Collaborative Hospital Data

In total, 75.0% of knee arthroplasty patients and 72.7% of hip arthroplasty patients received thromboprophylaxis consistent with the new ACCP recommendations (Figure 26). This equates to 73.8% overall. This did not significantly change when the appropriateness of doses prescribed was not included in the analysis (Figure 27).

Figure 26. Comparison of multicentre prescribing practices with the ACCP 9th Ed. Guideline (N=65).

Appropriate agent only Appropriate agent and dose only Appropriate agent, dose and

duration

NB: Excludes patients prescribed therapeutic anticoagulation for pre-existing medical conditions, and patients who experienced a postoperative complication during their inpatient admission.

Figure 27. Comparison of multicentre prescribing practices with the ACCP 9th Ed. Guideline (N=100).

Appropriate agent only Appropriate agent, dose and duration

NB: Excludes patients prescribed therapeutic anticoagulation for pre-existing medical conditions, and patients who experienced a postoperative complication during their inpatient admission.

0 10 20 30 40 50 60 70 80 Knee Arthroplasty (n=32) Hip Arthroplasty (n=33) R e sp o n d e n ts (% ) 0 10 20 30 40 50 60 70 80 Knee Arthroplasty (n=47) Hip Arthroplasty (n=53) R e sp o n d e n ts (% )

8.4 Discussion

The findings in this short reanalysis reveal a significantly greater compatibility between practice and the new ACCP Guideline. Whereas previously only 5.1% of patients on average undergoing a hip or knee arthroplasty at the RHH were prescribed complete courses of thromboprophylaxis according to the ACCP 7th Ed. Guideline, almost 32% were prescribed complete courses according to the ACCP 9th Ed. Guideline. Similarly, whereas only 53.8% of patients at the six hospitals surveyed in 2011 were prescribed NHMRC recommended thromboprophylaxis, 73.8% were prescribed thromboprophylaxis as recommended in the ACCP 9th Ed. Guideline. In both cases, the decrease in the guideline-practice gap was predominantly due to the adoption of aspirin as an appropriate option for pharmacological thromboprophylaxis in the ACCP 9th Ed. Guideline.

This reanalysis suggests prescribing patterns in previous years were generally more aligned with contemporary recommendations than recommendations existent at the time of prescribing; i.e. that practice preceded guidelines. This occurrence is likely due to a combination of factors; however two interconnected ones stand prominent. The methodology used to produce the ACCP 9th Ed. Guideline was reported to be more rigorous than previous editions, resulting in a guideline that is less based on opinion, and more on research data.207 Clear noncontroversial and evidence based recommendations are more likely to be employed than guidelines with recommendations that are unclear, controversial, or are based on opinion.20 This change in methodology may in part explain the increase in compatibility between practice and the updated ACCP Guideline.

Turner et al report that although there has been a significant rise in the number of CPG produced worldwide, few of these CPG meet quality criteria; ‘the link between research and recommendations is an area of particular weakness’.20

Guideline production is a lengthy and often time-consuming process, thereby negatively impacting on the ability of a professional body to make recommendations based on the most up to date evidence. This limitation is likely to be augmented for professional bodies such as the NHMRC and ACCP, as they produce multi- disciplinary guidelines. As noted in Chapter 7, surgeons review and discuss the latest research amongst themselves. They are able to implement changes immediately, and this may be why the results of this reanalysis suggest that practice preceded the guidelines. This limitation in guideline formulation must be addressed in order to prevent guidelines lagging behind the evidence.

CHAPTER NINE:SURGEONS AND THE ACCP9TH ED.GUIDELINE

9.1 Introduction

The data reanalysis outlined in Chapter 8 determined surgeons had been prescribing more in line with the ACCP 9th Ed. Guideline than the ACCP 7th Ed. Guideline for up to four years prior to its’ release. This suggested that the changes made to the Guideline were agreeable to surgeons in Australia. A second national survey of surgeons was conducted in order to explore surgeons’ opinions of the AACP 9th Ed. Guideline to determine if this was the case, and to identify if there had been any change in surgeons’ opinions since the previous survey conducted two years earlier.

The previous survey (outlined in Chapter 6) had been targeted at ASA members and had resulted in a small survey sample group. In an attempt to increase absolute numbers, and thus reliability and generalisability of the study findings, this survey was sent to all hip and knee orthopaedic surgeons identified in Australia (see 9.3 Methods for details). This different survey pool also allowed for comparison between ASA members and non-members to determine if there was any inherent difference in their opinions and preferences; and to determine if ASA membership had any influence on guideline familiarity and acceptability. Lastly, the larger sample size also allowed for more reliable comparisons between aspirin and anticoagulant users, thereby adding more data to the investigation into enablers and barriers to prescribing different pharmacological prophylaxis.

9.2 Aim

The aim of this study was three-fold:

 to explore Australian surgeons’ opinion of the ACCP 9th Ed. Guideline;

 to compare the opinions of ASA members and non-members;

 to determine if ASA members’ opinions had changed since the previous survey, conducted two years earlier; and

 to identify any differentiating characteristics between aspirin and anticoagulant users.

9.3 Methods

The absolute number of respondents to the survey outlined in Chapter 6 was small (25 surgeons), thereby limiting the generalisability of the findings and increasing the risk of nonresponse bias. Consequently, a number of strategies were employed to increase the absolute number of responses to this survey, many consistent with those trialled in Chapter 5. These strategies included:

 opening the survey to all surgeons in Australia, irrespective of whether they were ASA members or not,

 shortening the survey considerably from the template used in Chapter 6,

 making the survey available in both a soft and hard copy format,

 including a hard copy of the survey in every reminder letter so that surgeons could see how short and quick it was to complete,

 personally signing and including a personal ‘thank you’ note in each invitation and reminder letter,

 distributing the survey directly from the university, thereby excluding any potential bias which may have been introduced by the professional endorsement of the previous survey, and lastly,

 using a 3rd generation Apple iPad draw (valued at AUD539) as an incentive to elicit participation.

9.3.1 Participant Selection and Invitation

The names and addresses of hip and knee surgeons were identified by searching through telephone listings and orthopaedic practice websites, and through general internet searches. An invitation to participate in the survey was sent to 485 surgeons in total. Some invitations were returned unopened because the surgeon was no longer at the said-practice. In these instances, follow-on practice details (where available) were identified and invitations (and follow-on reminders) were sent to the new practice.

9.3.2 The Survey

The survey was created with LimeSurvey and hosted on a University of Tasmania server. It contained a mixture of quantitative and qualitative questions that were divided into three sections covering: demographics and professional practising information; prophylaxis effectiveness and preferences; and lastly questions concerning familiarity with and opinion of contemporary guidelines (Appendix F). The quantitative styled questions were similar to those used in the study outlined in Chapter 6, however the qualitative open ended questions were focused on the ACCP 9th Ed. Guideline instead of the NHMRC Guideline.68 To ensure all participants had equal opportunity to provide an informed opinion on the ACCP Guideline the survey included a summary of its recommendations. Participants were asked to indicate whether they were ASA members or not in order to allow comparison of responses between this and the previous surgeon survey (and between ASA and non-ASA members’ responses).

The qualitative styled section included a space for participants to share their opinion on appropriate and inappropriate aspects of the ACCP 9th Ed. Guideline, as well as general comments

on thromboprophylaxis. This approach allowed exploration of their opinions in a way that check- box styled questions could not achieve; and minimised responses being influenced by the researchers’ presumptions.

The survey was open for participants to access for eight weeks in early 2012; during this time two reminder letters were sent encouraging surgeons to participate.