Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands.
BMJ Open. 2019 Jul 17;9(7):e029879. doi: 10.1136/bmjopen-2019-029879.
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.
A multicentre retrospective patient record review.
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.
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.
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.
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.
接受抗凝治疗的患者的手术需要仔细监测和风险评估，以防止伤害。需要中断抗凝剂并决定是否使用桥接抗凝剂会增加更多的复杂性。这一过程，即围手术期抗凝管理（PAM），通过使用指南得到优化。最佳的 PAM 可预防血栓栓塞和出血并发症。本研究旨在评估荷兰医院中 PAM 实践的可靠性。此外，还研究了医院之间和不同桥接剂量的差异。
一项多中心回顾性患者病历回顾。
对在代表荷兰 13 家医院的随机样本中接受手术的使用维生素 K 拮抗剂（VKA）抗凝剂的 268 名患者的记录进行了回顾，其中 259 名患者进行了分析。
我们的主要结局测量是 PAM 可靠性，用接受指南一致护理的患者百分比表示。纳入了 7 个 PAM 步骤。次要结局测量包括使用的不同桥接剂量以及医院层面的实践差异分析。
术前依从性最低的是及时中断 VKA：58.8%（95%CI 50.0%至 67.7%），而及时进行术前评估的依从性最高：81%（95%CI 75.0%至 86.5%）。术后依从性最低的是及时重启 VKA：39.9%（95%CI 33.1%至 46.7%），而决定应用桥接的依从性最高：68.5%（95%CI 62.3%至 74.8%）。医院之间在及时进行术前评估（范围 41%至 100%）、国际标准化比值检测（范围 21%至 94%）和术后桥接（范围 20%至 88%）方面存在差异。亚治疗性桥接在 50.5%的患者中使用，并随患者体重增加而增加。
大多数 PAM 步骤的依从性令人不满意，反映了 PAM 的可靠性不佳。此外，医院的表现也存在差异。这增加了不良事件的风险，需要进行质量改进。尽管有强有力的支持证据基础和关于 PAM 的综合护理提供，但制定过程措施将很复杂。
