Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance

Abstract

Background Bridging anticoagulation is used in vitamin-K antagonist (VKA) patients undergoing invasive procedures and involves complex risk assessment in order to prevent thromboembolic and bleeding outcomes. Objectives Our aim was to assess guideline compliance and identify factors associated with bridging and especially, non-compliant bridging. Methods A retrospective review of 256 patient records in 13 Dutch hospitals was performed. Demographic, clinical, surgical and care delivery characteristics were collected. Compliance to the American College of Chest Physicians ninth edition guideline (AT9) was assessed. Multilevel regression models were built to explain bridging use and predict non-compliance. Results Bridging use varied from 15.0 to 83.3% (mean = 41.8%) of patients per hospital, whereas guideline compliance varied from 20.0 to 88.2% (mean = 68.5%) per hospital. Both established thromboembolic risk factors and characteristics outside thromboembolic risk assessment were associated with bridging use. Predictors for overuse were gastrointestinal surgery (OR 14.85, 95% CI 2.69–81.99), vascular surgery (OR 13.01, 95% CI 1.83–92.30), non-elective surgery (OR 8.67, 95% CI 1.67–45.14), lowest 25th percentile socioeconomic status (OR 0.33, 95% CI 0.11–1.02) and use of VKA reversal agents (OR 0.22, 95% CI 0.04–1.16). Conclusion Bridging anticoagulation practice was not compliant with the AT9 in 31.5% of patients. The aggregated AT9 thromboembolic risk was inferior to individual thromboembolic risk factors and other characteristics in explaining bridging use. Therefor the AT9 risk seems less important for the decision making in everyday practice. Additionally, a heterogeneous implementation of the guideline between hospitals was found. Further research and interventions are needed to improve bridging anticoagulation practice in VKA patients. Electronic supplementary material The online version of this article (10.1186/s12959-019-0204-x) contains supplementary material, which is available to authorized users.

Guideline Adherence As An Indicator of the Extent of Antithrombotic Overuse and Underuse: A Systematic Review

“…Study designs included 14 retrospective record reviews [ 20 21 22 23 24 25 26 27 28 29 30 31 32 33 ], 6 cohort studies [ 34 35 36 37 38 39 ] and 1 a case-control [ 40 ] (see Table 1 ). Four studies focused on overuse, 5on underuse, and 12 on both.…”

“…Large variation in the rates of antithrombotic overuse was observed across geographic regions with studies from Asia reporting the lowest levels of overuse (1.3–7.6%) [ 27 33 ], followed by Australia (24.1–42.9%) [ 20 23 24 ], and Europe (1.4–72.0%) [ 21 25 28 29 30 33 36 37 38 39 40 ], through to the highest variation in North America (6.6–73.0%) [ 26 31 32 34 35 ]. No clear time trend of increasing or decreasing overuse was observed over the period of the studies (2008–2020).…”

S1 guidelines “lumbar puncture and cerebrospinal fluid analysis” (abridged and translated version)

“…Patients anticoagulated with Phenprocoumon or other coumarin derivates should be transitionally switched to heparin, as this can be antagonized more rapidly. At this point we would like to refer to the S1 guideline of the DEGAM (German Society for General Medicine and Family Medicine) on the subject of bridging (AWMF 053/027 [ 111 , 122 ];). In emergencies, an attempt to normalize the blood coagulation can be undertaken by substituting coagulation factors.…”

Perioperative Guidelines on Antiplatelet and Anticoagulant Agents: 2022 Update

“…Of note, the perioperative thromboembolic risk in patients with AF or history of VTE might be overestimated by 30 to 80% of physicians [25]. The latter might explain the overzealous use of bridging therapy in patients at low risk for VTE [25].…”