Impact of recent guideline changes on aspirin prescribing after knee arthroplasty

Abstract

BackgroundPrior to 2012, the American Academy of Orthopaedic Surgeons (AAOS) and American College of Chest Physicians (ACCP) differed in their recommendations for postoperative pharmacologic venous thromboembolism prophylaxis (VTEP) after total joint arthroplasty. More specifically, aspirin (ASA) monotherapy was not endorsed by the ACCP as an acceptable prophylaxis. In 2012, the ACCP supported ASA monotherapy compared with no prophylaxis. Our aim was to investigate the impact of the convergence of ACCP and AAOS recommendations on surgeon prescribing patterns after knee arthroplasty (KA).MethodsThis is a retrospective chart review. We collected data to assess preoperative VTE risk and examined VTEP prescriptions on postoperative day 1 (POD1) and at discharge (D/C) from 7/2008 to 12/2011 (pre-period) and 1/2012 to 7/2014 (post-period). Adult patients undergoing primary and revision KA were identified by ICD-9 procedure codes. Patients on preoperative full-dose anticoagulation and with hypercoagulability disorders were excluded.ResultsOf 368 records reviewed, 329 were included in the analysis. There were no differences between the two period groups for age, sex, BMI, estrogen therapy, malignancy, smoking status, prior VTE, bilateral procedures, or surgery within 3 months. On POD1, in the pre-period, 4.6 % were prescribed ASA monotherapy versus 44.4 % in the post-period (p < 0.001). On D/C, in the pre-period, 13.9 % were prescribed ASA versus 55.6 % in the post-period (p < 0.001).ConclusionsOur results indicate a statistically significant change in orthopedist prescribing patterns after guideline convergence. Furthermore, there was no apparent change in VTE risk between the two study groups when excluding patients necessitating full anticoagulation. Prior literature has shown that the divergence in guidelines influenced physicians away from ASA and toward more potent anticoagulants in order to avoid potential litigation. Once its role in VTEP was supported by the ACCP, it appears that ASA monotherapy was readily and rapidly incorporated into clinical practice. ASA may be favored over other VTEP agents for its lower bleeding risk profile and cost. This study highlights the profound impact clinical practice guidelines have on clinician prescribing patterns. Although prospective randomized trials are needed to compare the efficacy of ASA with other VTEP agents, ASA is now a predominant part of the VTEP armamentarium after KA.

Venous Thromboembolism Prophylaxis After TKA: Aspirin, Warfarin, Enoxaparin, or Factor Xa Inhibitors?

“…Utilization trends for these agents are not well-studied. In one single-institution study, the rates of prescribing aspirin as the VTE agent increased after the convergence of the American Academy of Orthopaedic Surgeons and the American College of Chest Physicians guidelines, while all other agents including factor Xa inhibitors decreased [35]. In our study, the increase in factor Xa inhibitor use likely followed the results of the RECORD3 and RECORD4 trials.…”

Have Venous Thromboembolism Rates Decreased in Total Hip and Knee Arthroplasty?

“…A recent poll of over 1200 attendees of the 2016 meeting of the American Association of Hip and Knee Surgeons, showed that over 80% orthopedic surgeons use aspirin as the main VTE prophylaxis [24]. In the same vein, a retrospective analysis in the United States reported that while healthcare provider utilization of aspirin has increased (55.6% post-2012 vs pre-2012 13.9%, P < .001), there has not been an apparent change in VTE risk [25]. Additionally, over the last 5-10 years early discharge and outpatient protocols have been adopted, as well as a concomitant reduction in length of stay (LOS) [26e29].…”

Aspirin Compared with Anticoagulation to Prevent Venous Thromboembolism After Knee or Hip Arthroplasty: a Large Retrospective Cohort Study

“…6,17 Our previous retrospective cohort study which similarly investigated thromboembolic risk in a large nationally representative sample of patients receiving aspirin compared with anticoagulation after knee or hip replacement surgery between 2009 and 2012 in the USA found that aspirin-only was administered in 7.5-8% of cases, 6 while this proportion increased to more than 27% in our current study that covered a timeframe after publication of the updated American College of Chest Physicians (ACCP) guidelines. Similarly, a recent retrospective chart review of 329 patients undergoing knee arthroplasty at 2 tertiary care centers found that the proportion of patients receiving monotherapy with aspirin for postoperative thromboprophylaxis increased from 4.6 to 44.4% in the periods before and after the publication of ACCP guidelines in 2012 18 ; in these updated guidelines, the use of aspirin as a sole thromboprophylactic agent after knee or hip arthroplasty was newly endorsed and hence, consensus was reached with the recommendations made by the American Academy of Orthopedic Surgeons (AAOS). 1,19,20 It is notable that the Numbers are presented as n (%).…”