The continuum from surgery to home: Key thoughts on post-orthopedic surgery DVT

Healthcare is trending toward outpatient procedures, and technological advancements in surgical technique and pain management allow orthopedic surgeons to send their patients home within 24 hours of surgery. However, the patient's needs and care don't end when they leave the hospital.

DVT risks
Orthopedic surgery patients run the risk of developing deep vein thrombosis if they don't follow best practices post-surgery, which includes compression therapy. The American Academy of Orthopaedic Surgeons and The Joint Commission, among other organizations, recommend performing a strategic risk assessment on all patients to mitigate DVT risk factors after patient discharge.

According to the CDC, DVT/PE affects around 900,000 people per year in the United States and estimates suggest 60,000 to 100,000 Americans die of DVT/PE annually; although a single hospital or provider may only see a few patients with DVT per year. DVT is the third largest killer in the United States and can create lasting problems for the patient. Patients are at their peek for developing DVT during the first 14 days after surgical intervention and 10 percent to 30 percent of people die within one month of diagnosis.

"Just undergoing total joint replacement surgery places the patient automatically into a higher risk pool for DVT," says Mark Farrow, President and CEO of Compression Solutions. "When it comes to total joints, there should be no question that some sort of prophylactic care should be used."

Other key factors heightening the risk for DVT, according to German physician Rudolph Virchow's Triad, include:

• Endothelial injury — the actual trauma of surgery can compromise the endothelia lining of the blood vessels, which impairs blood flow;
• Stasis of blood flow — when patients have limited ambulation, there is limited pressure applied to the foot and a dynamic foot pump expedites the return of blood flow to the lower extremity;
• Hypocoagulability — surgical trauma can impact the actual constitution of the blood.

Orthopedic surgery patients aren't very mobile after surgery — they may have difficulty moving or standing — which places them at higher risk as well. Physicians can prescribe drugs, including anticoagulants, but there is still a chance the patient will develop a DVT; without the anticoagulants, the risk increases to 50 percent to 70 percent, according to a study published in Blood Coagulants Fibrinolysis.

"Clinical anticoagulants have been prescribed for years to reduce the risk of DVT," says Adolph Lombardi Jr., MD, President of Joint Implant Surgeons in New Albany, Ohio. "However, they carry with them one significant drawback and that is the possibility of the development of postoperative wound hematoma with subsequent drainage. Unfortunately, the consequences of wound hematoma and subsequent drainage can lead to an infection which is obviously one of the more catastrophic complications of an orthopedic procedure that involves any type of hardware."

Post-surgery patient compliance
Compliance is an additional concern. Not all patients are able to take anticoagulants and rely only on intermittent compression, and patients aren't always reliable about taking their medications. Some studies suggest only 25 percent of prescriptions are used to the full regimen. Patients aren't always compliant when they return home.

"In an effort to find a safer solution, surgeons have gravitated to the use of aspirin and have combined this with pneumatic compression," says Dr. Lombardi. "The combination has been documented in multiple studies to be extremely beneficial. Patients having orthopedic procedures performed in the ambulatory surgery center, especially those undergoing arthroplasty of the hip and knee, should be considered for this combined prophylaxis of aspirin and pneumatic compression."

Clinical studies published in professional medical journals show using anticoagulants on high risk patients can reduce DVTs by as much as 75 percent, and if you add intermittent compression, the risk factor drops below 1 percent to 3 percent.

"Hospitals and ASCs are coming under fire for readmissions. Patients are going home after outpatient surgery and then returning to the hospital with DVT, and hospitals aren't paid for the readmission," says Mr. Farrow. "Surgery centers with total joint replacements will start losing money if they don't have quality outcomes, and the physician pay will impacted in 2017. There is a huge push for outcomes-based medicine and making sure the total joint patient doesn't get readmitted."

Almost every total joint replacement patient receives intermittent compression on their legs at the hospital or surgery center before discharge. The hospital units often have large machines running the compressions, but that isn't the only option. There are small portable compression units on the marketplace now — including systems from Compression Solutions — that allow patients to take the equipment home.

"We built a small, portable, easy-to-use unit patients can use in the comfort of their own home and have the same quality of care as the hospital," says Mr. Farrow. The technology also keeps patients compliant. The portable compression system records whether the patient turns it on and how long it’s used. The usage information can be sent back to the company, which provides the information for the patient's physician.

"Drugs can't do that," says Mr. Farrow. "Physicians write a prescription and hope it gets filled and is used. We have around 90 percent to 92 percent compliance with patients turning on the system."

Portable compression technology
The portable compression device is placed on the operative extremity, therefore it fulfills the "Stasis of blood" aspect of Virchow's Triad by enhancing blood flow. The device also offers an effective alternative to more potent chemical anticoagulants. "There is little risk associated with utilization of pneumatic compression devices," says Dr. Lombardi. "They can be applied to the contralateral limb during the surgical procedure and therefore the DVT prophylaxis is started at the time of surgery."

In 2013, AAOS released a statement supporting intermittent compressions. The organization found intermittent compressions and 300 mg of aspirin are equal to any anticoagulant on the market.

"Our medical colleagues will improve the medical optimization of patients," says Dr. Lombardi. "Therefore, it is my impression that the future of DVT prevention will lean more and more to the use of ambulatory pneumatic compression devices combined with the use of low dose aspirin."

Physicians and healthcare providers are under more scrutiny now than ever with transparent quality and pricing metrics. Providers want to make sure their patients feel better as quickly as possible whether they're recovering at home or in a hospital.

"We are seeing a big uptick in usage of our product because of the pressures put on physicians to get good outcomes," says Mr. Farrow. "I think it will be a standard because total joints are the highest risk patients. Physicians want to do everything they can to make sure patients achieve a good outcome."

Economic benefits
The technology is also economically friendly. Most anticoagulants for DVT prevention can cost around $500 to $2,100 per prescription from the insurance company, patients or both. But the portable compression system doesn't cost the hospital, ASC or physician; it is typical for companies to bill the patient or insurance company for the product.

"The economic benefit far out-seats what could happen if the patient develops at DVT and the hospital isn't paid for subsequent treatment," says Mr. Farrow. "A DVT patient could cost the hospital $8,000 to $50,000."

The economic benefits fit the technology into bundled payments and the Medicare bundles nicely. When hospitals and ASCs are at-risk for patient outcomes, the intermittent compressions can make a huge difference, especially if the technology comes at no-cost to the providers.

"We are continuing to see an evolution in the paradigm of how total hip and total knee arthroplasties are being performed," says Dr. Lombardi. "Many centers have documented that these procedures can be safely performed in an outpatient surgical setting and that patients can be discharged to home the day of surgery. We are witnessing improved pain control which leads to increased ambulatory ability of the patients postoperatively. As more experience is gained in outpatient arthroplasty, more surgeries will be performed in this type of setting."

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