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Abstract
Objectives Surgery in patients on anticoagulants requires careful monitoring and risk assessment to prevent harm. Required interruptions of anticoagulants and deciding whether to use bridging anticoagulation add further complexity. This process, known as perioperative anticoagulant management (PAM), is optimised by using guidelines. Optimal PAM prevents thromboembolic and bleeding complications. The purpose of this study was to assess the reliability of PAM practice in Dutch hospitals. Additionally, the variations between hospitals and different bridging dosages were studied.
Design A multicentre retrospective patient record review.
Setting and participants Records from 268 patients using vitamin-K antagonist (VKA) anticoagulants who underwent surgery in a representative random sample of 13 Dutch hospitals were reviewed, 259 were analysed.
Primary and secondary outcome measures Our primary outcome measure was the reliability of PAM expressed as the percentage of patients receiving guideline compliant care. Seven PAM steps were included. Secondary outcome measures included different bridging dosages used and an analysis of practice variation on the hospital level.
Results Preoperative compliance was lowest for timely VKA interruptions: 58.8% (95% CI 50.0% to 67.7%) and highest for timely preoperative assessments: 81% (95% CI 75.0% to 86.5%). Postoperative compliance was lowest for timely VKA restarts: 39.9% (95% CI 33.1% to 46.7%) and highest for the decision to apply bridging: 68.5% (95% CI 62.3% to 74.8%). Variation in compliance between hospitals was present for the timely preoperative assessment (range 41%–100%), international normalised ratio testing (range 21%–94%) and postoperative bridging (range 20%–88%). Subtherapeutic bridging was used in 50.5% of patients and increased with patients’ weight.
Conclusions Unsatisfying compliance for most PAM steps, reflect suboptimal reliability of PAM. Furthermore, the hospital performance varied. This increases the risk for adverse events, warranting quality improvement. The development of process measures can help but will be complicated by the availability of a strong supporting evidence base and integrated care delivery regarding PAM.
- anticoagulation
- quality in health care
- surgery
- thromboembolism
- clinical audit
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Footnotes
Contributors MJM, NLD, MVH, MdB and CW designed the study and developed the study protocol. MVH chaired the expert panel and contributed to the study design. MJM and NLD organised the data collection. MJM collected the data. MJM performed statistical analyses. MJM and JFdG interpreted the results. MJM wrote the manuscript. All authors made critical revisions and approved the final version of the manuscript.
Funding This work was supported by the Dutch Ministry of Healthcare Welfare and Sport.
Competing interests None declared.
Ethics approval The study protocol was approved by the medical ethics committee of the VU University Medical Centre, Amsterdam, The Netherlands.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data may be obtained from a third party and are not publicly available.
Patient consent for publication Not required.