Mandated Venous Thromboembolism Prophylaxis: Possible Adverse Outcomes

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Abstract

The purpose of this study was to assess the prevalence and seriousness of adverse outcomes owing to mandatory venous thromboembolism (VTE) prophylaxis. A retrospective study of administrative claims data was conducted to look at the rate of VTEs and other complications in patients undergoing hip and knee arthroplasty. Additional analysis was done to determine whether patient characteristics could explain findings. Although rates of VTE remain unchanged from 2003 to 2007, the rate of immediate postprocedure hematoma, seroma, and hemorrhage went from 1.4% in 2003 to 9.6% in 2006. Return to a more conservative prophylaxis approach resulted in a marked decrease in rates of significant bleeding events. Although preventing VTEs is an important quality concern, mandating prophylaxis for all patients could have unintended adverse outcomes. These guidelines might need to be reevaluated for hip and knee arthroplasty patients.

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Materials and Methods

Mandated VTE prophylaxis, which included the use of both LMWH and warfarin, was instituted in July 2005 in our institution, an academic medical center with 600 inpatient beds. Regardless of risk of bleeding or risk of VTE, all patients undergoing THA were given warfarin (target INR of 2.0) starting on the day of surgery and 40 mg LMWH subcutaneously daily starting 12 hours after surgery. Patients undergoing TKA were given warfarin (target INR of 2.0) and were also given 40 mg LMWH if they had a

Administrative Data Analysis

The number of cases with the primary procedure of joint arthroplasty has increased from 586 cases in fiscal year 2005 to 759 cases in fiscal year 2007. Reported complications of any type (as indicated by the inclusion of any ICD-9 code in the range of 996.00 to 999.99 in the official patient record), including those not related to the orthopedic procedure, have increased from 22.7% to 31.4% of cases in the same period. The rate for readmission for reasons related directly to the orthopedic

Discussion

This study was undertaken to examine the increasing number of bleeding events that were occurring in joint arthroplasty patients after the introduction of mandatory VTE prophylaxis guidelines. We found a significant and alarming jump in the number of bleeding complications (hematoma, seroma, hemorrhage) after starting more aggressive anticoagulant therapy that included LMWH. A return to less aggressive therapy led to decreased rates of bleeding events in the 6 months after the policy change,

Acknowledgment

The authors would like to acknowledge Vince Gomez, University of Virginia, for his help with this manuscript.

References (23)

  • R.P. Pitto et al.

    Mechanical prophylaxis of deep-vein thrombosis after total hip replacement: a randomised clinical trial

    J Bone Joint Surg Br

    (2004)
  • Cited by (0)

    No benefits or funds were received in support of the study.

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