Multicentre validation of the Geneva Risk Score for hospitalised medical patients at risk of venous thromboembolism

Implementation of a transition of care pathway for low-risk patients presenting to the emergency department with venous thromboembolism

Inpatient management of low-risk patients with venous thromboembolism (VTE) places a large resource burden on the healthcare system. Adult patients diagnosed with deep vein thrombosis (DVT) or pulmonary embolism (PE) in the emergency department (ED) have historically been hospitalized and treated with therapeutic anticoagulation. However, over the last two decades, outpatient treatment of patients with acute DVT and low risk PE has become increasingly accepted as an effective and safe option for patients given the low risk of short-term clinical deterioration. The purpose of this project was to establish a transition of care (TCM) program for patients with acute VTE presenting to the ED. The primary goals for the project included better quality patient follow-up in the Vascular Medicine Nurse Practitioner (NP) within one week and medication adherence. The second goal was increasing appropriate ED discharges for patients with low-risk VTE. Outcome metrics include the rate of early discharge of low-risk patients with VTE, follow-up in the Vascular Medicine NP clinic, and anticoagulant adherence.

Development and internal validation of the Cleveland Clinic Bleeding Model to predict major bleeding risk at admission in medical inpatients

BACKGROUND

Guidelines recommend pharmacologic VTE prophylaxis for acutely ill medical patients at acceptable bleeding risk, but only the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) model has been validated for bleeding risk assessment.

OBJECTIVES

We developed and internally validated a risk assessment model (RAM) to predict major in-hospital bleeding using risk factors at admission and compared our model with IMPROVE.

METHODS

We selected patients admitted to medical services at 10 hospitals in the Cleveland Clinic Health System from 2017 to 2020. We identified major bleeding according to the International Society on Thrombosis and Haemostasis criteria, using a combination of diagnostic codes and laboratory values, and confirmed events with chart review. We fit a least absolute shrinkage selection operator logistic regression model in the training set and compared the discrimination and calibration of our model with the IMPROVE model in the validation set.

RESULTS

Among 46 314 admissions, 268 (0.58%) had a major bleed. The final RAM included 16 risk factors, of which prior bleeding (odds ratio [OR] = 4.83), peptic ulcer (OR = 3.82), history of sepsis (OR = 3.26), and steroid use (OR = 2.59) were the strongest. The Cleveland Clinic Bleeding Model had better discrimination than IMPROVE (area under the receiver operating characteristics curve = 0.85 vs 0.70; P < .001) and, at equivalent sensitivity (52%), categorized fewer patients as high risk (7.2% vs 11.8%; P < .001). Calibration was adequate (Brier score = 0.0057).

CONCLUSION

Using a large population of medical inpatients with verified major bleeding events, we developed and internally validated a RAM for major bleeding whose performance surpassed the IMPROVE model.

Advancing Thrombosis Research: A Novel Device for Measuring Clot Permeability

Thromboembolism, a global leading cause of mortality, needs accurate risk assessment for effective prophylaxis and treatment. Current stratification methods fall short in predicting thrombotic events, emphasizing the need for a deeper understanding of clot properties. Fibrin clot permeability, a crucial parameter in hypercoagulable states, impacts clot structure and resistance to lysis. Current clot permeability measurement limitations propel the need for standardized methods. Prior findings underscore the importance of clot permeability in various thrombotic conditions but call for improvements and more precise, repeatable, and standardized methods. Addressing these challenges, our study presents an upgraded, portable, and cost-effective system for measuring blood clot permeability, which utilizes a pressure-based approach that adheres to Darcy's law. By enhancing precision and sensitivity in discerning clot characteristics, this innovation provides a valuable tool for assessing thrombotic risk and associated pathological conditions. In this paper, the authors present a device that is able to automatically perform the permeability measurements on plasma or fibrinogen in vitro-induced clots on specific holders (filters). The proposed device has been tailored to distinguish clot permeability, with high precision and sensitivity, between healthy subjects and high cardiovascular-risk patients. The precise measure of clot permeability represents an excellent indicator of thrombotic risk, thus allowing the clinician, also on the basis of other anamnestic and laboratory data, to attribute a risk score to the subject. The proposed instrument was characterized by performing permeability measurements in plasma and purified fibrinogen clots derived from 17 Behcet patients and 15 sex- and age-matched controls. As expected, our results clearly indicate a significant difference in plasma clot permeability in Behcet patients with respect to controls (0.0533 ± 0.0199 d vs. 0.0976 ± 0.0160 d, p < 0.001). This difference was confirmed in the patient's vs. control fibrin clots (0.0487 ± 0.0170 d vs. 0.1167 ± 0.0487 d, p < 0.001). In conclusion, our study demonstrates the feasibility, efficacy, portability, and cost-effectiveness of a novel device for measuring clot permeability, allowing healthcare providers to better stratify thrombotic risk and tailor interventions, thereby improving patient outcomes and reducing healthcare costs, which could significantly improve the management of thromboembolic diseases.

Gynecological Cancer and Venous Thromboembolism: A Narrative Review to Increase Awareness and Improve Risk Assessment and Prevention

The prevention and appropriate management of venous thromboembolism in cancer patients is of paramount importance. However, the literature data report an underestimation of this major problem in patients with gynecological cancers, with an inconsistent venous thromboembolism risk assessment and prophylaxis in this patient setting. This narrative review provides a comprehensive overview of the available evidence regarding the management of venous thromboembolism in cancer patients, focusing on the specific context of gynecological tumors, exploring the literature discussing risk factors, risk assessment, and pharmacological prophylaxis. We found that the current understanding and management of venous thromboembolism in gynecological malignancy is largely based on studies on solid cancers in general. Hence, further, larger, and well-designed research in this area is needed.

