Peace—and aspirin—in our time

Nobel prizes probably won't be handed out, but peace has been declared between the American College of Chest Physicians and the American Academy of Orthopaedic Surgeons, and patients might be declared the conflict's winners.

"The guideline wars are over," trumpets the headline of an editorial written by Dr. Jay Lieberman, chairman of the University of Connecticut orthopedic surgery department and appearing in the Journal of the American Academy of Orthopaedic Surgeons.

Can it be true?

"I think it is," said Dr. Greg Brown, associate chief of surgery for outcomes, at Park Nicollet Health Services in St. Louis Park, Minn., who said the efforts to prevent one problem created another and inflated costs along the way.

Good intentions are at the core of this mess, but Brown noted that a conflict of interest may have made it worse.

The ACCP adopted guidelines for preventing venous thromboembolism events, or VTE, such as deep vein thrombosis—blood clots in the large veins of the legs. These can lead to pulmonary embolism when the blood clot breaks free and gets into the lungs. The guidelines called for prophylactic prescribing of anti-coagulants such as heparin or warfarin to prevent this.

Brown said aspirin often works just as well at a much lower cost and with much less risk for post-operative bleeding in patients who have hip or knee replacements or fractured hips. He didn't make friends among chest physicians as he frequently noted that six of the seven members of the 2004 ACCP guideline panel reported having potential conflicts of interests because of relationships with Sanofi-Aventis, an anti-coagulant manufacturer.

Brown's protests aside, the 2004 ACCP guidelines were adopted as performance measures by the Surgical Care Improvement Project and adopted as quality measures in the CMS-run Physician Group Practice Demonstration project, which Park Nicollet participated in.

"By not following (the group's) guidelines, I was essentially putting our institution at risk," Brown said, noting that Park Nicollet was "fully supportive" of him acting in the best interests of his patients.

While the ACCP's new guidelines allow for the use of aspirin, the group's enthusiasm for doing so is at a much lower level than it is for the AAOS docs.

In a February news release announcing the revised guidelines, the ACCP noted that "aspirin is an option—although not typically the agent of choice" for patients who just had major orthopedic surgery.

"Although we are not recommending aspirin as the optimal DVT/VTE prophylaxis, we have reviewed the existing evidence and concluded that aspirin is an acceptable option in some instances where preventive therapy is needed," guideline co-author Dr. Mark Crowther, McMaster University, Hamilton, Ontario, said in the release.

Brown said the goal is developing risk stratification protocols. In fact, he added, Park Nicollet has been doing so for two years and is analyzing performance data from this protocol.

"The issue is we don't do something one-size-fits-all in medicine," Brown said.

Follow Andis Robeznieks on Twitter: @MHARobeznieks.