How reliable is perioperative anticoagulant management? Determining guideline compliance and practice variation by a retrospective patient record review.
BMJ Open
; 9(7): e029879, 2019 07 17.
Article
em En
| MEDLINE
| ID: mdl-31320357
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 ANDPARTICIPANTS:
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 OUTCOMEMEASURES:
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.Palavras-chave
Texto completo:
1
Coleções:
01-internacional
Temas:
Geral
Base de dados:
MEDLINE
Assunto principal:
Complicações Pós-Operatórias
/
Tromboembolia
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Vitamina K
/
Fidelidade a Diretrizes
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Assistência Perioperatória
/
Anticoagulantes
Tipo de estudo:
Guideline
/
Observational_studies
/
Prognostic_studies
/
Risk_factors_studies
Limite:
Aged
/
Aged80
/
Female
/
Humans
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Male
/
Middle aged
País/Região como assunto:
Europa
Idioma:
En
Revista:
BMJ Open
Ano de publicação:
2019
Tipo de documento:
Article
País de afiliação:
Holanda