Risk Assessment Models for Venous Thromboembolism in Medical Inpatients

Importance

Thromboprophylaxis is recommended for medical inpatients at risk of venous thromboembolism (VTE). Risk assessment models (RAMs) have been developed to stratify VTE risk, but a prospective head-to-head comparison of validated RAMs is lacking.

Objectives

To prospectively validate an easy-to-use RAM, the simplified Geneva score, and compare its prognostic performance with previously validated RAMs.

Design, Setting, and Participants

This prospective cohort study was conducted from June 18, 2020, to January 4, 2022, with a 90-day follow-up. A total of 4205 consecutive adults admitted to the general internal medicine departments of 3 Swiss university hospitals for hospitalization for more than 24 hours due to acute illness were screened for eligibility; 1352 without therapeutic anticoagulation were included.

Exposures

At admission, items of 4 RAMs (ie, the simplified and original Geneva score, the Padua score, and the IMPROVE [International Medical Prevention Registry on Venous Thromboembolism] score) were collected. Patients were stratified into high and low VTE risk groups according to each RAM.

Main Outcomes and Measures

Symptomatic VTE within 90 days.

Results

Of 1352 medical inpatients (median age, 67 years [IQR, 54-77 years]; 762 men [55.4%]), 28 (2.1%) experienced VTE. Based on the simplified Geneva score, 854 patients (63.2%) were classified as high risk, with a 90-day VTE risk of 2.6% (n = 22; 95% CI, 1.7%-3.9%), and 498 patients (36.8%) were classified as low risk, with a 90-day VTE risk of 1.2% (n = 6; 95% CI, 0.6%-2.6%). Sensitivity of the simplified Geneva score was 78.6% (95% CI, 60.5%-89.8%) and specificity was 37.2% (95% CI, 34.6%-39.8%); the positive likelihood ratio of the simplified Geneva score was 1.25 (95% CI, 1.03-1.52) and the negative likelihood ratio was 0.58 (95% CI, 0.28-1.18). In head-to-head comparisons, sensitivity was highest for the original Geneva score (82.1%; 95% CI, 64.4%-92.1%), while specificity was highest for the IMPROVE score (70.4%; 95% CI, 67.9%-72.8%). After adjusting the VTE risk for thromboprophylaxis use and site, there was no significant difference between the high-risk and low-risk groups based on the simplified Geneva score (subhazard ratio, 2.04 [95% CI, 0.83-5.05]; P = .12) and other RAMs. Discriminative performance was poor for all RAMs, with an area under the receiver operating characteristic curve ranging from 53.8% (95% CI, 51.1%-56.5%) for the original Geneva score to 58.1% (95% CI, 55.4%-60.7%) for the simplified Geneva score.

Conclusions and Relevance

This head-to-head comparison of validated RAMs found suboptimal accuracy and prognostic performance of the simplified Geneva score and other RAMs to predict hospital-acquired VTE in medical inpatients. Clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies.

Evaluation of venous thromboembolism risk assessment models for hospital inpatients: the VTEAM evidence synthesis

Background

Pharmacological prophylaxis during hospital admission can reduce the risk of acquired blood clots (venous thromboembolism) but may cause complications, such as bleeding. Using a risk assessment model to predict the risk of blood clots could facilitate selection of patients for prophylaxis and optimise the balance of benefits, risks and costs.

Objectives

We aimed to identify validated risk assessment models and estimate their prognostic accuracy, evaluate the cost-effectiveness of different strategies for selecting hospitalised patients for prophylaxis, assess the feasibility of using efficient research methods and estimate key parameters for future research.

Design

We undertook a systematic review, decision-analytic modelling and observational cohort study conducted in accordance with Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines.

Setting

NHS hospitals, with primary data collection at four sites.

Participants

Medical and surgical hospital inpatients, excluding paediatric, critical care and pregnancy-related admissions.

Interventions

Prophylaxis for all patients, none and according to selected risk assessment models.

Main outcome measures

Model accuracy for predicting blood clots, lifetime costs and quality-adjusted life-years associated with alternative strategies, accuracy of efficient methods for identifying key outcomes and proportion of inpatients recommended prophylaxis using different models.

Results

We identified 24 validated risk assessment models, but low-quality heterogeneous data suggested weak accuracy for prediction of blood clots and generally high risk of bias in all studies. Decision-analytic modelling showed that pharmacological prophylaxis for all eligible is generally more cost-effective than model-based strategies for both medical and surgical inpatients, when valuing a quality-adjusted life-year at £20,000. The findings were more sensitive to uncertainties in the surgical population; strategies using risk assessment models were more cost-effective if the model was assumed to have a very high sensitivity, or the long-term risks of post-thrombotic complications were lower. Efficient methods using routine data did not accurately identify blood clots or bleeding events and several pre-specified feasibility criteria were not met. Theoretical prophylaxis rates across an inpatient cohort based on existing risk assessment models ranged from 13% to 91%.

Limitations

Existing studies may underestimate the accuracy of risk assessment models, leading to underestimation of their cost-effectiveness. The cost-effectiveness findings do not apply to patients with an increased risk of bleeding. Mechanical thromboprophylaxis options were excluded from the modelling. Primary data collection was predominately retrospective, risking case ascertainment bias.

Conclusions

Thromboprophylaxis for all patients appears to be generally more cost-effective than using a risk assessment model, in hospitalised patients at low risk of bleeding. To be cost-effective, any risk assessment model would need to be highly sensitive. Current evidence on risk assessment models is at high risk of bias and our findings should be interpreted in this context. We were unable to demonstrate the feasibility of using efficient methods to accurately detect relevant outcomes for future research.

