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1. Venous thromboembolism testing practices after orthopaedic trauma: prophylaxis regimen does not influence testing patterns

Author

Bryce E. Haac, MD, Nathan N. O'Hara, PhD, MHA, Elliott R. Haut, MD, MPH, Theodore T. Manson, MD, Gerard P. Slobogean, MD, Robert V. O'Toole, MD, Deborah M. Stein, MD, MPH, ADAPT Investigators, Herman Johal, Richard Van Besien, Peter Z. Berger, George B. Reahl, Dimitrius Marinos, Yasmin Degani, Daniel Mascarenhas, Daniel Connelly, and Thomas M. Scalea

Subjects
Orthopedic surgery, RD701-811
Abstract

Abstract. Objectives:. To determine venous thromboembolism (VTE) testing patterns in an orthopaedic trauma population and to evaluate for differences in VTE surveillance by prophylaxis regimen through a secondary analysis of the ADAPT trial. Design:. Prospective randomized trial. Setting:. Level I trauma center. Patients:. Three hundred twenty-nine adult (18 years and older) trauma patients presenting with an operative extremity fracture proximal to the metatarsals/carpals or any pelvic or acetabular fracture requiring VTE prophylaxis. Intervention:. VTE imaging studies recorded within 90 days post injury. Main Outcome Measurements:. Percentage of patients tested for VTE were compared between treatment groups using Fisher's exact test. Subsequently, multivariable regression was used to determine patient factors significantly associated with risk of receiving a VTE imaging study. Results:. Sixty-seven patients (20.4%) had VTE tests ordered during the study period. Twenty (29.9%) of these 67 patients with ordered VTE imaging tests had a positive finding. No difference in proportion of patients tested for VTE by prophylaxis regimen (18.8% on aspirin vs. 22.0% on LMWH, P = 0.50) was observed. Factors associated with increased likelihood of VTE testing included White race (adjusted odds ratio [aOR]: 2.61, 95% CI: 1.26–5.42), increased Injury Severity Score (aOR for every 1-point increase: 1.10, 95% CI: 1.05–1.15), and lower socioeconomic status based on the Area Deprivation Index (aOR for every 10-point increase: 1.14, 95% CI: 1.00–1.30). Conclusions:. VTE surveillance did not significantly differ by prophylaxis regimen. Patient demographic factors including race, injury severity, and socioeconomic status were associated with differences in VTE surveillance. Level of Evidence:. Level I, Therapeutic.

Published
2024
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2. Post-discharge adherence with venous thromboembolism prophylaxis after orthopedic trauma: Results from a randomized controlled trial of aspirin versus low molecular weight heparin

Author

Richard Van Besien, Daniel Connelly, Deborah M. Stein, Herman Johal, Thomas M. Scalea, Daniel Mascarenhas, Yasmin Degani, Theodore T. Manson, Peter Z. Berger, Robert V O'Toole, Dimitrius Marinos, Bryce E. Haac, George B Reahl, Gerard P. Slobogean, and Nathan N O'Hara

Subjects
Adult, Male, medicine.drug_class, Post discharge, Low molecular weight heparin, Critical Care and Intensive Care Medicine, Medication Adherence, law.invention, Fractures, Bone, 03 medical and health sciences, 0302 clinical medicine, Fibrinolytic Agents, Randomized controlled trial, law, Humans, Medicine, 030212 general & internal medicine, 030222 orthopedics, Aspirin, business.industry, Venous Thromboembolism, Heparin, Heparin, Low-Molecular-Weight, Patient Discharge, Orthopedic trauma, Treatment Outcome, Anesthesia, Chemoprophylaxis, Patient Compliance, Female, Surgery, business, Venous thromboembolism, Follow-Up Studies, medicine.drug
Abstract

Orthopedic trauma patients are often treated with venous thromboembolism (VTE) chemoprophylaxis with aspirin or low molecular weight heparin (LMWH) after discharge from their index admission, but adherence patterns are not known. We hypothesized that overall adherence would be moderate and greater with aspirin compared to LMWH.We conducted a randomized controlled trial of adult trauma patients with an operative extremity fracture or any pelvic/acetabular fracture requiring VTE prophylaxis. Patients were randomized to receive either LMWH 30 mg BID or aspirin 81 mg BID. Patients prescribed outpatient prophylaxis were contacted between 10 and 21 days after discharge to assess adherence measured by the validated Morisky Medication Adherence Scale (MMAS-8). Adherence scores were compared between the two treatment arms with similar results for intention-to-treat and as-treated analyses. As-treated multivariable logistic regression was performed to determine factors associated with low-medium adherence scores.One hundred fifty patients (64 on LMWH, 86 on aspirin) on chemoprophylaxis at time of follow-up completed the questionnaire. As-treated analysis showed that adherence was high overall (mean MMAS 7.2 out of 8, SD 1.5) and similar for the two regimens (LMWH: 7.4 vs. aspirin: 7.0, p = 0.13). However, patients on LMWH were more likely to feel hassled by their regimen (23% vs. 9%, p = 0.02). In a multivariable model, low-medium adherence was associated with taking LMWH as the prophylaxis medication (aOR 2.34, CI 1.06-5.18, p = 0.04), having to self-administer the prophylaxis (aOR 4.44, CI 1.45-13.61, p0.01), being of male sex (aOR 2.46, CI 1.10-5.49, p = 0.03), and of younger age (aOR 0.72 per additional 10 years of age, CI 0.57-0.91, p0.01).Overall post-discharge adherence with VTE prophylaxis was high. Several factors, including prophylaxis by LMWH, were associated with decreased adherence. These factors should be considered when managing patients and designing efficacy trials.Therapeutic, level II.

Published
2018
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