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Nation-Wide Utilization of Chemoprophylaxis for the Prevention of VTE in Radical Cystectomy: How Well Do Urologists Follow the Guidelines?
Stephen Reese, MD, Matthew Mossanen, MD, Steven Chang, MD.
Brigham and Women's Hospital, Boston, MA, USA.
BACKGROUND: Venous Thromboembolism (VTE), which comprises deep venous thrombosis (DVT) and pulmonary embolism (PE) is a major preventable source of morbidity and mortality for patients undergoing radical cystectomy. In an effort to decrease the incidence of VTE in patients undergoing urologic surgery, the American Urologic Association (AUA) published guideline in 2008 recommending best practices for the prevention of VTEs in patients undergoing urologic surgery. The guidelines recommend using chemoprophylaxis in patients who are at least at moderate risk unless there is a contraindication to the use of such agents, for which unequivocally all patients undergoing radical cystectomy qualify. We performed a population-based analysis to determine the utilization of chemoprophylaxis and the various factors which contributed to an increased likelihood of physicians not providing prophylaxis.
METHODS: A population-based analysis was performed using the Perspective Database (Premier, Inc, Charlotte, NC), a dataset capturing inpatient billing records for over 400 hospitals in the United States. Our study cohort included all adult patients who underwent radical cystectomy between 2006 and 2015. Patients were identified as having undergone a radical cystectomy for a cancer diagnosis by capturing ICD-9-CM codes. Patients who received chemoprophylaxis were identified by specific hospital charge billing descriptions, including the hospital days for which they received the chemoprophylaxis. Those patients who received chemoprophylaxis for at least 80% of their hospital stay were deemed to have received appropriate chemoprophylaxis. Drawing from a 51,976 patient sample,descriptive statistics and multivariate analysis were performed adjusting for sampling weights.
RESULTS: Utilization rate of appropriate VTE chemoprophylaxis differed by a number of patient characteristics (fig. 1). Appropriate use of chemoprophylaxis was only administered to 31.31% of the cohort on aggregate, although a 34.16 percentage point increase was noted over the study period, with a maximum rate of utilization at 52.02%. Patients with a higher charlson comorbidity index score, increasing age, and rural hospital locations, commercial insurance and an earlier year of surgery were all associated with increased likelihood of not received chemoprophylaxis (fig. 3). Patients who received appropriate VTE chemoprophylaxis compared to those who did not had higher rates of VTE, DVT, PE, length of hospital stay and lower 90 day hospital costs (fig. 2).
| Figure 1. Demographics. No. (%), Appropriate PPx = >80% of LOS (Max ppx)2006-2015 | | Characteristics | Total (n=51,976) | Appropriate Ppx(n=16,272) | | Duration of Ppx | 0.1 (0.25) | 0.93 (0.23) | | Anticoagulation Type | | | | Heparin | 18,602 (35.79) | | | Lovenox | 16,392 (31.54) | | | Charlson CI | | | | 0 | 20,564 (39.56) | 6,482 (31.52) | | 1 | 14,032 (27.00) | 4,363 (31.09) | | >=2 | 17,380 (33.44) | 5,427 (31.23) | | Age | | | | <55 | 4,320 (8.31) | 1,472 (34.09) | | >=55-64 | 10,831 (20.84) | 3,538 (32.66) | | >=65-74 | 19,305 (37.14) | 5,986 (31.01) | | >=75 | 17,519 (33.71) | 