Future work

Further research should evaluate routine prophylaxis strategies for all eligible hospitalised patients. Models that could accurately identify individuals at very low risk of blood clots (who could discontinue prophylaxis) warrant further evaluation.

Study registration

This study is registered as PROSPERO CRD42020165778 and Researchregistry5216.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127454) and will be published in full in Health Technology Assessment; Vol. 28, No. 20. See the NIHR Funding and Awards website for further award information.

Association of pharmacologic thromboprophylaxis with clinically relevant bleeding and hospital-acquired anemia in medical inpatients: the risk stratification for hospital-acquired venous thromboembolism in medical patients study

BACKGROUND

Pharmacologic thromboprophylaxis (pTPX) might exacerbate the risk of clinically relevant bleeding (CRB) and hospital-acquired anemia (HAA) in older multimorbid inpatients.

OBJECTIVES

We aimed to evaluate the association of pTPX use with CRB and HAA.

METHODS

We used data from a prospective cohort study conducted in 3 Swiss university hospitals. Adult patients admitted to internal medicine wards with no therapeutic anticoagulation were included. pTPX use was ascertained during hospitalization. Outcomes were in-hospital CRB and HAA. We calculated incidence rates by status of pTPX. We assessed the association of pTPX with CRB using survival analysis and with HAA using logistic regression, adjusted for infection, length of stay, and the International Medical Prevention Registry on Venous Thromboembolism bleeding risk score.

RESULTS

Among 1305 patients (mean age, 63.7 years; 44% women, 90% at low risk of bleeding), 809 (62%) received pTPX. The incidence of CRB was 2.4 per 1000 patient-days and was not significantly higher in patients with pTPX than in those without. We found no significant association between pTPX and CRB. HAA was frequent (20.2%) and higher in patients with pTPX than in those without (23.2% vs 15.3%). The incidence of HAA was 21.2 per 1000 patient-days and did not significantly differ between patients with pTPX and those without. We found an association between pTPX and HAA (adjusted odds ratio, 1.4; 95% CI, 1.0-2.1).

CONCLUSION

Our study confirmed the safety of pTPX in medical inpatients at low risk of bleeding but identified an association between pTPX and HAA. Adherence to guidelines that recommend administering pTPX to medical inpatients at increased venous thromboembolism risk and low bleeding risk is necessary.

Thrombosis and Bleeding Risk Scores Are Strongly Associated with Mortality in Hospitalized Patients with COVID-19: A Multicenter Cohort Study

Background: Internationally established guidelines mention pharmacological prophylaxis for all hospitalized COVID-19 patients. However, there are concerns regarding the efficacy and safety of anticoagulants. This study investigated the associations between thrombosis/bleeding risk scores and clinical outcomes. Methods: We conducted a retrospective review of adult patients admitted to two hospitals between 2021 and 2022. We analyzed clinical data, laboratory results, low molecular weight heparin (LMWH) use, thrombosis, bleeding, and 30-day survival. Results: Of the 160 patients, 69.4% were female, and the median age was 59 years. The rates of thrombotic complications and mortality were 12.5% and 36.3%, respectively. LMWH prophylaxis was administered to 73 of the patients (45.6%). The patients with high Padua prediction scores (PPS) and high IMPROVEVTE scores had a significantly higher risk of venous thromboembolism (VTE) compared to those with low scores (30.8% vs. 9.0%, p = 0.006 and 25.6% vs. 7.7%, p = 0.006). Similarly, elevated IMPROVEVTE and IMPROVEBRS scores were associated with increased mortality (hazard ratios of 7.49 and 6.27, respectively; p < 0.001). Interestingly, LMWH use was not associated with a decreased incidence of VTE when stratified by risk groups. Conclusions: this study suggests that COVID-19 patients with high thrombosis and bleeding risk scores have a higher mortality rate.

Ability of Caprini and Padua risk-assessment models to predict venous thromboembolism in a nationwide Veterans Affairs study

OBJECTIVE

Venous thromboembolism (VTE) is a preventable complication of hospitalization. Risk-stratification is the cornerstone of prevention. The Caprini and Padua are two of the most commonly used risk-assessment models (RAMs) to quantify VTE risk. Both models perform well in select, high-risk cohorts. Although VTE RAMs were designed for use in all hospital admissions, they are mostly tested in select, high-risk cohorts. We aim to evaluate the two RAMs in a large, unselected cohort of patients.

METHODS

We analyzed consecutive first hospital admissions of 1,252,460 unique surgical and non-surgical patients to 1298 Veterans Affairs facilities nationwide between January 2016 and December 2021. Caprini and Padua scores were generated using the Veterans Affairs' national data repository. We determined the ability of the two RAMs to predict VTE within 90 days of admission. In secondary analyses, we evaluated prediction at 30 and 60 days, in surgical vs non-surgical patients, after excluding patients with upper extremity deep vein thrombosis, in patients hospitalized ≥72 hours, after including all-cause mortality in a composite outcome, and after accounting for prophylaxis in the predictive model. We used area under the receiver operating characteristic curves (AUCs) as the metric of prediction.

