Underuse of Postcesarean Thromboembolism Prophylaxis

Friedman, Alexander M. MD; Ananth, Cande V. PhD, MPH; Lu, Yu-Shiang MA; D’Alton, Mary E. MD; Wright, Jason D. MD

Obstetrics & Gynecology:
doi: 10.1097/AOG.0000000000000007
Contents: Cesarean Delivery: Original Research
Abstract

OBJECTIVE: To characterize contemporary practice patterns for postcesarean thromboembolism prophylaxis and determine whether opportunities to substantially decrease maternal mortality and morbidity in this clinical setting are being missed.

METHODS: A commercial hospitalization database that includes procedure and diagnosis codes, health care provider and hospital information, and patient demographic data were used to analyze use of venous thromboembolism prophylaxis after cesarean delivery in the United States between 2003 and 2010. The analysis evaluated whether patients received pharmacologic prophylaxis, mechanical prophylaxis, combined prophylaxis, or no prophylaxis. Hospital-level factors and patient characteristics were included in multivariable regression models evaluating prophylaxis administration.

RESULTS: We identified 1,263,205 women who underwent cesarean delivery. Within the cohort, 75.7% (n=955,787) received no thromboembolism prophylaxis, 22.1% (n=278,669) received mechanical prophylaxis alone, 1.3% (n=16,639) received pharmacologic prophylaxis, and 1.0% (n=12,110) received combination prophylaxis. The rate of prophylaxis increased from 8.4% in 2003 to 41.6% in 2010. Prophylaxis rates varied significantly by geographic region. Medical risk factors for thromboembolism were associated with only modest increases in prophylaxis.

CONCLUSION: Although our findings demonstrated increased adoption of postcesarean venous thromboembolism prophylaxis, fewer than half of patients received recommended care as of 2010, and significant variation was present. Thromboembolism prophylaxis is underused and represents a major opportunity to reduce maternal morbidity and mortality. Risk assessment tools and thromboprophylaxis guidelines are needed to assure high-quality, uniform care.

LEVEL OF EVIDENCE: III

In Brief

Although routine postcesarean thromboprophylaxis is increasing, there is still a major underuse of this effective and economic means to reduce maternal morbidity and mortality.

Author Information

Divisions of Maternal Fetal Medicine and Gynecologic Oncology, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, and the Department of Epidemiology, Joseph J. Mailman School of Public Health, Columbia University, New York, New York.

Corresponding author: Alexander M. Friedman, MD, Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, 622 West 168th Street, PH 16-66, New York, NY 10032; e-mail: alexander.friedman@gmail.com.

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2013 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.