Northwestern Quality Improvement, Research, & Education in Surgery, Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
Canning Thoracic Institute, Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
JAMA Netw Open. 2023 Sep 5;6(9):e2335311. doi: 10.1001/jamanetworkopen.2023.35311.
Venous thromboembolism (VTE) represents a major source of preventable morbidity and mortality and is a leading cause of death in the US after cancer surgery. Previous research demonstrated variability in VTE chemoprophylaxis prescribing, although it is unknown how these rates compare with performance in the Veterans Health Administration (VHA).
To determine VTE rates after cancer surgery, as well as rates of inpatient and outpatient (posthospital discharge) chemoprophylaxis adherence within the VHA.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study within 101 hospitals of the VHA health system included patients aged 41 years or older without preexisting bleeding disorders or anticoagulation usage who underwent surgical treatment for cancer with general surgery, thoracic surgery, or urology between January 1, 2015, and December 31, 2022. The VHA Corporate Data Warehouse, Pharmacy Benefits Management database, and the Veterans Affairs Surgical Quality Improvement Program database were used to identify eligible patients. Data analysis was conducted between January 2022 and July 2023.
Inpatient surgery for cancer with general surgery, thoracic surgery, or urology.
Rates of postoperative VTE events within 30 days of surgery and VTE chemoprophylaxis adherence were determined. Multivariable Poisson regression was used to determine incidence-rate ratios of inpatient and postdischarge chemoprophylaxis adherence by surgical specialty.
Overall, 30 039 veterans (median [IQR] age, 67 [62-71] years; 29 386 men [97.8%]; 7771 African American or Black patients [25.9%]) who underwent surgery for cancer and were at highest risk for VTE were included. The overall postoperative VTE rate was 1.3% (385 patients) with 199 patients (0.7%) receiving a diagnosis during inpatient hospitalization and 186 patients (0.6%) receiving a diagnosis postdischarge. Inpatient chemoprophylaxis was ordered for 24 139 patients (80.4%). Inpatient chemoprophylaxis ordering rates were highest for patients who underwent procedures with general surgery (10 102 of 10 301 patients [98.1%]) and lowest for patients who underwent procedures with urology (11 471 of 17 089 patients [67.1%]). Overall, 3142 patients (10.5%) received postdischarge chemoprophylaxis, with notable variation by specialty.
These findings indicate the overall VTE rate after cancer surgery within the VHA is low, VHA inpatient chemoprophylaxis rates are high, and postdischarge VTE chemoprophylaxis prescribing is similar to that of non-VHA health systems. Specialty and procedure variation exists for chemoprophylaxis and may be justified given the low risks of overall and postdischarge VTE.
静脉血栓栓塞症（VTE）是可预防的发病率和死亡率的主要来源，也是美国癌症手术后死亡的主要原因。先前的研究表明，VTE 化学预防的处方存在差异，尽管尚不清楚这些比率与退伍军人健康管理局（VHA）的表现相比如何。
确定癌症手术后的 VTE 发生率，以及 VHA 内住院和门诊（出院后）化学预防的依从率。
设计、设置和参与者：这是一项在 VHA 医疗系统的 101 家医院内进行的回顾性队列研究，纳入了年龄在 41 岁或以上、无预先存在的出血性疾病或抗凝药物使用史的患者，这些患者接受了普通外科、胸外科或泌尿科手术治疗癌症，手术时间为 2015 年 1 月 1 日至 2022 年 12 月 31 日。VHA 公司数据仓库、药房福利管理数据库和退伍军人事务部手术质量改进计划数据库被用于确定合格患者。数据分析于 2022 年 1 月至 2023 年 7 月进行。
普通外科、胸外科或泌尿科手术治疗癌症。
确定术后 30 天内 VTE 事件的发生率和 VTE 化学预防的依从率。多变量泊松回归用于确定按手术专业划分的住院和出院后化学预防的发病率比值比。
共有 30399 名（中位[IQR]年龄，67[62-71]岁；29386 名男性[97.8%]；7771 名非裔或非裔美国人患者[25.9%]）接受癌症手术且 VTE 风险最高的退伍军人被纳入研究。总的术后 VTE 发生率为 1.3%（385 例），其中 199 例（0.7%）在住院期间确诊，186 例（0.6%）在出院后确诊。24139 名患者（80.4%）开具了住院化学预防药物。普通外科手术患者的住院化学预防药物开具率最高（10102 名/10301 名患者[98.1%]），泌尿科手术患者的最低（17089 名/11471 名患者[67.1%]）。总体而言，3142 名患者（10.5%）接受了出院后化学预防，不同专业之间存在显著差异。
这些发现表明，VHA 内癌症手术后的总体 VTE 发生率较低，VHA 住院化学预防药物的开具率较高，出院后 VTE 化学预防药物的开具与非 VHA 卫生系统相似。化学预防药物存在专业和程序差异，考虑到总体和出院后 VTE 的风险较低，这些差异可能是合理的。
