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

M J Moesker,N R Bijsterveld,J F De Groot,M C De Bruijne,J W R Twisk,M V Huisman,N L Damen,C Wagner

doi:10.1186/s12959-019-0204-x

Abstract

BackgroundBridging 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.ObjectivesOur aim was to assess guideline compliance and identify factors associated with bridging and especially, non-compliant bridging.MethodsA 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.ResultsBridging 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).ConclusionBridging 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.

Highlights

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
This study aims to determine guideline compliance of bridging anticoagulation in everyday practice and identify factors associated with bridging use, especially predictors for non-compliant under- and overuse of bridging anticoagulation in Dutch hospitals
Study population In total, 268 records were reviewed of which 256 records were eligible for bridging anticoagulation analyses (Fig. 2)

Summary

Introduction

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. Long-term use of oral anticoagulants such as vitamin-K antagonists (VKA) reduces the risk of thromboembolic events in patients with atrial fibrillation, venous thromboembolism or mechanical heart valves [1,2,3]. When these patients undergo invasive procedures, such as surgery, the anticoagulant therapy often needs interruption to reduce bleeding. In an effort to reduce this risk, short-acting low molecular weight heparin (LMWH) or unfractionated heparin (UFH) are temporarily administered. This is known as ‘bridging anticoagulation’ [5,6,7]. Anticoagulants are consistently identified in adverse event studies as factors involved in preventable adverse events [8, 9], partially occurring in the context of bridging [10]

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