Practice patterns in high-risk bariatric venous thromboembolism prophylaxis

Updated Trends in Inferior Vena Cava Filter Use by Indication in the United States After Food and Drug Administration Safety Warnings: A Decade Analysis From 2010 to 2019

BACKGROUND

Overall inferior vena cava filter (IVCF) utilization has decreased in the United States since the 2010 US Food and Drug Administration (FDA) safety communication. The FDA renewed this safety warning in 2014 with additional mandates on reporting IVCF-related adverse events. We evaluated the impact of the FDA recommendations on IVCF placements for different indications from 2010 to 2019 and further assessed utilization trends by region and hospital teaching status.

METHODS

Inferior vena cava filter placements between 2010 and 2019 were identified in the Nationwide Inpatient Sample database using the associated International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision codes. Inferior vena cava filter placements were categorized by indication for venous thromboembolism (VTE) "treatment" in patients with VTE diagnosis and contraindication to anticoagulation and "prophylaxis" in patients without VTE. Generalized linear regression was used to analyze utilization trends.

RESULTS

A total of 823 717 IVCFs were placed over the study period, of which 644 663 (78.3%) were for VTE treatment and 179 054 (21.7%) were for prophylaxis indications. The median age for both categories of patients was 68 years. The total number of IVCFs placed for all indications decreased from 129 616 in 2010 to 58 465 in 2019, with an aggregate decline rate of -8.4%. The decline rate was higher between 2014 and 2019 than between 2010 and 2014 (-11.6% vs -7.2%). From 2010 to 2019, IVCF placement for VTE treatment and prophylaxis trended downward at rates of -7.9% and -10.2%, respectively. Urban nonteaching hospitals saw the highest decline for both VTE treatment (-17.2%) and prophylactic indications (-18.0%). Hospitals located in the Northeast region had the highest decline rates for VTE treatment (-10.3%) and prophylactic indications (-12.5%).

CONCLUSION

The higher decline rate in IVCF placements between 2014 and 2019 compared with 2010 and 2014 suggests an additional impact of the renewed 2014 FDA safety indications on national IVCF utilization. Variations in IVCF use for VTE treatment and prophylactic indications existed across hospital teaching types, locations, and regions.

CLINICAL IMPACT

Inferior vena cava filters (IVCF) are associated with medical complications. The 2010 and 2014 FDA safety warnings appeared to have synergistically contributed to a significant decline in IVCF utilization rates from 2010 - 2019 in the US. IVC filter placements in patients without venous thromboembolism (VTE) declined at a higher rate than VTE. However, IVCF utilization varied across hospitals and geographical locations, likely due to the absence of universally accepted clinical guidelines on IVCF indications and use. Harmonization of IVCF placement guidelines is needed to standardize clinical practice, thereby reducing the observed regional and hospital variations and potential IVC filter overutilization.

Venous thromboembolism (VTE) prophylaxis after bariatric surgery: a national survey of MBSAQIP director practices

BACKGROUND

Venous thromboembolism (VTE) is the most common cause of death following metabolic/bariatric surgery (MBS), with most events occurring after discharge. The available evidence on ideal prophylaxis type, dosage, and duration after discharge is limited.

OBJECTIVES

Assess metabolic/bariatric surgeon VTE prophylaxis practices and define existing variability.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited centers.

METHODS

The members of the ASMBS Research Committee developed and administered a web-based survey to MBSAQIP medical directors and ASMBS members to examine the differences in clinical practice regarding the administration of VTE prophylaxis after MBS.

RESULTS

Overall, 264 metabolic/bariatric surgeons (136 medical directors and 128 ASMBS members) participated in the survey. Both mechanical and chemical VTE prophylaxis was used by 97.1% of the participants, knee-high compression devices by 84.7%, enoxaparin (32.4% 40 mg every 24 hours, 22.7% 40 mg every 12 hours, 24.4% adjusted the dose based on body mass index) by 56.5%, and heparin (46.1% 5000 units every 8 hours, 22.6% 5000 units every 12 hours, 20.9% 5000 units once preoperatively) by 38.1%. Most surgeons (81.6%) administered the first dose preoperatively, while the first postoperative dose was given on the evening of surgery by 44% or the next morning by 42.2%. Extended VTE prophylaxis was prescribed for 2 weeks by 38.7% and 4 weeks by 28.9%.

