $908,268 per quality-adjusted life year. Sensitivity analysis supported this finding in > 75% of simulated cases; scenarios favoring enoxaparin included those with > 4% post-discharge event rates. Aspirin versus no prophylaxis demonstrated a favorable ratio of $106,601 per quality-adjusted life year. Findings were vulnerable to a post-discharge thromboembolism rate < 1%, aspirin-associated bleeding rate > 1%, median hospital costs of bleeding > 3 × , and decreased efficacy of aspirin (RR > 0.75). The average out-of-pocket cost of choosing an aspirin ePpx strategy increased by $54 per patient versus $708 per patient with enoxaparin. CONCLUSIONS Low-dose aspirin extended prophylaxis following inflammatory bowel disease surgery has a favorable cost-safety profile and may be an attractive alternative approach.
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Leeds IL, Canner JK, DiBrito SR, Safar B. Do Cost Limitations of Extended Prophylaxis After Surgery Apply to Ulcerative Colitis Patients? Dis Colon Rectum 2022; 65:702-712. [PMID: 34840290 PMCID: PMC8995329 DOI: 10.1097/dcr.0000000000002056] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal surgery patients with ulcerative colitis are at increased risk of postoperative venous thromboembolism. Extended prophylaxis for thromboembolism prevention has been used in colorectal surgery patients, but it has been criticized for its lack of cost-effectiveness. However, the cost-effectiveness of extended prophylaxis for postoperative ulcerative colitis patients may be unique. OBJECTIVE This study aimed to assess the cost-effectiveness of extended prophylaxis in postoperative ulcerative colitis patients. DESIGN A decision analysis compared costs and benefits in postoperative ulcerative colitis patients with and without extended prophylaxis over a lifetime horizon. SETTING Assumptions for decision analysis were identified from available literature for a typical ulcerative colitis patient's risk of thrombosis, age at surgery, type of thrombosis, prophylaxis risk reduction, bleeding complications, and mortality. MAIN OUTCOME MEASURES Costs ($) and benefits (quality-adjusted life year) reflected a societal perspective and were time-discounted at 3%. Costs and benefits were combined to produce the main outcome measure, the incremental cost-effectiveness ratio ($ per quality-adjusted life year). Multivariable probabilistic sensitivity analysis modeled uncertainty in probabilities, costs, and disutilities. RESULTS Using reference parameters, the individual expected societal total cost of care was $957 without and $1775 with prophylaxis (not cost-effective; $257,280 per quality-adjusted life year). Preventing a single mortality with prophylaxis would cost $5 million (number needed to treat: 6134 individuals). Adjusting across a range of scenarios upheld these conclusions 77% of the time. With further sensitivity testing, venous thromboembolism cumulative risk (>1.5%) and ePpx regimen pricing (<$299) were the 2 parameters most sensitive to uncertainty. LIMITATIONS Recommendations of decision analysis methodology are limited to group decision-making, not an individual risk profile. CONCLUSION Routine ePpx in postoperative ulcerative colitis patients is not cost-effective. This finding is sensitive to higher-than-average rates of venous thromboembolism and low-cost prophylaxis opportunities. See Video Abstract at http://links.lww.com/DCR/B818. SE APLICAN LAS LIMITACIONES DE COSTOS DE LA PROFILAXIS PROLONGADA DESPUS DE LA CIRUGA A LOS PACIENTES CON COLITIS ULCEROSA ANTECEDENTES:Los pacientes de cirugía colorrectal con colitis ulcerosa tienen un mayor riesgo de tromboembolismo venoso posoperatorio. La profilaxis extendida para la prevención de la tromboembolia se ha utilizado en pacientes con cirugía colorrectal, aunque ha sido criticada por su falta de rentabilidad. Sin embargo, la rentabilidad de la profilaxis prolongada para los pacientes posoperados con colitis ulcerosa puede ser aceptable.OBJETIVO:Evaluar la rentabilidad de la profilaxis prolongada en pacientes posoperados con colitis ulcerosa.DISEÑO:Un análisis de decisiones comparó los costos y beneficios en pacientes posoperados con colitis ulcerosa con y sin profilaxis prolongada de por vida.AJUSTE:Los supuestos para el análisis de decisiones se identificaron a partir de la literatura disponible para el riesgo de trombosis de un paciente con colitis ulcerosa típica, la edad al momento de la cirugía, el tipo de trombosis, la reducción del riesgo con profilaxis, las complicaciones hemorrágicas y la mortalidad.PRINCIPALES MEDIDAS DE RESULTADO:Los costos ($) y los beneficios (año de vida ajustado por calidad) reflejaron una perspectiva social y se descontaron en el tiempo al 3%. Los costos y los beneficios se combinaron para producir la principal medida de resultado, la relación costo-efectividad incremental ($ por año de vida ajustado