Optimizing Prophylaxis Against Venous Thromboembolism in Bariatric Surgery

描述（由申请人提供）：在过去的十年里，随着手术率的飞速增长，减肥手术已经成为美国第二大最常见的腹部手术。尽管随着时间的推移，减肥手术变得越来越安全，静脉血栓栓塞（VTE）仍然是潜在可预防的发病率和死亡率的主要原因。预防策略，包括围手术期抗凝和下腔静脉（IVC）过滤器放置，可以降低静脉血栓栓塞及其后遗症的风险。然而，这些治疗本身就有并发症的风险，而且非常昂贵。在缺乏关于最佳静脉血栓栓塞预防的良好证据的情况下，外科医生和医院之间的做法差别很大。例如，在密歇根州的23个减肥手术项目中，胃旁路术后出院后使用低分子量肝素的比例从0%到96%不等；术前IVC滤器放置的使用率从0-40%不等。最激进的做法风格并不一定转化为更安全的手术。例如，在密歇根州的5家医院中，最严重的并发症（导致死亡或永久残疾）的发生率高出3倍，这些医院为10%以上的患者安装了IVC过滤器。不受欢迎的实践变化对医疗保健成本也有明显的影响。在这5家“异常”医院，与IVC过滤器放置相关的支付每年超过数百万美元。该项目的目标是减少密歇根州实施减肥手术的医院之间静脉血栓栓塞预防的差异，最终目标是改善结果和降低成本。这项研究将基于密歇根减肥手术合作组织（MBSC）的前瞻性临床登记和质量改进基础设施，MBSC是一个涉及密歇根州所有医院和外科医生进行减肥手术的全州联盟。在方法方面，我们的项目将以Keystone ICU项目建立的数据驱动、协作质量改进的模板为基础。Keystone ICU项目是约翰霍普金斯大学（Johns Hopkins University）和密歇根健康与医院协会（Michigan Health and Hospital Association）的患者安全专家的共同努力，在降低密歇根导管败血症和其他重症监护并发症的发生率方面取得了巨大成功。静脉血栓栓塞（VTE）是最常见的可预防的医院死亡原因。在缺乏关于最佳静脉血栓栓塞预防减肥手术的良好证据的情况下，实践和结果差异很大。该项目的目标是减少密歇根州实施减肥手术的医院间静脉血栓栓塞丙基反应的差异，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.