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Description
Background: Venous thromboembolism (VTE) remains a major cause of preventable postoperative morbidity following colorectal surgery, with a substantial proportion of events occurring after discharge. Although professional guidelines recommend considering extended post-discharge prophylaxis (EPPx) for high-risk patients particularly those with malignancy, substantial comorbidity, or prolonged hospitalization national adoption remains inconsistent. Emerging real-world studies suggest that EPPx utilization is low; however, these investigations have largely focused on cancer-only cohorts or earlier time periods and may not reflect contemporary surgical practice, including increasing use of minimally invasive approaches and wider availability of direct oral anticoagulants (DOACs). As a result, there is limited understanding of how EPPx is being used across the full spectrum of colorectal procedures in the modern era. A broad, updated evaluation is needed to characterize utilization patterns and to assess whether EPPx is associated with improved 90-day outcomes in insured U.S. populations. Objectives To measure national EPPx utilization after colorectal resection from 2017–2021, capturing contemporary patterns in both benign and malignant indications. To identify demographic, clinical, and procedural predictors of EPPx use, including surgical approach, comorbidity burden, and hospitalization characteristics. To evaluate the association between EPPx and 90-day postoperative outcomes, including symptomatic VTE, major bleeding, readmission, emergency department visits, reoperation, and mortality. Methods: Using IBM MarketScan Commercial and Medicare Supplemental Databases (2017–2021), we are constructing a retrospective cohort of adults =18 years undergoing inpatient colorectal resection identified by ICD-10-PCS codes for colon (0DTK*, 0DTL*, 0DTM*, 0DTN*, 0DTE*, 0DTF*, 0DTG*) and rectal (0DTP*) procedures. Surgical approach is categorized as open (“…0ZZ”) or minimally invasive/robotic (“…4ZZ”). The index date is hospital discharge; continuous insurance enrollment -90/+90 days is required. Exclusion criteria include acute VTE before or during index admission, therapeutic anticoagulation, pregnancy, hospice, in-hospital mortality, and missing demographics. Exposure is defined as prophylactic-dose anticoagulant dispensing within 0–7 days post-discharge, including low–molecular-weight heparin (LMWH; e.g., enoxaparin) or direct oral anticoagulants (DOACs; e.g., rivaroxaban or apixaban). Comparator is no EPPx. Primary outcome is 90-day symptomatic VTE. Secondary outcomes include major bleeding, all-cause readmission, emergency department visits, reoperation, and mortality. A day-7 landmark analysis mitigates immortal-time bias. Multivariable Cox models will adjust for demographics, comorbidities, surgical approach, anatomic site, indication (benign vs malignant), length of stay, ICU admission, transfusion, discharge disposition, and perioperative chemotherapy or radiation. Planned subgroup analyses include surgical approach, age category, and disease indication. Expected Results: We anticipate that EPPx uptake will remain low throughout 2017–2021, with only modest increases over time. Utilization is expected to be higher among malignancy cases, open procedures, patients with prolonged hospitalization, and those with greater comorbidity. We hypothesize that EPPx will be associated with a lower incidence of 90-day symptomatic VTE without a substantial increase in major bleeding. Variation by approach, indication, and patient age is anticipated. Analyses are ongoing. Conclusions: This study is expected to provide the most contemporary national evaluation of EPPx utilization and outcomes following colorectal surgery. Findings will support risk-stratified decision-making and may inform guideline refinement for high-risk surgical populations.
Extended Post-Discharge Venous Thromboembolism Prophylaxis After Colorectal Resection: A MarketScan Analysis of 2017–2021 Surgical Outcomes
Applied
Background: Venous thromboembolism (VTE) remains a major cause of preventable postoperative morbidity following colorectal surgery, with a substantial proportion of events occurring after discharge. Although professional guidelines recommend considering extended post-discharge prophylaxis (EPPx) for high-risk patients particularly those with malignancy, substantial comorbidity, or prolonged hospitalization national adoption remains inconsistent. Emerging real-world studies suggest that EPPx utilization is low; however, these investigations have largely focused on cancer-only cohorts or earlier time periods and may not reflect contemporary surgical practice, including increasing use of minimally invasive approaches and wider availability of direct oral anticoagulants (DOACs). As a result, there is limited understanding of how EPPx is being used across the full spectrum of colorectal procedures in the modern era. A broad, updated evaluation is needed to characterize utilization patterns and to assess whether EPPx is associated with improved 90-day outcomes in insured U.S. populations. Objectives To measure national EPPx utilization after colorectal resection from 2017–2021, capturing contemporary patterns in both benign and malignant indications. To identify demographic, clinical, and procedural predictors of EPPx use, including surgical approach, comorbidity burden, and hospitalization characteristics. To evaluate the association between EPPx and 90-day postoperative outcomes, including symptomatic VTE, major bleeding, readmission, emergency department visits, reoperation, and mortality. Methods: Using IBM MarketScan Commercial and Medicare Supplemental Databases (2017–2021), we are constructing a retrospective cohort of adults =18 years undergoing inpatient colorectal resection identified by ICD-10-PCS codes for colon (0DTK*, 0DTL*, 0DTM*, 0DTN*, 0DTE*, 0DTF*, 0DTG*) and rectal (0DTP*) procedures. Surgical approach is categorized as open (“…0ZZ”) or minimally invasive/robotic (“…4ZZ”). The index date is hospital discharge; continuous insurance enrollment -90/+90 days is required. Exclusion criteria include acute VTE before or during index admission, therapeutic anticoagulation, pregnancy, hospice, in-hospital mortality, and missing demographics. Exposure is defined as prophylactic-dose anticoagulant dispensing within 0–7 days post-discharge, including low–molecular-weight heparin (LMWH; e.g., enoxaparin) or direct oral anticoagulants (DOACs; e.g., rivaroxaban or apixaban). Comparator is no EPPx. Primary outcome is 90-day symptomatic VTE. Secondary outcomes include major bleeding, all-cause readmission, emergency department visits, reoperation, and mortality. A day-7 landmark analysis mitigates immortal-time bias. Multivariable Cox models will adjust for demographics, comorbidities, surgical approach, anatomic site, indication (benign vs malignant), length of stay, ICU admission, transfusion, discharge disposition, and perioperative chemotherapy or radiation. Planned subgroup analyses include surgical approach, age category, and disease indication. Expected Results: We anticipate that EPPx uptake will remain low throughout 2017–2021, with only modest increases over time. Utilization is expected to be higher among malignancy cases, open procedures, patients with prolonged hospitalization, and those with greater comorbidity. We hypothesize that EPPx will be associated with a lower incidence of 90-day symptomatic VTE without a substantial increase in major bleeding. Variation by approach, indication, and patient age is anticipated. Analyses are ongoing. Conclusions: This study is expected to provide the most contemporary national evaluation of EPPx utilization and outcomes following colorectal surgery. Findings will support risk-stratified decision-making and may inform guideline refinement for high-risk surgical populations.
