Venous Thromboembolism Prophylaxis: Inadequate and Overprophylaxis When Comparing Perceived Versus Calculated Risk

An Electronic Medical Record Intervention to Increase Pharmacologic Prophylaxis for Venous Thromboembolism in Emergency Department Observation Patients

STUDY OBJECTIVE

The role of venous thromboembolism (VTE) prophylaxis among patients receiving emergency department (ED) observation unit care is unclear. We investigated an electronic health record-based clinical decision support tool aimed at increasing pharmacologic VTE prophylaxis use among at-risk patients placed in ED observation units.

METHODS

We conducted an interrupted time-series study of an Epic-based best practice advisory implemented in May 2019 at a health care system comprising 2 academic medical centers and 4 community hospitals with dedicated ED observation units. The best practice advisory alerted staff at 24 hours to conduct a risk assessment and linked to a VTE prophylaxis order set. We used an interrupted time series, Bayesian structured time series, and a multivariable mixed-effect regression model to estimate the intervention effect.

RESULTS

Prior to the best practice advisory implementation, there were 8,895 ED observation unit patients with a length of stay more than or equal to 24 hours, and 0.9% received pharmacologic VTE prophylaxis. Afterward, there were 12,664 ED observation unit patients with a length of stay more than or equal to 24 hours, and 4.8% received pharmacologic VTE prophylaxis. The interrupted time series and causal impact analysis showed a statistically significant increase in VTE prophylaxis (eg, absolute percent difference 3.8%, 95% confidence interval 3.5 to 4.1). In a multivariable model, only the intervention was significantly associated with receiving VTE prophylaxis (odds ratio 4.56, 95% confidence interval 2.22 to 9.37).

CONCLUSION

An electronic health record-based alert helped to prompt staff caring for ED observation unit patients at risk for VTE with prolonged visits to order recommended pharmacologic prophylaxis. The best risk assessment model to use and the true incidence of VTE events in this population are unclear.

Derivation, validation and assessment of a novel nomogram-based risk assessment model for venous thromboembolism in hospitalized patients with lung cancer: A retrospective case control study

Purpose

This study aimed to develop and validate a specific risk-stratification nomogram model for the prediction of venous thromboembolism(VTE) in hospitalized patients with lung cancer using readily obtainable demographic, clinical and therapeutic characteristics, thus guiding the individualized decision-making on thromboprophylaxis on the basis of VTE risk levels.

Methods

We performed a retrospective case–control study among newly diagnosed lung cancer patients hospitalized between January 2016 and December 2021. Included in the cohort were 234 patients who developed PTE and 936 non-VTE patients. The patients were randomly divided into the derivation group (70%, 165 VTE patients and 654 non-VTE patients) and the validation group (30%, 69 VTE patients and 282 non-VTE patients). Cut off values were established using a Youden´s Index. Univariate and multivariate regression analyses were used to determine independent risk factors associated with VTE. Variance Inflation Factor(VIF) was used for collinearity diagnosis of the covariates in the model. The model was validated by the consistency index (C-index), receiver operating characteristic curves(ROC) and the calibration plot with the Hosmer-Lemeshow goodness-of-fit test. The clinical utility of the model was assessed through decision curve analysis(DCA). Further, the comparison of nomogram model with current models(Khorana, Caprini, Padua and COMPASS-CAT) was performed by comparing ROC curves using the DeLong’s test.

Results

The predictive nomogram modle comprised eleven variables: overweight(24-28) defined by body mass index (BMI): [odds ratio (OR): 1.90, 95% confidence interval (CI): 1.19-3.07], adenocarcinoma(OR:3.00, 95% CI: 1.88-4.87), stageIII-IV(OR:2.75, 95%CI: 1.58-4.96), Central venous catheters(CVCs) (OR:4.64, 95%CI: 2.86-7.62), D-dimer levels≥2.06mg/L(OR:5.58, 95%CI:3.54-8.94), PT levels≥11.45sec(OR:2.15, 95% CI:1.32-3.54), Fbg levels≥3.33 g/L(OR:1.76, 95%CI:1.12-2.78), TG levels≥1.37mmol/L (OR:1.88, 95%CI:1.19-2.99), ROS1 rearrangement(OR:2.87, 95%CI:1.74-4.75), chemotherapy history(OR:1.66, 95%CI:1.01-2.70) and radiotherapy history(OR:1.96, 95%CI:1.17-3.29). Collinearity analysis with demonstrated no collinearity among the variables. The resulting model showed good predictive performance in the derivation group (AUC 0.865, 95% CI: 0.832-0.897) and in the validation group(AUC 0.904,95%CI:0.869-0.939). The calibration curve and DCA showed that the risk-stratification nomogram had good consistency and clinical utility. Futher, the area under the ROC curve for the specific VTE risk-stratification nomogram model (0.904; 95% CI:0.869-0.939) was significantly higher than those of the KRS, Caprini, Padua and COMPASS-CAT models(Z=12.087, 11.851, 9.442, 5.340, all P<0.001, respectively).