por calidad). El análisis de sensibilidad probabilística multivariable modeló la incertidumbre en probabilidades, costos y desutilidades.RESULTADOS:Utilizando parámetros de referencia, el costo total de atención social esperado individual fue de $957 sin profilaxis y $1775 con profilaxis (no rentable; $257,280 por año de vida ajustado por calidad). La prevención de una sola mortalidad con profilaxis costaría $5.0 millones (número necesario a tratar: 6.134 personas). El ajuste en una variedad de escenarios mantuvo estas conclusiones el 77% de las veces. Con más pruebas de sensibilidad, el riesgo acumulado de TEV (>1,5%) y el precio del régimen de ePpx (<$299) fueron los dos parámetros más sensibles a la incertidumbre.LIMITACIONES:Las recomendaciones de la metodología de análisis de decisiones se limitan a la toma de decisiones en grupo, no a un perfil de riesgo individual.CONCLUSIÓN:La profilaxis extendida de rutina en pacientes posoperados con colitis ulcerosa no es rentable. Este hallazgo es sensible a tasas de TEV superiores al promedio y oportunidades de profilaxis de bajo costo. Consulted Video Resumen en http://links.lww.com/DCR/B818. (Traducción-Dr. Felipe Bellolio).
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Affiliation(s)
- Ira L Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Qualitative analysis of randomized controlled trials informing recommendations for venous thromboembolism prophylaxis after distal lower extremity injuries. OTA Int 2022; 5:e201. [PMID: 35919108 PMCID: PMC9278901 DOI: 10.1097/oi9.0000000000000201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 02/05/2022] [Indexed: 11/26/2022]
Abstract
Purpose: The purpose of this study is to assess the quality of evidence to stratify recommendations for chemoprophylaxis following distal lower extremity trauma. Methods: Literature review identified primary studies investigating venous thromboembolism (VTE) chemoprophylaxis following traumatic injury distal to the knee. Inclusion criteria were randomized controlled trials in adult patients treated with and without operative intervention. Each primary study was assessed by the Consolidated Standards of Reporting Trials 2010 checklist and Modified Coleman methodology score. Results: Literature review resulted in 462 studies, of which 9 met inclusion and exclusion criteria. All studies included low molecular weight heparin as a treatment group with 2 (22%) also including a treatment group with a direct factor Xa inhibitor. Five studies (56%) used placebo as a control group. The mean Modified Coleman Methodology score was 63% (range 51%–72%), a categorical rating of Fair. The mean Consolidated Standards of Reporting Trials score was 78% (range 56%–97%). Most studies (89%) screened all asymptomatic subjects for deep venous thrombosis. Statistical significance in VTE incidence among prophylactic treatment groups was not achieved in 78%. Conclusions: Development of consensus for VTE prophylaxis recommendations following traumatic injury distal to the knee is complicated by heterogenous study populations, low incidence of VTE in study populations, and inconsistent definitions of clinically important VTE. Low molecular weight heparin is not consistently superior for preventing VTE. Chemoprophylaxis should be considered on an individual basis in the presence of additional risk factors, although an externally validated, evidence-based risk assessment tool does not currently exist. Level of Evidence: IV, therapeutic
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Ng IC, Barnes C, Biswas S, Wright D, Dagal A. When is it safe to resume anticoagulation in traumatic brain injury? Curr Opin Anaesthesiol 2022; 35:166-171. [PMID: 35131968 DOI: 10.1097/aco.0000000000001117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW When to resume or initiate anticoagulation therapy following traumatic brain injury (TBI) is controversial. This summary describes the latest evidence to guide best practice. RECENT FINDINGS Following trauma, prophylactic, and therapeutic anticoagulation (TAC) have been widely encouraged to prevent major comorbidities such as pulmonary embolism and deep venous thrombosis. Increased rebleeding risk and potentially catastrophic outcome from initiation of anticoagulation treatment in TBI are mainly influenced by institutional guidelines or physician preference in the absence of level I or II recommendations. In recent years, there has been an increasing number of TBI in the elderly population on anticoagulation for other medical conditions; this complicates the decision and timing to restart anticoagulation after the injury. SUMMARY Strategies and timing to start prophylactic and TAC differ significantly between institutions and physicians. Each TBI patient should be evaluated on a case-by-case basis on when to start anticoagulation. More investigation is required to guide best practice.