RESULTS

A total of 330,388 (26.4%) surgical and 922,072 (73.6%) non-surgical consecutively hospitalized patients (total N = 1,252,460) were analyzed. Caprini scores ranged from 0 to 28 (median, 4; interquartile range [IQR], 3-6); Padua scores ranged from 0-13 (median, 1; IQR, 1-3). The RAMs showed good calibration and higher scores were associated with higher VTE rates. VTE developed in 35,557 patients (2.8%) within 90 days of admission. The ability of both models to predict 90-day VTE was low (AUCs: Caprini, 0.56; 95% confidence interval [CI], 0.56-0.56; Padua, 0.59; 95% CI, 0.58-0.59). Prediction remained low for surgical (Caprini, 0.54; 95% CI, 0.53-0.54; Padua, 0.56; 95% CI, 0.56-0.57) and non-surgical patients (Caprini, 0.59; 95% CI, 0.58-0.59; Padua, 0.59; 95% CI, 0.59-0.60). There was no clinically meaningful change in predictive performance in any of the sensitivity analyses.

CONCLUSIONS

Caprini and Padua RAM scores have low ability to predict VTE events in a cohort of unselected consecutive hospitalizations. Improved VTE RAMs must be developed before they can be applied to a general hospital population.

The effect of obligatory Padua prediction scoring in hospitalized medically ill patients: A retrospective cohort study

BACKGROUND

Venous thromboembolism (VTE) is considered a preventable cause of mortality. The evidence for the benefit of VTE prophylaxis in acute medical patients is non-conclusive. Meta-analysis of RCTs failed to demonstrate reduction of all-cause mortality, while showing higher risk of bleeding. The Israeli Ministry of Health has instructed to assess all acute medical patients for the risk for VTE using the Padua Prediction Score, without mandating prophylaxis.

AIM

To evaluate the effect of filling the Padua score on clinical outcomes and VTE prophylaxis rates.

METHODS

Retrospective Study was performed in Israel during the years 2014-2017. The participants were divided to Padua compliance vs non-compliance group. Primary outcome: 30-day mortality. Secondary outcomes: 90-day incidence of VTE and suspected major bleeding. A propensity-weighted logistic multiple regression was performed.

RESULTS

18,890 patients were included in the study. The fulfillment of the Padua score was associated with an increased use of VTE prophylaxis, OR 1.66 (95% CI 1.49-1.84). However, there was no reduction of mortality or VTE events, OR 1.13 (95% CI 0.97-1.31) and OR 1.22 (95% CI 0.79-1.8) respectively. Hospitalizations related to hemoglobin decrease were not statistically different between the two groups.

CONCLUSIONS

Padua score for the assessment of VTE risk in medical wards was associated with higher administration of pharmacological prophylaxis without reduction in VTE or mortality rate. Its usage should be reassessed as a performance measure.

Development and validation of a risk model for hospital-acquired venous thrombosis: the Medical Inpatients Thrombosis and Hemostasis study

BACKGROUND

Regulatory organizations recommend assessing hospital-acquired (HA) venous thromboembolism (VTE) risk for medical inpatients.

OBJECTIVES

To develop and validate a risk assessment model (RAM) for HA-VTE in medical inpatients using objective and assessable risk factors knowable at admission.

METHODS

The development cohort included people admitted to medical services at the University of Vermont Medical Center (Burlington, Vermont) between 2010 and 2019, and the validation cohorts included people admitted to Hennepin County Medical Center (Minneapolis, Minnesota), University of Michigan Medical Center (Ann Arbor, Michigan), and Harris Health Systems (Houston, Texas). Individuals with VTE at admission, aged <18 years, and admitted for <1 midnight were excluded. We used a Bayesian penalized regression technique to select candidate HA-VTE risk factors for final inclusion in the RAM.

RESULTS

The development cohort included 60 633 admissions and 227 HA-VTE, and the validation cohorts included 111 269 admissions and 651 HA-VTE. Seven HA-VTE risk factors with t statistics ≥1.5 were included in the RAM: history of VTE, low hemoglobin level, elevated creatinine level, active cancer, hyponatremia, increased red cell distribution width, and malnutrition. The areas under the receiver operating characteristic curve and calibration slope were 0.72 and 1.10, respectively. The areas under the receiver operating characteristic curve and calibration slope were 0.70 and 0.93 at Hennepin County Medical Center, 0.70 and 0.87 at the University of Michigan Medical Center, and 0.71 and 1.00 at Harris Health Systems, respectively. The RAM performed well stratified by age, sex, and race.

CONCLUSION

We developed and validated a RAM for HA-VTE in medical inpatients. By quantifying risk, clinicians can determine the potential benefits of measures to reduce HA-VTE.

The Use of Risk Scores for Thromboprophylaxis in Medically Ill Patients-Rationale and Design of the RICO trial

Background  Venous thromboembolism (VTE) in hospitalized medically ill patients is a significant cause of morbidity and mortality. Guidelines suggest that VTE and bleeding risk assessment models (RAMs) should be integrated into the clinical decision-making process on thromboprophylaxis. However, poor evidence is available comparing the use of a RAM versus clinical judgement in evaluating VTE and bleeding occurrence. Methods  Reducing Important Clinical Outcomes in hospitalized medical ill patients (RICO) is a multicenter, cluster-randomized, controlled clinical trial (ClinicalTrials.gov Identifier: NCT04267718). Acutely ill patients hospitalized in Internal Medicine wards are randomized to the use of RAMs-namely the Padua Prediction Score and the International Medical Prevention Registry on Venous Thromboembolism Bleeding Score-or to clinical judgement. The primary study outcome is a composite of symptomatic objectively confirmed VTE and major bleeding at 90-day follow-up. Secondary endpoints include the evaluation of clinical outcomes at hospital discharge and the assessment of VTE prophylaxis prescription during the study period. In order to demonstrate a 50% reduction in the primary outcome in the experimental group and assuming an incidence of the primary outcome of 3.5% in the control group at 90-day; 2,844 patients across 32 centers will be included in the study. Discussion  The RICO trial is a randomized study of clinical management assessing the role of RAMs in hospitalized medical ill patients with the aim of reducing VTE and bleeding occurrence. The study has the potential to improve clinical practice since VTE still represents an important cause of morbidity and mortality in this setting.

