ORIGINAL ARTICLE
Adherence With Postdischarge Venous Thromboembolism Chemoprophylaxis Recommendations After Colorectal Cancer Surgery Among Elderly Medicare Beneficiaries Ryan P. Merkow, MD, MS,∗ † Karl Y. Bilimoria, MD, MS,∗ Min-Woong Sohn, PhD,∗ ‡ Elissa H. Oh, MA,∗ Morgan M. Sellers, MD,∗ Jennifer L. Paruch, MD,∗ † Jeanette W. Chung, PhD,∗ and David J. Bentrem, MD, MS∗ § Objectives: To assess national adherence with extended venous thromboembolism (VTE) chemoprophylaxis guideline recommendations after colorectal cancer surgery. Background: Postoperative VTE remains a major cause of morbidity and mortality after abdominal cancer surgery. On the basis of the results from randomized controlled trials, since 2007, national guidelines have suggested that these patients be discharged on VTE chemoprophylaxis. Methods: Medicare beneficiaries undergoing open colorectal cancer resections in 2008–2009 were identified using the Medicare Provider Analysis and Review data and limited to those who were enrolled and used Part D for their postoperative prescriptions. Postdischarge use of low-molecular-weightheparin and other anticoagulants was assessed. Results: A total of 5078 patients underwent open colorectal cancer surgery and met the inclusion criteria. Of these, 77% underwent colectomy and 23% underwent proctectomy. A prescription for an anticoagulant was filled immediately after discharge for 77 (1.5%) patients, and a low-molecular-weightheparin for 60 (1.2%) patients. On multivariable analysis, patients were more likely to receive postdischarge VTE chemoprophylaxis if undergoing rectal cancer surgery [incidence rate ratio (IRR), 1.83; 95% confidence interval, 1.07–3.12; vs colon], if higher educational status (IRR, 2.20; 95% confidence interval, 1.23–3.95; vs low education), or if they had a higher Elixhauser comorbidity index (IRR, 1.13; 95% confidence interval, 1.01–1.25; vs lower index). Conclusions: Although VTE remains a major issue after abdominal cancer surgery, only 1.5% of Medicare beneficiaries undergoing colorectal cancer surgery received care consistent with established guidelines for postdischarge VTE chemoprophylaxis. Barriers to adherence must be elucidated to improve the quality of care for abdominal and pelvic cancer surgery patients. Keywords: cancer, colorectal, prophylaxis, surgery, venous thromboembolism
(CMS) considers VTE a never event and penalizes hospitals for higher than expected VTE complications after certain procedures. Abdominal cancer patients undergoing surgery are at particularly high risk for VTE, which is the most common preventable cause of 30-day deaths in this population.3 Importantly, at least one third of VTE events occur after patients are discharged from the hospital.4 To date, at least 3 randomized controlled trials and one metaanalysis have demonstrated that prolonged chemoprophylaxis after discharge from the hospital can dramatically reduce VTE rates among patients with abdominal and pelvic malignancies.5–8 Bergqvist et al,5 in a double-blind randomized controlled trial comparing extended duration VTE prophylaxis with low-molecular-weight-heparin (LMWH) with short-course chemoprophylaxis and placebo, found a significant reduction in VTE from 12.0% to 4.8%. This reduction persisted at 3 months. Subsequent studies have confirmed these findings, and in 2007 prolonged VTE chemoprophylaxis was recommended after major abdominal and pelvic cancer surgery by the American Society of Clinical Oncology9 and National Cancer Center Network,10 and the American College of Chest Physician guidelines.11 Despite these recommendations, a number of financial, social, and provider-level barriers may discourage prolonged VTE chemoprophylaxis. Moreover, limited data exist on the extent to which guideline recommendations are being followed, particularly after major abdominal cancer surgery in the United States. Our objectives were to (1) assess the use of postdischarge VTE chemoprophylaxis after colorectal cancer surgery among Medicare beneficiaries in the United States and (2) evaluate predictors of guideline adherence. Because colorectal cancer surgery is a common abdominal operation performed for cancer, and patients are at considerable risk for VTE, it was the ideal population for this study.