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Affiliation(s)
- Ireana C Ng
- Harborview Medical Center, UW Medicine, Seattle, Washington
| | | | - Subarna Biswas
- Keck School of Medicine of USC, Health Sciences Campus, Los Angeles, California, USA
| | - David Wright
- Harborview Medical Center, UW Medicine, Seattle, Washington
| | - Arman Dagal
- Harborview Medical Center, UW Medicine, Seattle, Washington
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Chemoprophylaxis for venous thromboembolism in pelvic and/or acetabular fractures: A systematic review. Injury 2022; 53:1449-1454. [PMID: 35148902 DOI: 10.1016/j.injury.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is unclear which pharmacological agents, and at what dosage and timing, are most effective for venous thromboembolism (VTE) prophylaxis in patients with pelvic/acetabular fractures. METHODS We searched the Cochrane Database of Systematic Reviews, Embase, Web of Science, EBSCO, and PubMed on October 3, 2020, for English-language studies of VTE prophylaxis in patients with pelvic/acetabular fractures. We applied no date limits. We included studies that compared efficacy of pharmacological agents for VTE prophylaxis, timing of administration of such agents, and/or dosage of such agents. We recorded interventions, sample sizes, and VTE incidence, including deep vein thrombosis (DVT) and pulmonary embolism. RESULTS Two studies (3604 patients) compared pharmacological agents, reporting that patients who received direct oral anticoagulants (DOACs) were less likely to develop DVT than those who received low molecular weight heparin (LMWH) (p < 0.01). Compared with unfractionated heparin (UH), LMWH was associated with lower odds of VTE (odds ratio [OR] = 0.37, 95% confidence interval [CI]: 0.22-0.63) and death (OR = 0.27, 95% CI: 0.10-0.72). Three studies (3107 patients) compared timing of VTE prophylaxis, reporting that late prophylaxis was associated with higher odds of VTE (OR = 1.9, 95% CI: 1.2-3.2) and death (OR = 4.0, 95% CI: 1.5-11) and higher rates of symptomatic DVT (9.2% vs. 2.5%, p = 0.03; and 22% vs. 3.1%, p = 0.01). One study (31 patients) investigated dosage of VTE prophylaxis, reporting that a higher proportion of patients with acetabular fractures were underdosed (23% of patients below range of anti-Factor Xa [aFXa] had acetabular fractures vs. 4.8% of patients within adequate range of aFXa, p<0.01). CONCLUSIONS Early VTE chemoprophylaxis (within 24 or 48 h after injury) was better than late administration in terms of VTE and death. Many patients with acetabular fractures are underdosed with LMWH, with inadequate aFXa levels. Compared with UH, LMWH was associated with lower odds of VTE and death. DOACs were associated with lower risk of DVT compared with LMWH. LEVEL OF EVIDENCE III, systematic review of retrospective cohort studies.