Contemporary adequacy of thromboprophylaxis in acutely ill medical patients in Switzerland: a bi-centric prospective cohort

BACKGROUND

Venous thromboembolism is a dreaded complication of hospitalised patients, with associated morbidity, mortality and increased healthcare costs. Previous studies have shown that pharmacological thromboprophylaxis, though effective, is inadequately administered in a large proportion of medical inpatients.

STUDY AIMS

Our primary aim was to evaluate the contemporary adequacy of thromboprophylaxis in medical inpatients admitted to two Swiss hospitals (a university hospital and a regional hospital). The secondary aim was to estimate the 90-day incidence of relevant thrombotic and bleeding events.

METHODS

In this prospective cohort, patients were recruited at the University Hospital of Geneva and the Regional Hospital of Lugano between September 2020 and February 2021 and followed for 90 days for venous thromboembolism and bleeding events. The adequacy of thromboprophylaxis (pharmacological and/or mechanical) at 24h after hospital admission was evaluated according to the simplified Geneva risk score for hospital-associated venous thromboembolism.

RESULTS

Among 200 participants (100 at each site, mean age of 65 years), 57.5% were deemed at high risk of venous thromboembolism at admission. Thromboprophylaxis was adequate in 59.5% (95% CI 52.3-66.4%). Among high-risk and low-risk inpatients, thromboprophylaxis was adequate in 71.3% and 43.5%, respectively, with differences between sites. At 90 days, risks of adjudicated venous thromboembolism, major bleeding and mortality were 1.5%, 1.5% and 6.0%, respectively.

CONCLUSION

Despite the extensive literature on thromboprophylaxis, the adequacy of thromboprophylaxis has not improved and remains insufficient among medical inpatients. Implementation and evaluation of clinical decision support systems are critically needed in this field.

CLINICALTRIALS

gov number: NCT05306821.

Prediction of in-hospital bleeding in acutely ill medical patients: External validation of the IMPROVE bleeding risk score

INTRODUCTION

Pharmacological thromboprophylaxis slightly increases bleeding risk. The only risk assessment model to predict bleeding in medical inpatients, the IMPROVE bleeding risk score, has never been validated using prospectively collected outcome data.

METHODS

We validated the IMPROVE bleeding risk score in a prospective multicenter cohort of medical inpatients. Primary outcome was in-hospital clinically relevant bleeding (CRB) within 14 days of admission, a secondary outcome was major bleeding (MB). We classified patients according to the score in high or low bleeding risk. We assessed the score's predictive performance by calculating subhazard ratios (sHRs) adjusted for thromboprophylaxis use, positive and negative predictive values (PPV, NPV), and the area under the receiver operating characteristic curves (AUC).

RESULTS

Of 1155 patients, 8 % were classified as high bleeding risk. CRB and MB within 14 days occurred in 0.94 % and 0.47 % of low-risk and in 5.6 % and 3.4 % of high-risk patients, respectively. Adjusted for thromboprophylaxis, classification in the high-risk group was associated with an increased risk of 14-day CRB (sHR 4.7, 95 % confidence interval [CI] 1.5-14.5) and MB (sHR 4.9, 95%CI 1.0-23.4). PPV was 5.6 % and 3.4 %, while NPV was 99.1 % and 99.5 % for CRB and MB, respectively. The AUC was 0.68 (95%CI 0.66-0.71) for CRB and 0.73 (95%CI 0.71-0.76) for MB.

CONCLUSION

The IMPROVE bleeding risk score showed moderate to good discriminatory power to predict bleeding in medical inpatients. The score may help identify patients at high risk of in-hospital bleeding, in whom careful assessment of the risk-benefit ratio of pharmacological thromboprophylaxis is warranted.

Unprovoked Venous Thromboembolism: The Search for the Cause

Venous thromboembolism (VTE) is a common vascular disorder encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE). There is no data on global estimates of VTE prevalence and incidence. Most patients with unprovoked VTE require secondary thromboprophylaxis upon the completion of the primary treatment phase if they have no high bleeding risk. Risk prediction models can help identify patients at low VTE recurrence risk who may discontinue anticoagulation upon the completion of the primary treatment phase.

Overuse and underuse of thromboprophylaxis in medical inpatients

Background

Thromboprophylaxis (TPX) prescription is recommended in medical inpatients categorized as high risk of venous thromboembolism (VTE) by validated risk assessment models (RAMs), but how various RAMs differ in categorizing patients in risk groups, and whether the choice of RAM influences estimates of appropriate TPX use is unknown.

Objectives

To determine the proportion of medical inpatients categorized as high or low risk according to validated RAMs, and to investigate the appropriateness of TPX prescription.

Methods

This is a prospective cohort study of acutely ill medical inpatients from 3 Swiss university hospitals. Participants were categorized as high or low risk of VTE by validated RAMs (ie, the Padua, the International Medical Prevention Registry on Venous Thromboembolism, simplified, and original Geneva scores). We assessed prescription of any TPX at baseline. We considered TPX prescription in high-risk and no TPX prescription in low-risk patients as appropriate.

Results

Among 1352 medical inpatients, the proportion categorized as high risk ranged from 29.8% with the International Medical Prevention Registry on Venous Thromboembolism score to 66.1% with the original Geneva score. Overall, 24.6% were consistently categorized as high risk, and 26.3% as low risk by all 4 RAMs. Depending on the RAM used, TPX prescription was appropriate in 58.7% to 63.3% of high-risk (ie, 36.7%-41.3% underuse) and 52.4% to 62.8% of low-risk patients (ie, 37.2%-47.6% overuse).