5,276 (30.12) | | Gender | | | | Female | 8,176 (15.73) | 2,508 (30.68) | | Male | 43,800 (84.27) | 13,754 (31.42) | | Race | | | | Black | 2,460 (4.73) | 788 (32.03) | | Hispanic | 405 (0.78) | 80 (19.75) | | White | 41,699 (80.23) | 13,236 (31.74) | | Other | 7,412 (14.26) | 2,169 (29.26) | | Payer | | | | Commercial | 12,754 (24.54) | 3,977 (31.18) | | Medicaid | 1,884 (3.62) | 752 (39.94) | | Medicare | 34,937 (67.22) | 10,784 (30.87) | | Other | 2,400 (4.62) | 759 (31.64) | | Geography | | | | Midwest | 10,495(20.19) | 3,261 (31.07) | | Northeast | 8,962 (17.24) | 4,700 (52.45) | | South | 21,451 (41.27) | 6,102 (28.44) | | West | 11,068 (21.29) | 2,210 (19.97) | | Teaching Status | | | | No | 32,913 (63.32) | 9,036 (27.45) | | Yes | 19,063 (36.68) | 7,237 (37.96) | | Beds | | | | <300 | 13,620 (26.20) | 4,026 (29.56) | | >=300-500 | 19,612 (37.73) | 5,113 (26.07) | | >=500 | 18,744 (36.06) | 7,134 (38.06) | | Pop. Density | | | | Rural | 1,504 (2.89) | 317 (21.06) | | Urban | 50,472 (97.11) | 15,956 (31.61) | | Year | | | | 2006-2010 | 29,092 (55.97) | 6,789 (23.34) | | 2010-2015 | 22,884 (44.03) | 9,483 (41.44) |
| Figure 2: Outcomes - 2006-2015 | | Thromboembolism - 90 day | Total (n=51,976) | No Appropriate Ppx(n=33,340) | AppropriatePpx (n=18,636) | | VTE | 2,862(5.51) | 2046(5.73) | 816(5.01) | | DVT | 1992 (3.83) | 1320 (3.96) | 672 (3.61) | | PE | 1423 (2.74) | 967 (2.90) | 457 (2.45) | | Bleeding | 5283 (10.16) | 3,710(10.39) | 1,573 (9.66) | | LOS | 11.92(18.43) | 12.02(19.56) | 11.70(16.02) | | Any Readmission | 8,979(17.28) | 5,906(16.54) | 3,073(18.88) | | # Readmissions | 0.21 (1.22) | 0.21 (1.21) | 0.24 (1.26) | | 90 day cost | 34,351.10(71,976.40) | 33,893.60(75,842.42) | 35,169.50(65,477.85) |
| Figure 3: Multivariate Model Predicting Likelihood of NOT Receiving Appropriate Ppx. in Patients Undergoing Cystectomy 2006-2015 | | Characteristics | OR (95% CI) | P-value | | Charlson CI | | | | 0 | 1 (reference) | - | | 1 | 1.02 (0.97-1.07) | 0.63 | | >=2 | 1.06 (1.01-1.11) | 0.02* | | Age | | | | <55 | 1 (reference) | - | | >=55-64 | 1.13 (1.04-1.22) | 0.68 | | >=65-74 | 1.19 (1.10-1.30) | 0.04* | | >=75 | 1.26 (1.15-1.38) | <.0001* | | Gender | | | | Female | 1 (reference) | - | | Male | 0.98 (0.93-1.04) | 0.51 | | Race | | | | White | 1 (reference) | - | | Black | 1.05 (0.96-1.15) | 0.62 | | Hispanic | 1.19 (0.93-1.54) | 0.28 | | Other | 1.06 (1.00-1.13) | 0.79 | | Payer | | | | Medicare | 1 (reference) | - | | Medicaid | 0.87 (0.78-0.98) | 0.04* | | Commercial | 1.044 (0.98-1.11) | <.0001* | | Other | 0.89 (0.80-0.99) | 0.08 | | Geography | | | | Midwest | 1 (reference) | - | | Northeast | 0.40 (0.38-0.43) | 0.04* | | South | 1.26 (1.19-1.32) | <.0001* | | West | 1.89 (1.77-2.01) | <.0001* | | Teaching Status | | | | No | 1 (reference) | - | | Yes | 0.96 (0.92-1.00) | 0.07 | | Pop. Density | | | | Rural | 1 (reference) | - | | Urban | 0.51 (0.45-0.58) | <.0001* | | Year | | | | 2006-2010 | 1 (reference) | - | | 2010-2015 | 0.40 (0.38-0.42) | <.0001* |
CONCLUSIONS: We found limited use of chemoprophylaxis in a contemporary series of patients undergoing radical cystectomy, with a large increase in utilization over the study period. Greater compliance may be associated with a decreased risk for VTE, length of hospital stay and overall lower cost of patient care in patients undergoing radical cystectomy.
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