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Nederpelt CJ, Bijman Q, Krijnen P, Schipper IB. Equivalence of DOACS and LMWH for thromboprophylaxis after hip fracture surgery: Systematic review and meta-analysis. Injury 2022; 53:1169-1176. [PMID: 34916036 DOI: 10.1016/j.injury.2021.11.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 11/16/2021] [Accepted: 11/22/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients with hip fractures (HF) have an increased risk of venous thromboembolism (VTE). In elective orthopedic surgery direct oral anticoagulants (DOACs) have proven to be similarly or more effective compared to low molecular weight heparin (LMWH), but DOACs are not yet approved for thromboprophylaxis in trauma patients with HF. The aim of this study was to systematically review the literature comparing the effectiveness of DOACs and LMWH for thromboprophylaxis in trauma patients with surgically treated HF. MATERIALS AND METHODS We searched PubMed, the Cochrane Library, Web of Science, and Embase. The primary outcome was the incidence of VTE (symptomatic and asymptomatic combined). Secondary outcomes were symptomatic VTE; a symptomatic VTE, symptomatic deep venous thrombosis (DVT); symptomatic pulmonary embolism (PE); major, clinically relevant non-major (CRNM), and minor bleeding. Meta-analysis was performed to compare the odds of VTE and secondary outcomes between DOACs and LMWH. RESULTS The search resulted in 738 titles. Five studies matched inclusion criteria. In total, 4748 hip fracture patients were analyzed (DOACs: 2276 patients, LMWH: 2472 patients). The pooled odds ratio for the risk of VTE for DOAC use was 0.52 (95% confidence interval 0.25-1.11, p = 0.09) compared to LMWH. No statistically significant differences between DOAC and LMWH were found for asymptomatic VTE, symptomatic DVT, PE, major or CRNM bleeding, and minor bleeding. CONCLUSIONS Meta-analysis of the literature suggests that DOACs are associated with equivalent effectiveness and safety compared to LMWH.
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Affiliation(s)
- Charlie J Nederpelt
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands; Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States.
| | - Quinten Bijman
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Benjamin MW, Koomson A, Ismaiel H. Analysis of Adherence to Thromboprophylaxis and Incidence of Venous Thromboembolism After Lower Limb Orthopaedic Surgery. Cureus 2021; 13:e19746. [PMID: 34812337 PMCID: PMC8604429 DOI: 10.7759/cureus.19746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2021] [Indexed: 12/05/2022] Open
Abstract
Background The economic burden caused by venous thromboembolism (VTE) to the National Health Service (NHS) is approximately £640 million. There is a significant national drive for VTE prophylaxis prescription given the high morbidity and mortality rates associated with VTE following lower limb orthopaedic surgery. The primary objective of this analysis was to examine the adherence to the updated VTE guidelines, NG89, by the National Institute for Health and Care Excellence (NICE) regarding prophylaxis for patients undergoing lower limb orthopaedic surgery, where the weight-bearing status will be reduced postoperatively, in an urban community hospital. Methodology We looked at 586 patients who underwent elective lower limb orthopaedic surgeries over a two year time period. We reviewed their VTE prophylaxis administration. Results were shared with the Hospital Thrombosis Committee department. Education was provided to the relevant staff and hospital policy for VTE prophylaxis. The primary endpoint was to compare the proportion of patients receiving prophylaxis as per the hospital guidelines as well as complications arising from VTE. Results A total of 586 patients were included in this audit. Compliance with VTE pharmacological prophylaxis was recorded, as well as weight-bearing status advised postoperatively. Compliance with prophylaxis in patients who were non-weight-bearing postoperatively was 54.8%. There were three cases of recorded VTE; however, in all cases, appropriate VTE prophylaxis has been prescribed. Conclusion Increasing hospital-wide awareness and education of VTE and the fatal complications is imperative. All patients should be administered VTE prophylaxis as an inpatient and on discharge if their weight-bearing status is affected following lower limb orthopaedic surgery. Although our compliance rate for prescription of VTE prophylaxis did not achieve the standards set by NICE, all cases of recorded VTE had been correctly prescribed VTE prophylaxis on discharge.