METHODS
(Ann Surg 2014;260:103–108)
V
enous thromboembolism (VTE) can be a devastating and costly complication.1,2 The Center for Medicare and Medicaid Services
From the ∗ Northwestern Institute for Comparative Effectiveness Research (NICER) in Oncology, the Surgical Outcomes and Quality Improvement Center (SOQIC) and the Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; †Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL; ‡Center for Management of Complex Chronic Care, Hines VA Hospitals, Hines, IL; and §Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL. Presented at the Academic Surgical Congress, February 6, 2013, New Orleans, LA. Disclosure: Supported in part by the American Cancer Society (#280521) (Drs Merkow and Bilimoria) and the Northwestern Institute for Comparative Effectiveness Research in Oncology (Drs Merkow, Bilimoria, and Bentrem). The authors declare no conflicts of interest. Reprints: Ryan P. Merkow, MD, MS, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St, Suite 650, Chicago, IL 60611. E-mail: [email protected]. C 2013 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/13/26001-0103 DOI: 10.1097/SLA.0000000000000296
Annals of Surgery r Volume 260, Number 1, July 2014
Data Source This study was performed using complete Medicare fee-forservice data from 2008 to 2009. Beneficiaries were identified from the Medicare Provider Analysis and Review file if they underwent colon or rectal resection. The Medicare Provider Analysis and Review contains administrative discharge and final-action claims aggregated to the level of the patient stay within institutional inpatient facilities. All additional claims were identified from the Beneficiary Summary File, Medicare Outpatient and Carrier Standard Analytic Files. Outpatient prescription pharmacy claims were determined with the Medicare Part D Drug Event File.
Patient Selection and Exclusion Among the 117,195 patients who were 65 years old or more and underwent an open colorectal surgery during the study period, 49,993 underwent resection for cancer on the basis of International Current Diagnosis, 9th edition12 (ICD-9) codes (Appendix 1). Patients younger than 65 years or not enrolled in both Medicare Parts A and B were excluded from the analysis (n = 8303). In addition, www.annalsofsurgery.com | 103
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 260, Number 1, July 2014
Merkow et al
because the purpose of the study was to evaluate VTE chemoprophylaxis prescription use, patients not enrolled in Medicare Part D in the 3 months before surgery were also excluded (n = 22,190). Patients were also excluded if anticoagulation was used within 90 days of surgery (n = 1873), if they had a diagnosis of atrial fibrillation (n = 2612), prior VTE (n = 283), central nervous system hemorrhage (n = 30), or previous inferior vena cava filter placement (n = 70). Finally, patients were excluded if they did not fill a prescription within 7 days of hospital discharge (indicating they may have had other prescription drug coverage) (n = 6071), were discharged to another facility such as a nursing home (n = 3482), or died during their inpatient stay (n = 1). Consistent with randomized trials, laparoscopic surgery patients were not included in this study. The final cohort contained 5078 patients (Fig. 1).
income (≥$36,000 vs
Adherence With Postdischarge Venous Thromboembolism Chemoprophylaxis Recommendations After Colorectal Cancer Surgery Among Elderly Medicare Beneficiaries Ryan P. Merkow, MD, MS,∗ † Karl Y. Bilimoria, MD, MS,∗ Min-Woong Sohn, PhD,∗ ‡ Elissa H. Oh, MA,∗ Morgan M. Sellers, MD,∗ Jennifer L. Paruch, MD,∗ † Jeanette W. Chung, PhD,∗ and David J. Bentrem, MD, MS∗ § Objectives: To assess national adherence with extended venous thromboembolism (VTE) chemoprophylaxis guideline recommendations after colorectal cancer surgery. Background: Postoperative VTE remains a major cause of morbidity and mortality after abdominal cancer surgery. On the basis of the results from randomized controlled trials, since 2007, national guidelines have suggested that these patients be discharged on VTE chemoprophylaxis. Methods: Medicare beneficiaries undergoing open colorectal cancer resections in 2008–2009 were identified using the Medicare Provider Analysis and Review data and limited to those who were enrolled and used Part D for their postoperative prescriptions. Postdischarge use of low-molecular-weightheparin and other anticoagulants was assessed. Results: A total of 5078 patients underwent open colorectal cancer surgery and met the inclusion criteria. Of these, 77% underwent colectomy and 23% underwent proctectomy. A prescription for an anticoagulant was filled immediately after discharge for 77 (1.5%) patients, and a low-molecular-weightheparin for 60 (1.2%) patients. On multivariable analysis, patients were more likely to receive postdischarge VTE chemoprophylaxis if undergoing rectal cancer surgery [incidence rate ratio (IRR), 1.83; 95% confidence interval, 1.07–3.12; vs colon], if higher educational status (IRR, 2.20; 95% confidence interval, 1.23–3.95; vs low education), or if they had a higher Elixhauser comorbidity index (IRR, 1.13; 95% confidence interval, 1.01–1.25; vs lower index). Conclusions: Although VTE remains a major issue after abdominal cancer surgery, only 1.5% of Medicare beneficiaries undergoing colorectal cancer surgery received care consistent with established guidelines for postdischarge VTE chemoprophylaxis. Barriers to adherence must be elucidated to improve the quality of care for abdominal and pelvic cancer surgery patients. Keywords: cancer, colorectal, prophylaxis, surgery, venous thromboembolism
