Introduction Patients undergoing gynecologic cancer surgery at Vancouver General Hospital are recommended 28-days of low molecular weight heparin (LMWH) for post-operative thromboprophylaxis. Baseline survey (October 2021) revealed LMWH was associated with 91% adherence, but negatively impacted patient experience due to self-injection and cost. Our aim was to improve patient experience by reducing symptoms of pain and bruising by 50%, increasing adherence by 5%, and reducing financial toxicity over a 3-month period.

Methods Patients were offered a choice between apixaban (2.5 mg PO BID) or LMWH (enoxaparin 40 mg SQ daily) at discharge. A multidisciplinary team informed project design, implementation, and evaluation. Process interventions included pre-printed orders and a multimodal patient and care team education program. Telephone survey and chart audit informed outcome, process and balancing measures. Data were analyzed using statistical process control charts, descriptive statistics, and Mann-Whitney (two-sided, significance <0.05).

Results We included 127 consecutive patients from August to October 2022. Apixaban was chosen by 83.4% (n=106/127). Survey response rate was 73.2% (n=93/127). Patients who chose apixaban reported 72.8% reduction in pain, 52.9% reduction in bruising, 52.4% increase in comfort of administration, and 34.3% reduction in negative impact of the medication (p<0.00001 for all). Adherence was unchanged (92%). The proportion of patients paying less than $125 increased from 45% to 91%. There were no differences in balancing measures (bleeding, re-operation) and no VTE events.

Conclusion/Implications Introduction of apixaban for extended post-operative thromboprophylaxis was associated with significant improvements in patient-reported quality measures and reduced financial toxicity. Apixaban has become standard of care at our centre.