Conclusion

The proportion of medical inpatients considered as high or low VTE risk varied widely according to different RAMs. Only half of patients were consistently categorized in the same risk group by all RAMs. While TPX remains underused in high-risk patients, overuse in low-risk patients is even more pronounced.

Preventive strategies for hypercoagulation in Cushing's syndrome: when and how

PURPOSE

The endogenous hypercortisolism that characterizes Cushing's syndrome (CS) is associated with a state of hypercoagulability that significantly increases the risk of thromboembolic disease, especially, venous events. Despite this certainty, there is no consensus on the best thromboprophylaxis strategy (TPS) for these patients. Our aim was to summarize the published data about different thromboprophylaxis strategies, and to review available clinical tools assisting thromboprophylaxis decision making.

METHODS

Narrative review of thromboprophylaxis strategies in patients with Cushing's syndrome. A search was carried out on PubMed, Scopus and EBSCO until November 14th, 2022, and articles were selected based on their relevance and excluded in case of redundant content.

RESULTS

Literature is scarce regarding thromboprophylaxis strategies to be adopted in the context of endogenous hypercortisolism, most often being a case-by-case decision according to the centre expertise. Only three retrospective studies, with a small number of patients enrolled, evaluated the use of hypocoagulation for the thromboprophylaxis of patients with CS in the post-operative period of transsphenoidal surgery and/or adrenalectomy, but all of them with favourable results. The use of low molecular weight heparin is the most frequent option as TPS in CS context. There are numerous venous thromboembolism risk assessment scores validated for different medical purposes, but just one specifically developed for CS, that must be validated to ensure solid recommendations in this context. The use of preoperative medical therapy is not routinely recommended to decrease the risk of postoperative venous thromboembolic events. The peak of venous thromboembolic events occurs in the first three months post-surgery.

CONCLUSION

The need to hypocoagulate CS patients, mainly in the post-operative period of a transsphenoidal surgery or an adrenalectomy, is undoubtable, especially in patients with an elevated risk of venous thromboembolic events, but the precise duration and the hypocoagulation regimen to institute is yet to be determined with prospective studies.

A Novel Risk Assessment Model Predicts Major Bleeding Risk at Admission in Medical Inpatients

Background

Venous thromboembolism (VTE) is the leading cause of preventable hospital death in the US. Guidelines from the American College of Chest Physicians and American Society for Hematology recommend providing pharmacological VTE prophylaxis to acutely or critically ill medical patients at acceptable bleeding risk, but there is currently only one validated risk assessment model (RAM) for estimating bleeding risk. We developed a RAM using risk factors at admission and compared it with the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) model.

Methods

A total of 46,314 medical patients admitted to a Cleveland Clinic Health System hospital from 2017-2020 were included. Data were split into training (70%) and validation (30%) sets with equivalent bleeding event rates in each set. Potential risk factors for major bleeding were identified from the IMPROVE model and literature review. Penalized logistic regression using LASSO was performed on the training set to select and regularize important risk factors for the final model. The validation set was used to assess model calibration and discrimination and compare performance with IMPROVE. Bleeding events and risk factors were confirmed through chart review.

Results

The incidence of major in-hospital bleeding was 0.58%. Active peptic ulcer (OR = 5.90), prior bleeding (OR = 4.24), and history of sepsis (OR = 3.29) were the strongest independent risk factors. Other risk factors included age, male sex, decreased platelet count, increased INR, increased PTT, decreased GFR, ICU admission, CVC or PICC placement, active cancer, coagulopathy, and in-hospital antiplatelet drug, steroid, or SSRI use. In the validation set, the Cleveland Clinic Bleeding Model (CCBM) had better discrimination than IMPROVE (0.86 vs. 0.72, p < .001) and, at equivalent sensitivity (54%), categorized fewer patients as high-risk (6.8% vs. 12.1%, p < .001).

Conclusions

From a large population of medical inpatients, we developed and validated a RAM to accurately predict bleeding risk at admission. The CCBM may be used in conjunction with VTE risk calculators to decide between mechanical and pharmacological prophylaxis for at-risk patients.

Characteristics associated with diagnostic yield of imaging for deep venous thrombosis and pulmonary embolism in the emergency department, hospital, and office settings: An Optum Clinformatics claims database study (2015-2019)

BACKGROUND

Different patient characteristics influence the decision to order diagnostic imaging for deep venous thrombosis (DVT) and pulmonary embolism (PE) in different settings (emergency department (ED), hospital, and office). Diagnostic yield is defined as the proportion of tests that report positive results. We hypothesize different patient characteristics are associated with higher or lower diagnostic yield of imaging for DVT and PE in different settings.

METHODS

We used Optum Clinformatics™ national claims database (2015-2019) to assess the diagnostic yield of imaging for DVT and PE in three settings: (a) ED discharge, (b) Hospitalized, and (c) Office. We studied the patient characteristics associated with diagnostic yield using logistic regression.

RESULTS

Diagnostic imaging for DVT and PE was performed in 1,502,417 and 710,263 visits, respectively. Diagnostic yield for DVT and PE was 9.8 ± 0.1 % and 12.7 ± 0.1 %, respectively in the overall cohort. In the ED discharge, hospitalized, and office settings, diagnostic yield for DVT was 10.4 ± 0.1 %, 16.9 ± 0.1 %, and 6.5 ± 0.1 %, respectively, and that for PE 6.4 ± 0.1 %, 18.7 ± 0.1 %, and 8.8 ± 0.2 %, respectively. Of the patients who underwent imaging for DVT, higher diagnostic yield was more likely with thrombophilia, central venous access, and cancer. Of the patients who underwent imaging for PE, higher diagnostic yield was most likely with thrombophilia, respiratory failure, and heart failure or acute myocardial infarction.

