Patient-reported barriers for adherence to prophylactic enoxaparin after orthopedic trauma surgery.

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.

Accuracy of Trauma Surgeons Prospective Estimation of the Injury Severity Score: A Pilot Study.

Injury Severity Score (ISS) has limited utility as a prospective predictor of trauma outcomes as it is currently scored by abstractors post-discharge. This study aimed to determine accuracy of ISS estimation at time of admission. Attending trauma surgeons assessed the Abbreviated Injury Scale of each body region for patients admitted during their call, from which estimated ISS (eISS) was calculated. The eISS was considered concordant to abstracted ISS (aISS) if both were in the same category: mild (<9), moderate (9-15), severe (16-25), or critical (>25). Ten surgeons completed 132 surveys. Overall ISS concordance was 52.2%; 87.5%, 30.8%, 34.8%, and 61.7% for patients with mild, moderate, severe, and critical aISS, respectively; unweighted k = .36, weighted k = .69. This preliminarily supports attending trauma surgeons' ability to predict severity of injury in real time, which has important clinical and research implications.

Generalizability of COBRA: A Parsimonious Perioperative Venous Thromboembolism Risk Assessment Model.

INTRODUCTION: Standardized use of venous thromboembolism (VTE) risk assessment models (RAMs) in surgical patients has been limited, in part due to the cumbersome workflow addition required to use available models. The COBRA score-capturing cancer diagnosis, (old) age, body mass index, race, and American Society of Anesthesiologists Physical Status score-has been reported as a potentially automatable VTE RAM that circumvents the cumbersome workflow addition that most RAMs represent. We aimed to test the ability of the COBRA model to effectively risk-stratify patients across various populations. METHODS: Patients were included from the 2014-2019 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Participant Use Data File for two hospitals, representing colorectal, endocrine, breast, transplant, plastic, and general surgery services. COBRA score was calculated for each patient using preoperative characteristics. We calculated negative predictive value (NPV) for VTE outcomes and compared the COBRA score to NSQIP's expected VTE rate for all patients, between the two hospitals, and between subspecialty service lines. RESULTS: Of the 10,711 patients included, those with COBRA <4 (31%) had projected median VTE rate of 0.21% (interquartile range, 0.09-0.68%; mean, 0.54%). Patients with higher scores (69%) had median rate of 0.88% (0.26-2.07%; 1.46%); relative rate 2.7. The median projected VTE rates for patients identified as low risk were 0.21% and 0.16% and as high risk were 0.87% and 0.89% at hospitals one and 2, respectively. The median projected VTE rates for patients identified as low risk were 0.17%, 0.61%, and 0.08% and as high risk were 0.52%, 1.43%, and 0.18% among general, colorectal, and endocrine surgery patients, respectively. COBRA had NPV of 0.995 and sensitivity of 0.871 as compared to NPV 0.997 and sensitivity 0.857 of the NSQIP model. CONCLUSIONS: The COBRA score is concordant with the traditional gold standard NSQIP VTE RAM and demonstrates interhospital and service-specific generalizability, although performance was limited in especially low-risk patients. The model adequately risk-stratifies surgical patients preoperatively, potentially providing clinical decision support for perioperative workflows.

Improving Statewide Post-Operative Sepsis Performance Measurement Using Hospital Risk Adjustment Within a Surgical Collaborative.

Background: The Georgia Quality Improvement Program (GQIP) surgical collaborative participating hospitals have shown consistently poor performance in the post-operative sepsis category of National Surgical Quality Improvement Program data as compared with national benchmarks. We aimed to compare crude versus risk-adjusted post-operative sepsis rankings to determine high and low performers amongst GQIP hospitals. Patients and Methods: The cohort included intra-abdominal general surgery patients across 10 collaborative hospitals from 2015 to 2020. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) sepsis definition was used among all hospitals for case abstraction and NSQIP data were utilized to train and validate a multivariable risk-adjustment model with post-operative sepsis as the outcome. This model was used to rank GQIP hospitals by risk-adjusted post-operative sepsis rates. Rankings between crude and risk-adjusted post-operative sepsis rankings were compared ordinally and for changes in tertile. Results: The study included 20,314 patients with 595 cases of post-operative sepsis. Crude 30-day post-operative sepsis risk among hospitals ranged from 0.81 to 5.11. When applying the risk-adjustment model which included: age, American Society of Anesthesiology class, case complexity, pre-operative pneumonia/urinary tract infection/surgical site infection, admission status, and wound class, nine of 10 hospitals were re-ranked and four hospitals changed performance tertiles. Conclusions: Inter-collaborative risk-adjusted post-operative sepsis rankings are important to present. These metrics benchmark collaborating hospitals, which facilitates best practice exchange from high to low performers.