Conclusion

A high-performance nomogram model incorporated available clinical parameters, genetic and therapeutic factors was established, which can accurately predict the risk of VTE in hospitalized patients with lung cancer and to guide individualized decision-making on thromboprophylaxis. Notably, the novel nomogram model was significantly more effective than the existing well-accepted models in routine clinical practice in stratifying the risk of VTE in those patients. Future community-based prospective studies and studies from multiple clinical centers are required for external validation.

Acceptance of clinical decision support system to prevent venous thromboembolism among nurses: an extension of the UTAUT model

Background

Venous thromboembolism has been a major public health problem and caused a heavy disease burden. Venous thromboembolism clinical decision support system was proved to have a positive influence on the prevention and management of venous thromboembolism. As the direct users, nurses' acceptance of this system is of great importance to support the successful implementation of it. However, there are few relevant studies to investigate nurses' acceptance and the associated factors are still unclear.

Objective

To investigate the determinant factors of nurses' acceptance of venous thromboembolism clinical decision support system with the modified Unified Theory of Acceptance and Use of Technology.

Methods

We designed a questionnaire based on the modified Unified Theory of Acceptance and Use of Technology and then a cross-sectional survey was conducted among nurses in a tertiary hospital in Nanjing, China. Statistically, a Structural Equation Modeling -Partial Least Squares path modeling approach was applied to examine the research model.

Results

A total of 1100 valid questionnaires were recycled. The modified model explained 74.7%, 83.0% and 86% of the variance in user satisfaction, behavioral intention and user behavior, respectively. The results showed that performance expectancy (β = 0.254, p = 0.000), social influence (β = 0.136, p = 0.047), facilitating conditions (β = 0.245, p = 0.000), self-efficacy (β = 0.121, p = 0.048) and user satisfaction (β = 0.193, p = 0.001) all had significant effects on nurses' intention. Although effort expectancy (β = 0.010, p = 0.785) did not have a direct effect on nurses' intention, it could indirectly influence nurses' intention with user satisfaction as the mediator (β = 0.296, p = 0.000). User behavior was significantly predicted by facilitating conditions (β = 0.298, p = 0.000) and user intention (β = 0.654, p = 0.001).

Conclusion

The research enhances our understanding of the determinants of nurses' acceptance of venous thromboembolism clinical decision support system. Among these factors, performance expectancy was considered as the top priority. It highlights the importance of optimizing system performance to fit the users' needs. Generally, the findings in our research provide clinical technology designers and administrators with valuable information to better meet users' requirements and promote the implementation of venous thromboembolism clinical decision support system.

Correlation of Wells Score, Caprine Score, and Padua Score with Risk of Hypercoagulation Condition Based on D-dimer in Intra-articular, Periarticular, and Degenerative Fracture Patients of Inferior Extremity

BACKGROUND: Surgery for large joint areas can increase risk of venous thromboembolism, which can be in the form of pulmonary embolism or deep vein thrombosis (DVT). As much as, 40–60% of hemostasis abnormalities, specifically hypercoagulable diseases, are suspected of causing this condition. The risk of developing DVT can be assessed using a physiological examination such as Wells score, Caprini score, and Padua score. The scoring systems assess some of the patient’s symptoms and risk factors for increasing the incidence of DVT. Hypercoagulation conditions can be assessed using D-dimer, which is often considered a gold standard in measuring hypercoagulation conditions or as an indicator of DVT. AIM: We aimed to investigate correlation of Wells Score, Caprine Score, and Padua Score with risk of hypercoagulation condition based on d-dimer in intra-articular, periarticular, and degenerative fracture patients of inferior extremity. METHODS: This study used a cross-sectional design and was conducted on 34 participants that undergoing periarticular surgery. This study compared the Wells, Caprini, and Padua scores test against hypercoagulation conditions confirmed by the D-dimer examination. RESULTS: The correlation between Wells, Padua, Caprini scores, and D-dimer was 0.676, 0.023, and 0.395, respectively. CONCLUSION: There was a significant relationship between the Padua scores and the D-dimer.