CONCLUSIONS

In each setting, different patient characteristics influence the diagnostic yield of imaging for DVT and PE and can inform clinical practice. Judicious use of imaging for DVT and PE could reduce costs and avoid exposure to radiation and contrast.

Ability of Caprini and Padua Risk-Assessment Models to Predict Venous Thromboembolism in a Nationwide Study

Background

Venous thromboembolism (VTE) is a preventable complication of hospitalization. Risk-stratification is the cornerstone of prevention. The Caprini and Padua are the most commonly used risk-assessment models to quantify VTE risk. Both models perform well in select, high-risk cohorts. While VTE risk-stratification is recommended for all hospital admissions, few studies have evaluated the models in a large, unselected cohort of patients.

Methods

We analyzed consecutive first hospital admissions of 1,252,460 unique surgical and non-surgical patients to 1,298 VA facilities nationwide between January 2016 and December 2021. Caprini and Padua scores were generated using the VA's national data repository. We first assessed the ability of the two RAMs to predict VTE within 90 days of admission. In secondary analyses, we evaluated prediction at 30 and 60 days, in surgical versus non-surgical patients, after excluding patients with upper extremity DVT, in patients hospitalized ≥72 hours, after including all-cause mortality in the composite outcome, and after accounting for prophylaxis in the predictive model. We used area under the receiver-operating characteristic curves (AUC) as the metric of prediction.

Results

A total of 330,388 (26.4%) surgical and 922,072 (73.6%) non-surgical consecutively hospitalized patients (total n=1,252,460) were analyzed. Caprini scores ranged from 0-28 (median, interquartile range: 4, 3-6); Padua scores ranged from 0-13 (1, 1-3). The RAMs showed good calibration and higher scores were associated with higher VTE rates. VTE developed in 35,557 patients (2.8%) within 90 days of admission. The ability of both models to predict 90-day VTE was low (AUCs: Caprini 0.56 [95% CI 0.56-0.56], Padua 0.59 [0.58-0.59]). Prediction remained low for surgical (Caprini 0.54 [0.53-0.54], Padua 0.56 [0.56-0.57]) and non-surgical patients (Caprini 0.59 [0.58-0.59], Padua 0.59 [0.59-0.60]). There was no clinically meaningful change in predictive performance in patients admitted for ≥72 hours, after excluding upper extremity DVT from the outcome, after including all-cause mortality in the outcome, or after accounting for ongoing VTE prophylaxis.

Conclusions

Caprini and Padua risk-assessment model scores have low ability to predict VTE events in a cohort of unselected consecutive hospitalizations. Improved VTE risk-assessment models must be developed before they can be applied to a general hospital population.

Comparison of VTE risk scores in guidelines for VTE diagnosis in nonsurgical hospitalized patients with suspected VTE

BACKGROUND

The assessment of VTE likelihood with VTE risk scores is essential prior to imaging examinations during VTE diagnostic procedure. Little is known with respect to the disparity of predictive power for VTE diagnosis among VTE risk scores in guidelines for nonsurgical hospitalized patients with clinically suspected VTE.

METHODS

A retrospective study was performed to compare the predictive power for VTE diagnosis among the Wells, Geneva, YEARS, PERC, Padua, and IMPROVE scores in the leading authoritative guidelines in nonsurgical hospitalized patients with suspected VTE.

RESULTS

Among 3168 nonsurgical hospitalized patients with suspected VTE, VTE was finally excluded in 2733(86.3%) ones, whereas confirmed in 435(13.7%) ones. The sensitivity and specificity resulted from the Wells, Geneva, YEARS, PERC, Padua, and IMPROVE scores were (90.3%, 49.8%), (88.7%, 53.6%), (73.8%, 50.2%), (97.7%,16.9%), (80.9%, 44.0%), and (78.2%, 47.0%), respectively. The YI were 0.401, 0.423, 0.240, 0.146, 0.249, and 0.252 for the Wells, Geneva, YEARS, PERC, Padua, and IMPROVE scores, respectively. The C-index were 0.694(0.626-0.762), 0.697(0.623-0.772), 0.602(0.535-0.669), 0.569(0.486-0.652), 0.607(0.533-0.681), and 0.609(0.538-0.680) for the Wells, Geneva, YEARS, PERC, Padua, and IMPROVE scores, respectively. Consistency was significant in the pairwise comparison of Wells vs Geneva(Kappa 0.753, P = 0.565), YEARS vs Padua(Kappa 0.816, P = 0.565), YEARS vs IMPROVE(Kappa 0.771, P = 0.645), and Padua vs IMPROVE(Kappa 0.789, P = 0.812), whereas it did not present in the other pairs. The YI was improved to 0.304, 0.272, and 0.264 for the PERC(AUC 0.631[0.547-0.714], P = 0.006), Padua(AUC 0.613[0.527-0.700], P = 0.017), and IMPROVE(AUC 0.614[0.530-0.698], P = 0.016), with a revised cutoff of 5 or less, 6 or more, and 4 or more denoting the VTE-likely, respectively.

CONCLUSIONS

For nonsurgical hospitalized patients with suspected VTE, the Geneva and Wells scores perform best, the PERC scores performs worst despite its significantly high sensitivity, whereas the others perform intermediately, albeit the absolute predictive power of all isolated scores are mediocre. The predictive power of the PERC, Padua, and IMPROVE scores are improved with revised cutoffs.