CONCLUSIONS

VTE prophylaxis practices vary widely among metabolic/bariatric surgeons. Variability may be related to limited available comparative evidence. Large prospective clinical trials are needed to define optimal practices for VTE risk stratification and prophylaxis in bariatric surgery patients.

Inferior vena cava filters: a framework for evidence-based use

Venous thromboembolism (VTE) is a common cause of morbidity and mortality. Although most patients can be managed safely with anticoagulation, inferior vena cava filters (IVCFs) represent an important alternative to anticoagulation in a small subset of patients. IVCF use has expanded exponentially with the advent of retrievable filters. Indications for IVCFs have liberalized despite limited evidence supporting this practice. Because indiscriminate use of IVCFs can be associated with net patient harm, knowledge of the risks and benefits of these devices is essential to optimal evidence-based practice. Patients with acute VTE and absolute contraindications to anticoagulation or major complications from anticoagulation are universally agreed indications for IVCFs. However, the reliance on IVCFs for primary VTE prophylaxis in high-risk patients is not substantiated by the available literature. This review examines trends in IVCF use, practice-based recommendations on IVCF use in various clinical scenarios, complications associated with indwelling IVCFs, and indications for IVCF retrieval.

Incidence of Silent Deep Venous Thrombosis after Laparoscopic Bariatric Surgery in Patients Who Received Combined Mechanical and Chemical Thromboprophylaxis Compared to Patients Who Received Mechanical Thromboprophylaxis Only

Background. This prospective randomized study compares the incidence of silent deep venous thrombosis (DVT) among 2 groups of patients who underwent laparoscopic bariatric surgery. The first group received mechanical thromboprophylaxis only, while the second group received a combination of mechanical and chemical thromboprophylaxis. Methods. This study included 150 morbidly obese patients who underwent primary one-stage laparoscopic bariatric surgery (sleeve gastrectomy and mini-gastric bypass) over a 6-month period. Patients were randomly assigned to 2 groups: group A (n = 75) was subjected to mechanical thromboprophylaxis in the form of perioperative elastic stockings on both lower limbs and early postoperative ambulation, and group B (n = 75) was subjected to combined mechanical thromboprophylaxis and chemical thromboprophylaxis in the form of 40 mg subcutaneous enoxaparin 12 hours before surgery and postoperative enoxaparin (40 mg subcutaneous every 24 hours) for 2 weeks. Bilateral lower limb venous duplex was done for all patients before discharge, on the second and fourth weeks postoperatively, to detect silent DVT. Results. Nine patients out of 150 patients developed silent DVT (6%). All patients among group A were subjected to mechanical thromboprophylaxis only (12%) [P = .247, relative risk: .45, 95% confidence interval; .37-.62]. There was no silent DVT among group B who received combined mechanical and chemical thromboprophylaxis. No bleeding complications were reported in both groups. Conclusion. Combined mechanical and mechanical thromboprophylaxis is effective and safe in the prevention of silent DVT after laparoscopic bariatric surgery. Trial registration: The trial was registered in the Thai Clinical Trials Registry (TCTR20200127002) on January 20, 2020 retrospectively.

Racial disparities in inferior vena cava filter use in metabolic and bariatric surgery patients: Nationwide insights from the MBSAQIP database

BACKGROUND

Prophylactic inferior vena cava (IVC) filter use in bariatric surgery patients is a physician- and patient-dependent practice pattern with unclear safety and efficacy. Factors that mediate physicians' decisions for IVC filter placement preoperatively remain unclear. The role of race in decision-making also remains unclear.

METHODS

From the 2015-2016 MBASQIP database, patient characteristics leading to IVC filter use and outcomes after IVC filter placement were compared between Black and White primary bariatric surgery patients.

RESULTS

Prophylactic IVC filter was used in 0.66% of Black and White patients. IVC filter use was three-fold higher in Black patients, despite this cohort having a lower venous thromboembolism (VTE) risk profile than White counterparts. Black race was an independent predictor for IVC filter placement on multivariate analysis. After receiving an IVC filter, Black patients had higher rates of 30-day adverse outcomes.

