How reliable is perioperative anticoagulant management? Determining guideline compliance and practice variation by a retrospective patient record review

BMJ Open. 2019 Jul 17;9(7):e029879. doi: 10.1136/bmjopen-2019-029879.


Objectives: Surgery in patients on anticoagulants requires careful monitoring and risk assessment to prevent harm. Required interruptions of anticoagulants and deciding whether to use bridging anticoagulation add further complexity. This process, known as perioperative anticoagulant management (PAM), is optimised by using guidelines. Optimal PAM prevents thromboembolic and bleeding complications. The purpose of this study was to assess the reliability of PAM practice in Dutch hospitals. Additionally, the variations between hospitals and different bridging dosages were studied.

Design: A multicentre retrospective patient record review.

Setting and participants: Records from 268 patients using vitamin-K antagonist (VKA) anticoagulants who underwent surgery in a representative random sample of 13 Dutch hospitals were reviewed, 259 were analysed.

Primary and secondary outcome measures: Our primary outcome measure was the reliability of PAM expressed as the percentage of patients receiving guideline compliant care. Seven PAM steps were included. Secondary outcome measures included different bridging dosages used and an analysis of practice variation on the hospital level.

Results: Preoperative compliance was lowest for timely VKA interruptions: 58.8% (95% CI 50.0% to 67.7%) and highest for timely preoperative assessments: 81% (95% CI 75.0% to 86.5%). Postoperative compliance was lowest for timely VKA restarts: 39.9% (95% CI 33.1% to 46.7%) and highest for the decision to apply bridging: 68.5% (95% CI 62.3% to 74.8%). Variation in compliance between hospitals was present for the timely preoperative assessment (range 41%-100%), international normalised ratio testing (range 21%-94%) and postoperative bridging (range 20%-88%). Subtherapeutic bridging was used in 50.5% of patients and increased with patients' weight.

Conclusions: Unsatisfying compliance for most PAM steps, reflect suboptimal reliability of PAM. Furthermore, the hospital performance varied. This increases the risk for adverse events, warranting quality improvement. The development of process measures can help but will be complicated by the availability of a strong supporting evidence base and integrated care delivery regarding PAM.

Keywords: anticoagulation; clinical audit; quality in health care; surgery; thromboembolism.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Anticoagulants / therapeutic use*
  • Blood Loss, Surgical / prevention & control
  • Female
  • Guideline Adherence*
  • Humans
  • International Normalized Ratio
  • Male
  • Middle Aged
  • Netherlands / epidemiology
  • Perioperative Care / methods*
  • Postoperative Complications / epidemiology
  • Postoperative Complications / prevention & control*
  • Reproducibility of Results
  • Retrospective Studies
  • Thromboembolism / epidemiology
  • Thromboembolism / prevention & control*
  • Vitamin K / antagonists & inhibitors*


  • Anticoagulants
  • Vitamin K