(CMS) considers VTE a never event and penalizes hospitals for higher than expected VTE complications after certain procedures. Abdominal cancer patients undergoing surgery are at particularly high risk for VTE, which is the most common preventable cause of 30-day deaths in this population.3 Importantly, at least one third of VTE events occur after patients are discharged from the hospital.4 To date, at least 3 randomized controlled trials and one metaanalysis have demonstrated that prolonged chemoprophylaxis after discharge from the hospital can dramatically reduce VTE rates among patients with abdominal and pelvic malignancies.5–8 Bergqvist et al,5 in a double-blind randomized controlled trial comparing extended duration VTE prophylaxis with low-molecular-weight-heparin (LMWH) with short-course chemoprophylaxis and placebo, found a significant reduction in VTE from 12.0% to 4.8%. This reduction persisted at 3 months. Subsequent studies have confirmed these findings, and in 2007 prolonged VTE chemoprophylaxis was recommended after major abdominal and pelvic cancer surgery by the American Society of Clinical Oncology9 and National Cancer Center Network,10 and the American College of Chest Physician guidelines.11 Despite these recommendations, a number of financial, social, and provider-level barriers may discourage prolonged VTE chemoprophylaxis. Moreover, limited data exist on the extent to which guideline recommendations are being followed, particularly after major abdominal cancer surgery in the United States. Our objectives were to (1) assess the use of postdischarge VTE chemoprophylaxis after colorectal cancer surgery among Medicare beneficiaries in the United States and (2) evaluate predictors of guideline adherence. Because colorectal cancer surgery is a common abdominal operation performed for cancer, and patients are at considerable risk for VTE, it was the ideal population for this study.
METHODS
(Ann Surg 2014;260:103–108)
V
enous thromboembolism (VTE) can be a devastating and costly complication.1,2 The Center for Medicare and Medicaid Services
From the ∗ Northwestern Institute for Comparative Effectiveness Research (NICER) in Oncology, the Surgical Outcomes and Quality Improvement Center (SOQIC) and the Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; †Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL; ‡Center for Management of Complex Chronic Care, Hines VA Hospitals, Hines, IL; and §Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL. Presented at the Academic Surgical Congress, February 6, 2013, New Orleans, LA. Disclosure: Supported in part by the American Cancer Society (#280521) (Drs Merkow and Bilimoria) and the Northwestern Institute for Comparative Effectiveness Research in Oncology (Drs Merkow, Bilimoria, and Bentrem). The authors declare no conflicts of interest. Reprints: Ryan P. Merkow, MD, MS, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St, Suite 650, Chicago, IL 60611. E-mail: [email protected]. C 2013 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/13/26001-0103 DOI: 10.1097/SLA.0000000000000296
Annals of Surgery r Volume 260, Number 1, July 2014
Data Source This study was performed using complete Medicare fee-forservice data from 2008 to 2009. Beneficiaries were identified from the Medicare Provider Analysis and Review file if they underwent colon or rectal resection. The Medicare Provider Analysis and Review contains administrative discharge and final-action claims aggregated to the level of the patient stay within institutional inpatient facilities. All additional claims were identified from the Beneficiary Summary File, Medicare Outpatient and Carrier Standard Analytic Files. Outpatient prescription pharmacy claims were determined with the Medicare Part D Drug Event File.
Patient Selection and Exclusion Among the 117,195 patients who were 65 years old or more and underwent an open colorectal surgery during the study period, 49,993 underwent resection for cancer on the basis of International Current Diagnosis, 9th edition12 (ICD-9) codes (Appendix 1). Patients younger than 65 years or not enrolled in both Medicare Parts A and B were excluded from the analysis (n = 8303). In addition, www.annalsofsurgery.com | 103
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 260, Number 1, July 2014
Merkow et al
because the purpose of the study was to evaluate VTE chemoprophylaxis prescription use, patients not enrolled in Medicare Part D in the 3 months before surgery were also excluded (n = 22,190). Patients were also excluded if anticoagulation was used within 90 days of surgery (n = 1873), if they had a diagnosis of atrial fibrillation (n = 2612), prior VTE (n = 283), central nervous system hemorrhage (n = 30), or previous inferior vena cava filter placement (n = 70). Finally, patients were excluded if they did not fill a prescription within 7 days of hospital discharge (indicating they may have had other prescription drug coverage) (n = 6071), were discharged to another facility such as a nursing home (n = 3482), or died during their inpatient stay (n = 1). Consistent with randomized trials, laparoscopic surgery patients were not included in this study. The final cohort contained 5078 patients (Fig. 1).
income (≥$36,000 vs