CONCLUSIONS

In this study, Black race was independently associated with the likelihood of receiving a prophylactic IVC filter, despite lower rates of VTE risk factors and lack of recommendations for its use. Further research is needed to explore why this disparity in clinical practice exists.

Association Between Surgeon Practice Knowledge and Venous Thromboembolism

BACKGROUND

The most common cause of mortality following bariatric surgery is venous thromboembolism. Our study aimed to (1) determine the practice patterns of venous thromboembolism (VTE) chemoprophylaxis among bariatric surgeons participating in a large statewide quality collaborative and (2) compare the results of surgeon self-reported chemoprophylaxis practices to actual practices from abstracted chart data.

METHODS

We administered a 13-question survey to 66 surgeons across a statewide collaborative aimed at revealing VTE practice patterns such as medication type, dosage, timing, duration, and level of trainee involvement (response rate 93%). We conducted on-site data audits to examine the charts of all patients that had developed VTE during the study period and 15 other randomly selected patient charts per site. We then evaluated both the ordered perioperative chemoprophylaxis and the actual administered chemoprophylaxis from nursing and electronic records.

RESULTS

There was 31% overall discordance between self-reported and abstracted chart data for pre-operative VTE dosing regimens. Among patients who had a VTE, 39% of administered chemoprophylaxis did not match surgeon responses. Conversely, among patients who did not have a VTE, only 29% were discordant (p = 0.03). In contrast, for post-operative VTE dosing, there was no significant difference in the rate of discordance in patients with and without a VTE (47% discordance vs 38%, p = 0.0552, respectively).

CONCLUSIONS

Greater discordance between surgeon self-reported and actual perioperative VTE chemoprophylaxis is associated with significantly increased risk of VTE. Further understanding of the system characteristics associated with these practices may yield insights into how best to improve appropriate VTE chemoprophylaxis.

Less pain and earlier discharge after implementation of a multidisciplinary enhanced recovery after surgery (ERAS) protocol for laparoscopic sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) may be complicated by postoperative pain, nausea, and vomiting, with consequent increases in length of stay (LOS), decreased patient satisfaction, and higher costs. While enhanced recovery after surgery (ERAS) protocols have been in circulation for many years, there is no standard ERAS protocol for bariatric surgery.

METHODS

Data were collected prospectively and compared to a historical control. All patients undergoing LSG, ages 18 to 75, were included in the pathway; those with preoperative chronic opioid use were excluded from our results. Statistical analysis was performed using t-statistics and chi-squared test. Ninety patients undergoing LSG, performed by a single surgeon, were included in our ERAS group from November 26, 2018, to April 30, 2019, and were compared to a historical control of 570 patients who underwent LSG over the previous 5 years (pre-ERAS). Measured outcomes included discharge opioid prescriptions issued, hospital length of stay, 30-day readmissions, reoperations, morbidity, and mortality.

RESULTS

Ten (11%) ERAS patients vs 100% of pre-ERAS patients received opioid prescriptions upon, or after, discharge (p < 0.001). The ERAS group LOS decreased to 1.36 days vs 2.40 days in the pre-ERAS group (p < 0.001). 30-day readmission rates were 0% for ERAS patients vs 3.09% for pre-ERAS patients (p = 0.149). 30-day reoperation rates were 0% for ERAS patients vs 0.54% for pre-ERAS patients (p = 1). Thirty-day morbidity rates were 3.33% (3) for ERAS patients vs 3.27% for pre-ERAS patients (p = 1); there was no 30-day mortality in either group.

CONCLUSION

ERAS for LSG results in a clinical and statistically significant reduction in postoperative opioid use and LOS, without increasing 30-day readmissions, reoperations, morbidity, or mortality.

