Physicians' perceptions of the definition of major bleeding in major orthopedic surgery: results of an international survey

Decisions regarding choice of thromboprophylaxis in patients undergoing major orthopedic surgery are based on assessment of individual patient risk for thrombosis versus risk for bleeding. An international survey sought physician views on definitions and relative importance of different types of major bleeding. A random sample of physicians from five countries (100 physicians per country, mainly surgeons) completed an internet-based 13-question survey on perceptions, concerns, and relevance of bleeding associated with thromboprophylaxis in major orthopedic surgery. Over 80% of responders were concerned or very concerned about bleeding with >70% considering surgical-site bleeding as the most concerning, and relevant type and site for bleeding. Nearly 80% of responders considered surgical-site bleeding to increase patient length of hospital stay, and >70% noted that it complicates patient rehabilitation. After fatal bleeding, bleeding leading to re-operation was ranked as the most concerning type of major bleed. Less than half of responders reported closely reading the major-bleeding definitions in clinical study publications. Most responders favored anticoagulants that could offer a reduced bleeding risk and similar venous thromboembolism (VTE) prevention compared to current anticoagulants rather than a decrease in VTE and similar bleeding risk. There is a disconnect between the definitions of major bleeding that surgeons would apply to describe bleeding associated with VTE thromboprophylaxis, and those used in clinical studies reporting the safety profiles of newer anticoagulant agents. Misperceptions about the benefit-to-harm profiles of thromboprophylactic therapies may incorrectly inform treatment choices in patients at high risk for post-operative VTE.