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Affiliation(s)
- Miles W Benjamin
- Trauma and Orthopaedics, Barnsley Hospital NHS Foundation Trust, London, GBR
| | | | - Hany Ismaiel
- Trauma and Orthopaedics, Barnsley Hospital NHS Foundation Trust, Barnsley, GBR
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Lee KE, Lim F, Colombel JF, Hur C, Faye AS. Cost-effectiveness of Venous Thromboembolism Prophylaxis After Hospitalization in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 28:1169-1176. [PMID: 34591970 PMCID: PMC9890631 DOI: 10.1093/ibd/izab246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) have a 2- to 3-fold greater risk of venous thromboembolism (VTE) than patients without IBD, with increased risk during hospitalization that persists postdischarge. We determined the cost-effectiveness of postdischarge VTE prophylaxis among hospitalized patients with IBD. METHODS A decision tree compared inpatient prophylaxis alone vs 4 weeks of postdischarge VTE prophylaxis with 10 mg/day of rivaroxaban. Our primary outcome was quality-adjusted life years (QALYs) over 1 year, and strategies were compared using a willingness to pay of $100,000/QALY from a societal perspective. Costs (in 2020 $USD), incremental cost-effectiveness ratios (ICERs) and number needed to treat (NNT) to prevent 1 VTE and VTE death were calculated. Deterministic 1-way and probabilistic analyses assessed model uncertainty. RESULTS Prophylaxis with rivaroxaban resulted in 1.68-higher QALYs per 1000 persons compared with no postdischarge prophylaxis at an incremental cost of $185,778 per QALY. The NNT to prevent a single VTE was 78, whereas the NNT to prevent a single VTE-related death was 3190. One-way sensitivity analyses showed that higher VTE risk >4.5% and decreased cost of rivaroxaban ≤$280 can reduce the ICER to <$100,000/QALY. Probabilistic sensitivity analyses favored prophylaxis in 28.9% of iterations. CONCLUSIONS Four weeks of postdischarge VTE prophylaxis results in higher QALYs compared with inpatient prophylaxis alone and prevents 1 postdischarge VTE among 78 patients with IBD. Although postdischarge VTE prophylaxis for all patients with IBD is not cost-effective, it should be considered in a case-by-case scenario, considering VTE risk profile, costs, and patient preference.
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Affiliation(s)
- Kate E Lee
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Francesca Lim
- Department of Medicine, Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Adam S Faye
- Address correspondence to: Adam S. Faye, MD MS, Assistant Professor of Medicine & Population Health, NYU Langone Division of Gastroenterology, New York University, New York, NY, USA, 303 East 33rd Street, New York, NY 10016, USA ()
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Muscatelli SR, Zheng H, Hughes RE, Cowen ME, Hallstrom BR. Non-Inferiority of Aspirin for Venous Thromboembolism Prophylaxis After Hip Arthroplasty in a Statewide Registry. J Arthroplasty 2021; 36:2068-2075.e2. [PMID: 33589277 DOI: 10.1016/j.arth.2021.01.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/05/2021] [Accepted: 01/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Uncertainty remains surrounding the use of aspirin as a sole chemoprophylactic agent to reduce the risk of venous thromboembolism (deep vein thrombosis or pulmonary embolism) and bleeding after primary total hip arthroplasty. METHODS We performed a non-inferiority analysis of a retrospective cohort of patients undergoing total hip arthroplasty from April 1, 2013 to December 31, 2018. Cases were retrieved from the Michigan Arthroplasty Registry Collaborative Quality Initiative database and performed by 355 surgeons at 61 hospitals throughout Michigan. Surgical setting ranged from small community hospitals to large academic and non-academic centers. The primary outcomes were post-operative venous thromboembolism event or death and bleeding event. RESULTS Of the 59,747 patients included, 32,878 (55.03%) were female, and the mean age was 64.5. A total of 462 (0.77%) composite venous thromboembolism events occurred. There were 221 (0.71%) and 129 (0.80%) venous thromboembolism events in patients receiving aspirin only and anticoagulants only, respectively. Aspirin was non-inferior to anticoagulants for composite venous thromboembolism events (odds ratio 0.99, 95% confidence interval 0.79-1.26, P < .001). Bleeding events occurred in 767 (1.28%) patients, with 304 (0.97%) and 281 (1.74%) bleeding events in patients receiving aspirin only and anticoagulants only, respectively. Aspirin was non-inferior to anticoagulants for bleeding events (odds ratio 0.62, 95% confidence interval 0.52-0.74, P < .001). CONCLUSION Aspirin is not inferior to other anticoagulants as pharmacologic venous thromboembolism prophylaxis with regards to post-operative risk of venous thromboembolism or bleeding. Sole use of aspirin for venous thromboembolism prophylaxis after total hip arthroplasty should be considered in the appropriate patient.
