Optimizing Prophylaxis Against Venous Thromboembolism in Bariatric Surgery

描述(由申请人提供)：在过去的十年里，随着减肥手术的比例飙升，减肥手术已经成为美国第二大最常见的腹部手术。虽然随着时间的推移，减肥手术变得更加安全，但静脉血栓栓塞症(VTE)仍然是潜在的可预防的发病率和死亡率的主要原因。预防性措施，包括围手术期抗凝和放置下腔静脉滤器，可能会降低VTE及其后遗症的风险。然而，这些治疗本身就与并发症的风险有关，而且非常昂贵。在缺乏关于最佳VTE预防的良好证据的情况下，外科医生和医院的做法差别很大。例如，在密歇根州的23个减肥手术项目中，胃旁路术后出院后低分子肝素的使用率从0%到96%不等；术前下腔静脉滤器放置的使用率从0%到40%不等。最具侵略性的实践风格并不一定会转化为更安全的手术。例如，最严重的并发症(导致死亡或永久性残疾)的发生率在密歇根州的5家医院高出3倍，这些医院为超过10%的患者安装了IVC过滤器。不受欢迎的做法变化也对医疗保健成本有明显的影响。与5家“离群点”医院放置下腔静脉滤器相关的费用每年超过数百万美元。该项目的目标是减少在密歇根州进行减肥手术的医院之间的VTE预防差异，最终目标是改善结果和降低成本。这项研究将基于密歇根州减肥手术合作组织(MBSC)的预期临床登记和质量改进基础设施，该组织是一个全州范围的联盟，涉及密歇根州所有从事减肥手术的医院和外科医生。在方法方面，我们的项目将建立在Keystone ICU项目建立的数据驱动的协作式质量改进模板的基础上，Keystone ICU项目是约翰·霍普金斯大学的患者安全专家和密歇根州健康与医院协会的联合努力，在降低密歇根州导管败血症和其他重症监护并发症方面取得了非凡的成功。静脉血栓栓塞症(VTE)是最常见的可预防的住院死亡原因。在缺乏良好证据的情况下，在减肥手术中最佳的静脉血栓栓塞术，实践和结果差别很大。该项目的目标是减少在密歇根州进行减肥手术的医院之间的VTE松弛差异，最终目标是改善结果和降低成本。

DESCRIPTION (provided by the applicant): With rates skyrocketing over the last decade, weight loss (bariatric) surgery has become the second most common abdominal operation in the United States. Although bariatric surgery has become safer over time, venous thromboembolism (VTE) remains a major cause of potentially preventable morbidity and mortality. Prophylactic strategies, including perioperative anticoagulation and inferior vena cava (IVC) filter placement, may reduce the risk of VTE and its sequelae. However, these treatments are themselves associated with risks of complications and are very costly. In the absence of good evidence regarding optimal VTE prophylaxis, practices vary widely among surgeons and hospitals. Among the 23 bariatric surgery programs in Michigan, for example, the use of low-molecular weight heparin following discharge after gastric bypass varied from 0% to 96%; the use of preoperative IVC filter placement varied from 0-40%. The most aggressive practice styles do not necessarily translate to safer surgery. For example, rates of the most serious complications (resulting in death or permanent disability) are 3-times higher at the 5 Michigan hospitals that place IVC filters in more than 10% of their patients. Unwanted practice variation also has obvious implications for health care costs. Payments associated with IVC filter placement at the 5 "outlier" hospitals exceed several million dollars annually. The goals of this project are to reduce variation in VTE prophylaxis among hospitals performing bariatric surgery in Michigan, with the ultimate goal of improving outcomes and reducing costs. The study will be based on the prospective clinical registry and quality improvement infrastructure of the Michigan Bariatric Surgery Collaborative (MBSC), a statewide consortium involving all hospitals and surgeons performing bariatric surgery in Michigan. In terms of approach, our project will build off of templates for data-driven, collaborative quality improvement established by the Keystone ICU Project, a joint endeavor between patient safety experts at Johns Hopkins University and the Michigan Health and Hospital Association that has been extraordinarily successful in reducing rates of catheter sepsis and other intensive care complications in Michigan. Venous thromboembolism (VTE) is the most common preventable cause of hospital death. In the absence of good evidence regarding optimal VTE prohylaxis in bariatric surgery, practices and outcomes vary widely. The goals of this project are to reduce variation in VTE propylaxis among hospitals performing bariatric surgery in Michigan, with the ultimate goal of improving outcomes and reducing costs.