AUTHORS
Brianna R Bakow, MD, Manila Gaddh, MD2, Radhika Gangaraju, MD, MSPH3, Bharadhwaj Kolipakkam, MBBS4, Ming Lim, MBBCh, MS5, Karlyn A Martin, MD MS6, Sudhanshu Mulay, MBBS7, Usha S Perepu, MD8, Rachel Rosovsky, MD, MPH9, Rishabh Singh, MD10, Gerald A Soff, MD11, Senthil Sukumar, MD,MSc12, Ishan Tatake, MD13, Lisa Baumann Kreuziger, MD, MS14
AFFILIATIONS
1 Brigham and Women's Hospital, Boston, Massachusetts, United States, Harvard Medical School, Boston, Massachusetts, United States
2 Emory University School of Medicine, Atlanta, Georgia, United States
3 University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, United States
4 Virginia Commonwealth University Health, Richmond, United States
5 University of Utah Health, Salt Lake City, Utah, United States
6 University of Vermont, Burlington, Vermont, United States
7 Yale School of Medicine, New Haven, Connecticut, United States
8 Mays Cancer Center, San Antonio, Texas, United States, UT Health San Antonio, San Antonio, Texas, United States
9 Harvard Medical School, Boston, Massachusetts, United States, Massachusetts General Hospital, Boston, Massachusetts, United States
10 Indiana University School of Medicine, Indianapolis, Indiana, United States
11 Sylvester Comprehensive Cancer Center, Miami, Florida, United States, University of Miami Health Systems, Miami, Florida, United States
12 Baylor College of Medicine, Houston, Texas, United States
13 Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
14 Medical College of Wisconsin, Milwaukee, Wisconsin, United States, Versiti, Milwaukee, Wisconsin, United States
ABSTRACT
Introduction
Perioperative anticoagulation management is common, but guideline interpretation varies across institutions, clinicians, medical specialty, and language used. The Venous Thromboembolism Network U.S. (VENUS) Systems-Based Hematology Committee collaborated with MDCalc to develop a clinical decision-support tool to standardize interpretation (“Perioperative Anticoagulation Management Algorithm”) of the American College of Chest Physicians Perioperative Management of Antithrombotic Therapy guidelines. The tool translates guideline recommendations into patient-specific anticoagulant dates and times for holding anticoagulation before a planned procedure or surgery. Briefly, the provider enters the surgery date, anticoagulant agent, and bleeding risk of the surgery, and the tool provides last dose date and time prior to surgery. We evaluated providers’ concordance with guideline-recommended anticoagulant interruption (fidelity) before and after using the tool, as well as its acceptability, appropriateness, and feasibility.
Methods
We conducted a cross-sectional, self-administered electronic survey via RedCap distributed nationally to 221 medical providers between April and July 2026. Providers were eligible if they self-identified as participating in any aspect of perioperative anticoagulation planning or management. The survey included 18 items evaluating demographic and practice characteristics, interpretation of two clinical anticoagulation management scenarios, acceptability, appropriateness, and feasibility of use utilizing a 5-point Likert scale. Scenario 1 addressed the perioperative management of apixaban before a procedure with low-to-moderate bleeding risk, whereas Scenario 2 addressed the management of rivaroxaban before a high-bleeding-risk procedure. Participants interpreted the perioperative anticoagulation instructions before and after using the MDCalc tool (). McNemar tests on paired proportions were used to compare the percentage of people who gave correct responses to the patient scenarios.
Results
A total of 97 providers completed at least part of the survey (43.9% overall response rate) and 67 (30.3%) completed all the patient scenarios and implementation questions. Among participants reporting a professional role (n=64), 43.8% were physicians, 43.8% were pharmacists, 11.1% were advanced practice providers, and one (1.6%) provider was a registered nurse. Of the 35 respondents that provided a primary medical specialty, the most common specialties represented included hematology/oncology (77.1%, n=27) and internal/family and hospital medicine (17.2%, n=6). In both clinical scenarios, the rate of providers who correctly identified the appropriate timing for preoperative anticoagulation discontinuation increased after use of the perioperative anticoagulation algorithm tool (Case 1: 52.9% to 94.1%, p<0.001; Case 2: 45.6% to 63.2%; p<0.001). For Scenario 2, the less robust identification of the correct timing appeared to reflect differing interpretations of when the final rivaroxaban dose should be administered, with responses divided between morning and evening despite the scenario specifying morning dosing. Most participants agreed (somewhat or strongly) that the calculator was easy to use (97.0%), easy to learn (98.5%), was relevant to their patients (92.5%) and that they felt confident using it for their patients (90.8%). Ninety percent of participants felt it was feasible to use the tool to determine perioperative anticoagulation.
Conclusions
In this study, the perioperative anticoagulation tool improved the ability to identify guideline-recommended timing for preoperative anticoagulant discontinuation. Almost all providers felt that the calculator was easy to learn and use, was relevant to the perioperative needs of their patients and felt confident using it. These findings support the algorithm’s appropriateness, acceptability, and feasibility. Broad use of the MDCalc tool may help improve consistency in interpretation of perioperative anticoagulation recommendations and help standardize management practices.
DISCLOSURES
Brianna R Bakow, MD: Anthos Therapeutics - Research Funding