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Affiliation(s)
- Stefano R Muscatelli
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Huiyong Zheng
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Richard E Hughes
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Mark E Cowen
- Quality Insitute, St. Joseph Mercy Hospital, Ann Arbor, MI
| | - Brian R Hallstrom
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
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Updated guidelines to reduce venous thromboembolism in trauma patients: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2021; 89:971-981. [PMID: 32590563 PMCID: PMC7587238 DOI: 10.1097/ta.0000000000002830] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Weng XS, Liu J, Wu D. Chinese Survey on Enhanced Recovery after Surgery and Thromboprophylaxis Following Arthroplasty. Orthop Surg 2020; 12:900-906. [PMID: 32489003 PMCID: PMC7307227 DOI: 10.1111/os.12705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/13/2020] [Accepted: 04/25/2020] [Indexed: 12/28/2022] Open
Abstract
Objective To examine the current perspectives of enhanced recovery after surgery (ERAS) and the clinical practice applications of important ERAS principles among Chinese orthopaedic surgeons. Methods This was a cross‐sectional study using an online survey that was completed between November and December 2018. A 16‐item online questionnaire regarding the experiences of ERAS, perceptions of methods, and durations and concerns of venous thromboembolism (VTE) prophylaxis was sent to 2000 orthopaedic surgeons nationwide, and 1720 (86%) surgeons responded. Statistical analyses were conducted to assess all respondents' results and to compare differences among subgroups that were stratified according to city and hospital level, as well as their professional title. Results According to the results of the survey, ERAS awareness was high (65.1%) and most surgeons recognized the importance of thromboprophylaxis. However, the timing of ERAS was not consistent, with 22.8%, 31.9%, and 37.7% of surgeons choosing to initiate pharmaceutical prophylaxis within <6 h, 6–12 h, and 12–24 h after surgery, respectively. Low‐molecular‐weight heparin was mainly selected during hospitalization, and new oral anticoagulants (NOACs) were the first choice after discharge. Regarding postoperative antithrombotic therapy, particularly when combined with analgesics, the potential bleeding risk was mostly considered (80.0%)Tranexamic acid was believed to have no effect on the timing of NOAC therapy initiation (56.2%). Most of the above outcomes were influenced by the hospital level and professional title of the surgeon. Surgeons who had higher awareness on ERAS and better adhered to the guidelines were from higher‐level hospitals as well as had more advanced professional titles. City level partly might influence their practice but not impact surgeons' awareness. Conclusions The awareness and perception of the concept of ERAS and prophylactic antithrombotic regimens remain different among Chinese orthopaedic surgeons in different level cities and with various professional titles. Continuing medical educations (CME) on VTE prophylaxis is needed for improving the quality of health care in China.
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Affiliation(s)
- Xi-Sheng Weng
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Juan Liu
- Medical Affairs Department, Pfizer Inc, Shanghai, China
| | - Duo Wu
- Medical Affairs Department, Pfizer Inc, Guangzhou, China
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Cost-Benefit Limitations of Extended, Outpatient Venous Thromboembolism Prophylaxis Following Surgery for Crohn's Disease. Dis Colon Rectum 2019; 62:1371-1380. [PMID: 31596763 PMCID: PMC6788772 DOI: 10.1097/dcr.0000000000001461] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with Crohn's disease are at increased risk of postoperative venous thromboembolism. Historically, extended outpatient prophylaxis has not met conventional measures of societal cost-benefit advantage. However, extended prophylaxis for patients with Crohn's disease may be more cost-effective because of the patients' high thrombotic risk and long life expectancy. OBJECTIVE This study aimed to assess the cost-effectiveness of extended prophylaxis in patients with Crohn's disease after abdominal surgery. DESIGN A decision tree model was used to assess the incremental cost-effectiveness and cost per case averted with extended-duration venous thromboembolism prophylaxis following abdominal surgery. SETTING The risk of a postdischarge thrombotic event, age at surgery, type of thrombotic event, prophylaxis risk reduction, bleeding complications, and mortality were