Reply to Letter: “Ulcerative Colitis Is Associated With an Increased Risk of Venous Thromboembolism in the Postoperative Period

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We appreciate the interest and comments of Dr Nepogodiev and colleagues in our analysis of venous thromboembolism among surgical patients with ulcerative colitis (UC).1 They have raised important points regarding extended prophylaxis of UC patients in the postoperative period.
Because of the nature of the ACS National Surgical Quality Improvement Project's data collection scheme, information such as data pertaining to a patient's medical history is limited and data on in-hospital therapies exclusive of the operating room are not well captured. Information such as a history of VTE and in-hospital VTE prophylaxis regimens is simply unavailable. Although the ACS National Surgical Quality Improvement Project collects information about medical history, such as a history of myocardial infarction, coronary artery disease, peripheral vascular disease, stroke, and transient ischemic attack (among many others), it does not capture a history of deep vein thrombosis or pulmonary embolism. Despite this shortcoming of the data set, a history of VTE may not be relevant, given the low incidence of recurrent VTE among patients treated with an appropriate course of anticoagulants.2,3 With regard to whether or not the patients received guideline-based prophylaxis, there should be no difference between patients treated for inflammatory bowel disease and other patients in terms of VTE prophylaxis regimen because all patients were treated at similar institutions and all data were collected up to 2012 (before the implementation of extended postdischarge use of VTE prophylaxis for cancer patients). VTE prophylaxis in US hospitals is likely to become a publicly reported quality measure in the near future, but compliance with established guidelines is imperfect.4
Despite a relatively high number needed to treat, extended VTE prophylaxis would likely be cost-effective in a US health system model. As Dr Nepogodiev has noted, approximately 25% of patients with inflammatory bowel disease with VTE require intensive care, with approximately 10% of these patients dying.5 In our series that includes only surgical patients, the mortality rate (30-day) was not as high. Intensive care in the United States is very costly, both from a payer perspective and in terms of utilizing hospital resources, and the cost of extended prophylaxis is likely to be far less than an intensive care unit admission.6 Even nonfatal VTE is costly, and warfarin therapy requires frequent monitoring, clinic visits, and nursing care.7,8 We agree that a formal cost analysis is necessary to provide robust, fully informed recommendations regarding prolonged prophylaxis.

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