Surgeon Attitudes to Guideline-Concordant Extended Pharmacologic Venous Thromboembolism Prophylaxis after Cancer Surgery Within a Regional Health System: A Qualitative Study.

Abstract

While infrequent, venous thromboembolism (VTE) is a significant cause of morbidity and mortality after cancer surgery. Extended pharmacologic VTE prophylaxis (ePPX) decreases VTE risk and is recommended by professional societies. Observational studies have shown limited ePPX utilization, although reasons for non-adherence have not been forthcoming from existing data. The aim of this study was to obtain insight toward surgeon practices and attitudes regarding ePPX within a regional health system. Semi-structured interviews were conducted with 13 surgeons and 2 advanced practice providers who perform gastrointestinal, urologic, or gynecologic cancer resections. Interviews characterized perceptions of VTE risk, VTE prevention strategies, and an electronic medical record-based decision support tool to improve ePPX utilization. Transcripts were thematically analyzed with conceptual coding. Thirteen surgeons and two advance-practice providers were interviewed; 5 were female. Six surgeons practice in the community and seven practice in the academic setting. Sixty percent (n = 9; 8 academic) of providers utilized ePPX 'routinely', with professional society guidelines and medical literature the most cited reasons. Thirty-three percent (n = 5; 4 community) of providers utilized ePPX 'selectively', with injection medication and surgeon routine the most cited reasons. One community surgeon 'never' utilized ePPX. Academic providers were more likely to utilize ePPX than community providers. All providers were open to the electronic medical record decision support tool. Diverse practice patterns of ePPX were identified across providers, with community surgeons more likely to prescribe ePPX selectively or never. Surgeon education, utilization of an oral medication, and cost mitigation may improve ePPX adherence.