estimated by using existing published sources. PATIENTS Studied were patients with Crohn's disease versus routine care. INTERVENTION We constructed a decision analysis to compare costs and outcomes in patients with Crohn's disease postoperatively with and without extended prophylaxis over a lifetime horizon. MAIN OUTCOME MEASURES Productivity costs ($) and benefits (quality-adjusted life-year) were used to reflect a societal perspective and were time discounted at 3%. Multivariable probabilistic sensitivity analysis accounted for uncertainty in probabilities, costs, and utility weights. RESULTS With the use of reference parameters, the individual expected societal total cost of care was $399.83 without and $1387.95 with prophylaxis. Preventing a single mortality with prophylaxis would cost $43.00 million (number needed to treat: 39,839 individuals). The incremental cost was $1.90 million per quality-adjusted life-year. Adjusting across a range of scenarios upheld these conclusions 88% of the time. With further sensitivity testing, subpopulations with postdischarge thrombosis rates greater than 4.9% favors postoperative extended-duration venous thromboembolism prophylaxis. LIMITATIONS Further investigation is needed to determine if specific high-risk individuals can be preemptively identified in the Crohn's surgical population for targeted prophylaxis. CONCLUSION Extended prophylaxis in patients with Crohn's disease postoperatively is not cost-effective when the cumulative incidence of posthospital thrombosis remains less than 4.9%. These findings are driven by the low absolute risk of thrombosis in this population and the considerable cost of universal treatment. See Video Abstract at http://links.lww.com/DCR/A998. LIMITACIONES DE COSTO-BENEFICIO DE LA PROFILAXIS AMBULATORIA PROLONGADA DEL TROMBOEMBOLISMO VENOSO DESPUÉS DE CIRUGÍA EN CASOS DE ENFERMEDAD DE CROHN:: Los pacientes con enfermedad de Crohn tienen un mayor riesgo de tromboembolismo venoso postoperatorio. Históricamente, la profilaxis ambulatoria prolongada no ha cumplido con las medidas convencionales de ventajas en costo-beneficio para la sociedad. Sin embargo, la profilaxis prolongada en los pacientes con Crohn puede ser más rentable debido al alto riesgo trombótico y a una larga esperanza de vida en estos pacientes.Evaluar la rentabilidad de la profilaxis prolongada en pacientes postoperados de un Crohn.Se utilizó un modelo de árbol de decisión para evaluar el incremento de rentabilidad y el costo por cada caso evitado con la profilaxis prolongada de tromboembolismo venoso después de cirugía abdominal.Se calcularon utilizando fuentes publicadas el riesgo de evento trombótico posterior al alta, la edad del paciente al momento de la cirugía, el tipo de evento trombótico, la reducción del riesgo de profilaxis, las complicaciones hemorrágicas y la mortalidad.Se estudiaron los pacientes de atención rutinaria versus aquellos portadores de Crohn.Construimos un arbol de análisis decisional para comparar costos y resultados de pacientes portadores de Crohn, con y sin profilaxis prolongada en el postoperatorio en un horizonte de por vida.Los costos de productividad ($) y los beneficios (año de vida ajustado por calidad) se utilizaron para reflejar la perspectiva social y se descontaron en el tiempo de un 3%. El análisis de sensibilidad probabilística multivariable dió cuenta de la incertidumbre en las probabilidades, costos y peso de utilidades.Usando parámetros de referencia, el costo total social esperado de la atención individual fue de $ 399.83 sin y $ 1,387.95 con profilaxis. La prevención del deceso de un paciente con profilaxis costaría $ 43.00 millones (valor requerido para tratar: 39,839 individuos). El costo incrementado fue de $ 1.90 millones por año de vida ajustado por la calidad. El ajuste a través de una gama de escenarios confirmó estas conclusiones el 88% del tiempo. Con pruebas de sensibilidad adicionales, las subpoblaciones con tasas de trombosis posteriores al alta fueron superiores al 4,9% y favorecían la profilaxis prolongada del tromboembolismo venoso en el postoperatorio.Se necesita más investigación para determinar si se puede identificar de manera preventiva los individuos específicos de alto riesgo en la población quirúrgica de Crohn en casos de profilaxis dirigida.La profilaxis prolongada en pacientes postoperados de un Crohn no es rentable cuando la incidencia acumulada de trombosis posthospitalaria sigue siendo inferior al 4,9%. Estos hallazgos son impulsados por el bajo riesgo absoluto de trombosis en esta población y el costo considerable del tratamiento universal. Vea el resumen del video en http://links.lww.com/DCR/A998.
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