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Is development of postoperative venous thromboembolism related to thromboprophylaxis use? A case-control study in the Veterans Health Administration.

Borzecki AM, Cowan AJ, Cevasco M, Shin MH, Shwartz M, Itani K, Rosen AK. Is development of postoperative venous thromboembolism related to thromboprophylaxis use? A case-control study in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety. 2012 Aug 1; 38(8):348-58.

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BACKGROUND: Observational studies continue to report thromboprophylaxis underuse for postoperative pulmonary embolism/deep vein thrombosis (pPE/DVT) despite the long-standing existence of prevention guidelines. However, data are limited on whether thromboprophylaxis use differs between patients developing pPE/DVT versus those who do not or on why prophylaxis is withheld. METHODS: Administrative data (2002-2007) from 28 Veterans Health Administration hospitals were screened for discharges with (1) pPE/DVT as flagged by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator software and (2) pharmacoprophylaxis-recommended procedures, and the medical records were reviewed to ascertain true pPE/DVT cases. Controls were selected by matching cases by hospital, age, sex, diagnosis-related group, and predicted probability for developing pPE/DVT, and who underwent a pharmacoprophylaxis-recommended procedure. Records were assessed for "appropriate pharmacoprophylaxis use," defined primarily per American College of Chest Physicians (ACCP) guidelines, and reasons for anticoagulant nonuse. RESULTS: The 116 case-control pairs were similar in terms of demographics, surgery type, ACCP risk category, and appropriate pharmacoprophylaxis rates overall. Of the highest-risk patients, respective pharmacoprophylaxis rates among cases and controls were 88% versus 92% among hip/knee replacements and 31% versus 48% among cancer patients. Of the cases and controls who did not receive appropriate pharmacoprophylaxis, only about 25% had documented contraindications. Reviewers identified contraindications in 14% of cases and 9% of controls. CONCLUSIONS: Similarities in preventive pPE/DVT practice between cases and controls suggest that pPE/DVTs occur despite implementation of guideline-adherent practices.

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