Appropriate Use Criteria
Antithrombotic Therapies for Spine Surgery
Results
Based on inclusion criteria and level of evidence, manuscripts were reviewed in detail and evidentiary tables completed which formed the basis for the level of evidence for each scenario which raters used to inform their rating.2-62 The completed evidentiary tables along with results of all individual final ratings can be found on the NASS website, www.spine.org.
Initiation of Anticoagulation within 24 Hours after Surgery
For appropriateness of starting anticoagulation within 24 hours, 71 (74%) scenarios had a final rating of 'Appropriate with Agreement'. Of these 71 scenarios, 42 (59%) had 'High' risk factors vs 29 (41%) had 'Low' risk factors (p=0.005), and 48 (68%) had 'Spinal Cord Injury (SCI) = Yes' vs 23 (32%) had 'Spinal Cord Injury = No' (p=0.005). All 48 scenarios listing 'Spinal Cord Injury = Yes' received a final rating of 'Appropriate with Agreement' for starting anticoagulation within 24hrs.' (Figure 1) In the absence of SCI but presence of high-risk factors otherwise, those scenarios that also included a diagnosis of neoplasm or trauma were rated appropriate 94% of the time. There was no significant difference between final appropriateness rating for differing diagnosis, procedure, operative duration or approach (p > 0.05; Table 3).
No scenarios received a final rating as ‘rarely appropriate’.
Figure 1. Decision tree for appropriateness of starting anticoagulation within 24 hours after surgery.
Table 3.
Initiation of Anticoagulation between 1-4 Days after Surgery
For appropriateness of starting anticoagulation between 1-4 days, 94 (98%) scenarios had a final rating of 'Appropriate with Agreement' (Table 3). There was no significant association between final rating and any of the modifier variables.
Agreement Of the 25 scenarios with a final rating as ‘Uncertain or Disagreement’ for initiating anticoagulation within 24 hours, 12 of the scenarios had a median score of 7 but had disagreement among the ratings. (Figure 2) Among the scenarios with disagreement, none of the individual modifiers were significantly associated with the final rating.
There was near unanimous agreement for appropriateness of initiating anticoagulation between 1-4 days after surgery, independent of the diagnosis, procedure type, operative duration, risk factors, surgical approach, or presence of a spinal cord injury.
Figure 2. Disagreement ratings in 24 hour scenario.