Identifying the factors influencing practice variation in thrombosis medicine: A qualitative content analysis of published practice-pattern surveys

Practice variation, the differences in clinical management between physicians, is one reason why patient outcomes may differ. Identifying factors that contribute to practice variation in areas of clinical uncertainty or equipoise may have implications for understanding and improving patient care. To discern what factors may influence practice variation, we completed a qualitative content analysis of all practice-pattern surveys in thrombosis medicine in the last 10years. Out of 2117 articles screened using a systematic search strategy, 33 practice-pattern surveys met eligibility criteria. Themes were identified using constant comparative analysis of qualitative data. Practice variation was noted in all 33 practice-pattern surveys. Contributing factors to variation included lack of available evidence, lack of clear and specific guideline recommendations, past experience, patient context, institutional culture and the perceived risk and benefit of a particular treatment. Additional themes highlight the value placed on expertise in challenging clinical scenarios, the complexity of practice variation and the value placed on minimizing practice variation.

Inferior vena cava filters

Use of inferior vena cava (IVC) filters has increased dramatically in recent decades, despite a lack of evidence that their use has impacted venous thromboembolism (VTE)-related mortality. This increased use appears to be primarily driven by the insertion of retrievable filters for prophylactic indications. A growing body of evidence, however, suggests that IVC filters are frequently associated with clinically important adverse events, prompting a closer look at their role. We sought to narratively review the current evidence on the efficacy and safety of IVC filter placements. Inferior vena cava filters remain the only treatment option for patients with an acute (within 2-4 weeks) proximal deep vein thrombosis (DVT) or pulmonary embolism and an absolute contraindication to anticoagulation. In such patients, anticoagulation should be resumed and IVC filters removed as soon as the contraindication has passed. For all other indications, there is insufficient evidence to support the use of IVC filters and high-quality trials are required. In patients where an IVC filter remains, regular follow-up to reassess removal and screen for filter-related complications should occur.

Perioperative management of bariatric surgery patients

PURPOSE

The perioperative management of bariatric surgery patients is described.

SUMMARY

Obesity and anatomical changes create unique challenges for clinicians when caring for bariatric surgery patients. Common bariatric surgery procedures performed include Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding. Pain management in the acute postoperative period depends on careful dosing of opioid agents and the use of adjunctive agents. Prevention and management of infectious complications include appropriate surgical prophylaxis, monitoring and rapid treatment of suspected intra-abdominal infections, and detection and treatment of Helicobacter pylori infection. Venous thromboembolism (VTE) prophylaxis and treatment are complicated by obesity, and the use of pharmacologic agents must be balanced with bleeding risk. Bleeding is a serious complication that should be closely monitored in the immediate postoperative period. Blood products remain first-line therapy for the treatment of bleeding in this population. Acute differences in drug absorption as well as emerging hormonal changes necessitate the immediate postoperative adjustment of chronic medications to ensure both safety and efficacy. Pharmacists are valuable members of interprofessional teams for bariatric surgery patients because they provide expertise on the availability of dosage forms and dosage modification to ensure that patient pharmacotherapy is not interrupted; assist in the management of hypertension, diabetes, and psychotropic medications; and ensure appropriate antimicrobial prophylaxis and VTE prophylaxis and treatment dosages.

CONCLUSION

The management of patients in the perioperative period of bariatric surgery requires appropriate selection and dosing of medications for pain management and treatment of infectious complications, VTE, bleeding, and other chronic diseases.

Prevention of venous thromboembolism in patients undergoing bariatric surgery

Bariatric surgical procedures are now a common method of obesity treatment with established effectiveness. Venous thromboembolism (VTE) events, which include deep vein thrombosis and pulmonary embolism, are an important source of postoperative morbidity and mortality among bariatric surgery patients. Due to an understanding of the frequency and seriousness of these complications, bariatric surgery patients typically receive some method of VTE prophylaxis with lower extremity compression, pharmacologic prophylaxis, or both. However, the optimal approach in these patients is unclear, with multiple open questions. In particular, strategies of adjusted-dose heparins, postdischarge anticoagulant prophylaxis, and the role of vena cava filters have been evaluated, but only to a limited extent. In contrast to other types of operations, the literature regarding VTE prophylaxis in bariatric surgery is notable for a dearth of prospective, randomized clinical trials, and current professional guidelines reflect the uncertainties in this literature. Herein, we summarize the available evidence after systematic review of the literature regarding approaches to VTE prevention in bariatric surgery. Identification of risk factors for VTE in the bariatric surgery population, analysis of the effectiveness of methods used for prophylaxis, and an overview of published guidelines are presented.