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Adherence With Postdischarge Venous Thromboembolism Chemoprophylaxis Recommendations After Colorectal Cancer Surgery Among Elderly Medicare Beneficiaries

Merkow, Ryan P. MD, MS*,†; Bilimoria, Karl Y. MD, MS*; Sohn, Min-Woong PhD*,‡; Oh, Elissa H. MA*; Sellers, Morgan M. MD*; Paruch, Jennifer L. MD*,†; Chung, Jeanette W. PhD*; Bentrem, David J. MD, MS*,§

doi: 10.1097/SLA.0000000000000296
Original Articles

Objectives: To assess national adherence with extended venous thromboembolism (VTE) chemoprophylaxis guideline recommendations after colorectal cancer surgery.

Background: Postoperative VTE remains a major cause of morbidity and mortality after abdominal cancer surgery. On the basis of the results from randomized controlled trials, since 2007, national guidelines have suggested that these patients be discharged on VTE chemoprophylaxis.

Methods: Medicare beneficiaries undergoing open colorectal cancer resections in 2008–2009 were identified using the Medicare Provider Analysis and Review data and limited to those who were enrolled and used Part D for their postoperative prescriptions. Postdischarge use of low-molecular-weight-heparin and other anticoagulants was assessed.

Results: A total of 5078 patients underwent open colorectal cancer surgery and met the inclusion criteria. Of these, 77% underwent colectomy and 23% underwent proctectomy. A prescription for an anticoagulant was filled immediately after discharge for 77 (1.5%) patients, and a low-molecular-weight-heparin for 60 (1.2%) patients. On multivariable analysis, patients were more likely to receive postdischarge VTE chemoprophylaxis if undergoing rectal cancer surgery [incidence rate ratio (IRR), 1.83; 95% confidence interval, 1.07–3.12; vs colon], if higher educational status (IRR, 2.20; 95% confidence interval, 1.23–3.95; vs low education), or if they had a higher Elixhauser comorbidity index (IRR, 1.13; 95% confidence interval, 1.01–1.25; vs lower index).

Conclusions: Although VTE remains a major issue after abdominal cancer surgery, only 1.5% of Medicare beneficiaries undergoing colorectal cancer surgery received care consistent with established guidelines for postdischarge VTE chemoprophylaxis. Barriers to adherence must be elucidated to improve the quality of care for abdominal and pelvic cancer surgery patients.

Postoperative venous thromboembolism remains a major cause of morbidity and mortality after abdominal and pelvic cancer surgery. National guidelines recommend extended venous thromboembolism chemoprophylaxis. After excluding patients with contraindications, we found only 1.5% of colorectal cancer patients undergoing surgery filled a prescription for an anticoagulant after discharge.

*Northwestern Institute for Comparative Effectiveness Research (NICER) in Oncology, the Surgical Outcomes and Quality Improvement Center (SOQIC) and the Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL

Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL

Center for Management of Complex Chronic Care, Hines VA Hospitals, Hines, IL; and

§Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL.

Reprints: Ryan P. Merkow, MD, MS, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St, Suite 650, Chicago, IL 60611. E-mail:

Presented at the Academic Surgical Congress, February 6, 2013, New Orleans, LA.

Disclosure: Supported in part by the American Cancer Society (#280521) (Drs Merkow and Bilimoria) and the Northwestern Institute for Comparative Effectiveness Research in Oncology (Drs Merkow, Bilimoria, and Bentrem). The authors declare no conflicts of interest.

© 2014 by Lippincott Williams & Wilkins.