Thromboprophylaxis

This retrospective analysis of thromboprophylaxis fills several gaps in the literature. It is the first study of its kind in British Columbia, and the study population encompassed all adults, not just elderly patients. Hospital pharmacists are usually aware of the prescribing patterns in their respective institutions, but often little is known about what occurs once patients are discharged. This study offered the benefit of observing what was happening outside of the hospital, after patients were discharged. Use of the PharmaNet database allowed us to determine the total duration of thromboprophy- lactic therapy, which in turn enabled us to observe gaps in adherence to the recommended guidelines. These results showed poor adherence to the recommended guidelines and revealed that patients were receiving suboptimal therapy. Although most patients received at least some thromboprophy- laxis, most did not receive an adequate duration of therapy. We strongly suspect that this problem exists in other jurisdictions in Canada, and we therefore emphasize the need for similar audits at other hospitals that provide orthopedic surgery services.

These results are consistent with those for similar audits conducted with comparable objectives in mind. A survey of 397 Canadian orthopedic surgeons reported that only 36% of physicians ordered postdischarge thromboprophylaxis for their patients. A 2008 retrospective clinical audit of adherence to a thromboprophylaxis protocol for surgical patients found that only 29% of patients received adequate therapy. An audit of various hospitals in the United States examined compliance with the ACCP guidelines and found that of 2324 patients admitted for orthopedic surgery, 36.8% had received an inadequate duration of thromboprophylaxis and 56.3% had received no prophylaxis. Another recently published study based on a large US health claims database (and reported in abstract form) found that only 40% of 3497 patients who underwent orthopedic surgery received the appropriate thromboprophylaxis as described by the ACCP guidelines.
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Through this study, we sought to provide other sites offering orthopedic surgery with a framework to assess the level of adherence to thromboprophylaxis for their patients. Our suggestion is that all sites complete similar audits using in- hospital and postdischarge data. In addition, future studies should include a component to identify the reasons for nonad-herence, so that specific deficiencies can be addressed. For example, other sites could use a prospective observational design in which orthopedic surgery patients are followed to determine if they actually receive their prescriptions and if so, whether they go on to fill those prescriptions. In addition, patients who receive but do not fill prescriptions could be asked why they have not done so.

Many potential barriers might explain the lack of adherence evident at the authors’ community hospital. These potential barriers include lack of appropriate risk stratification, lack of prescribing, lack of filling of prescriptions by patients, prohibitive cost of thromboprophylactic agents, and lack of follow-up in the community. One drawback of this study was our inability to determine whether the lack of filling of postdischarge prescriptions in the community was a result of physicians not prescribing the medications or patients not filling prescriptions. As mentioned, one barrier that might contribute to a patient’s decision to not fill a prescription could be the cost of LMWH. Despite guidelines recommending up to 28-35 days of therapy for high-risk patients, the provincial drug coverage program provides funding for only up to 10 days of therapy. The increased workload and transition to INR monitoring in the community for patients receiving vitamin K antagonists may also be a barrier. Other potential barriers could be physicians’ heightened level of concern regarding their patients’ risk of bleeding with these agents, lack of awareness of current guidelines, and individual physicians’ prescribing patterns. Further research may be warranted to determine the specific barriers that are causing this lack of adherence, to allow implementation of effective changes to current practice in the authors’ institution.
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Recommendations that could be considered to improve adherence in the future include creation of preprinted order sets incorporating the hospital’s policy for use of these agents, preprinted discharge prescriptions, further involvement of pharmacy staff, education of surgeons and patients, better criteria for determining the risk of bleeding (in relation to potential benefit of thromboprophylaxis), and individual site audits (including follow-up audits). In addition, more research is needed to identify specific areas where change is needed, as each hospital may have particular reasons for nonadherence.

This study had some limitations. For example, some patients may have been discharged from one hospital to another hospital, rather than to home, but because PharmaNet is a community-based system, we would have been unable to track prescriptions filled at another facility. With oral tablets of multiple strengths (e.g., warfarin), it is sometimes difficult to determine the duration of therapy, as patients may be taking more than one tablet per dose. Therefore, even though we were able to determine the filling of these prescriptions, this could represent a source of error. The intent was to analyze informa­tion for 200 patients, but only 170 patients were included. However, this did not compromise the reliability of the data. In consultation with a statistician, we had 95% confidence (± 6.02%, instead of the prespecified ± 5%) that the sample of 170 patients was representative of the 510 patients who underwent total hip replacement, total knee replacement, or hip fracture repair during the study period. Finally, these findings apply only to the situation at Burnaby Hospital and may not necessarily reflect practice in other jurisdictions.
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In conclusion, adherence to the 2008 ACCP guidelines for duration of thromboprophylaxis after orthopedic surgery was suboptimal at the authors’ community hospital. The method­ology used in this study could be used by other hospitals to assess compliance with recommendations during the hospital stay and after discharge. Future studies examining this issue should consider methods that allow identification of barriers to adherence, including barriers to the prescribing and procurement of therapy for use after discharge.