A review of venous thromboembolism risk assessment models for different patient populations: What we know and don't!

Venous thromboembolism (VTE) is a common cause of morbidity and mortality in hospitalized patients. Globally, it is also the third leading vascular disease, after myocardial infarction and stroke. The incidence of VTE is reportedly higher in Western countries than in Asian countries. However, recent reports suggest an increasing incidence of VTE in Asian countries, including India. Since VTE is largely a preventable disease, early identification of risk factors can lead to disease prevention or the adoption of appropriate prophylactic measures. To this end, several VTE risk assessment models (RAMs) have been developed and validated for different populations who are at risk of developing VTE, such as hospitalized patients with medical illness/surgical indication, patients with cancer, and pregnant women. Evidence indicates that the systematic use of RAMs improves prophylaxis rates and lowers the burden of VTE. Given the increasing burden of VTE in the Indian population and poor prophylaxis rates, the implementation of systematic RAMs in routine clinical practice might ameliorate the disease burden in the country. We have assessed the evidence-based utilities of available RAMs and have delineated the most common and suitable RAMs for different populations including coronavirus disease 2019 affected patients. This review depicts the current status of implementation and validation of RAMs in the Indian scenario. It also highlights the need for additional validation studies, improved awareness, and implementation of RAMs in clinical practice for lowering the burden of VTE.

Applicability of the Padua scale for Chinese rheumatic in-patients with venous thromboembolism

OBJECTIVE

To investigate the risk factors for venous thromboembolism (VTE) in hospitalized patients with rheumatic diseases in China. The efficacy of the Padua scale was evaluated and an improved model for predicting VTE in hospitalized patients with rheumatic diseases was developed.

METHODS

Records of 2282 patients hospitalized in the department of rheumatology of the Sichuan Provincial People's Hospital were retrospectively reviewed. The risk factors for VTE were analyzed. The efficacy of the Padua scale was evaluated, Padua-combined prediction model and the independent risk factor-combined prediction model for predicting VTE were assessed using the receiver operating curve (ROC).

RESULTS

A total of 50 patients in the VTE group and 2232 in the non-VTE group were included. Antiphospholipid syndrome (APS), VTE history, a hospital stay of over 3 days, high D-dimer (D-D), and decreased serum albumin were independent risk factors for VTE. APS was very closely associated with VTE (OR = 19.446). Padua scores in the VTE group and the non-VTE group were 3 (2, 6) and 2 (1, 2) points, respectively (p < 0.05), and the proportion of high-risk patients were 48.0% and 7.4%, respectively (p < 0.05). The incidence of VTE in the high-risk (Padua score ≥4) and low-risk (Padua score <4) groups was 12.7% and 1.2%, respectively (p < 0.05). The area under curve (AUC) of the Padua scale, Padua combined prediction model (Padua scale along with D-D and serum albumin), and the independent risk factor-combined prediction model was 0.771, 0.836, and 0.873, respectively.

CONCLUSION

The Padua scale has limited predictive efficacy of VTE in hospitalized rheumatic patients. The independent risk factor-combination prediction model was superior in predicting VTE compared to Padua scale and Padua-combined prediction model.

Perioperative Prevention of Venous Thromboembolism in Abdominal Surgery Patients Based on the Caprini or the Padua Risk Score-A Single Centre Prospective Observational Study

Surgical patients should receive perioperative thromboprophylaxis based on risk assessment, and the Caprini score is validated for this purpose. Whether the Padua score, originally devised for medical patients, can be useful in surgical patients remains to be fully clarified. This study aimed to evaluate perioperative thromboprophylaxis based on the Caprini or the Padua score in elective abdominal surgery. A total of 223 patients undergoing elective abdominal surgery for malignant or benign disease were prospectively evaluated. The patients were divided into two groups in which thromboprophylaxis was prescribed according to either the Caprini score (n = 122) or the Padua score (n = 101). Patients with high-risk scores in both groups received nadroparin. The alternate risk score in each group was calculated for evaluation purposes only. During a 3-month follow-up, we assessed patients for symptomatic venous thromboembolism (VTE), bleeding, or mortality. In the Caprini score group, 87 patients (71%) had a high risk for VTE (≥5 points), while 38 patients (38%) had a high risk for VTE (≥4 points) in the Padua score group; p < 0.00001. The overall correlation between the Caprini and Padua scores was moderate (r= 0.619), with 85 patients having high Caprini and discordant Padua scores. Ten patients died during follow-up (4.5%), and five developed non-fatal symptomatic VTE (2.2%). Among the five major bleeding incidents recorded (1.8%), two cases were possibly associated with pharmacological thromboprophylaxis. The incidence of adverse outcomes did not differ between the two groups. The odds ratio for adverse outcomes was significantly higher with a high Caprini or Padua risk score, malignant disease, age ≥65 years, and active smoking. We found no significant differences in adverse outcomes between abdominal surgical patients who received perioperative thromboprophylaxis based on either the Caprini or the Padua risk score. However, a discordant Padua score was noted in almost 40% of patients who had a high Caprini score, suggesting that the latter may be more sensitive than the Padua score in surgical patients.

Superior Predictive Value of D-Dimer to the Padua Prediction Score for Venous Thromboembolism in Inpatients with AECOPD: A Multicenter Cohort Study

Background

The optimal tool for risk prediction of venous thromboembolism (VTE) in inpatients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is still unknown. This study aimed to evaluate whether D-dimer could predict the risk of VTE in inpatients with AECOPD compared to the Padua Prediction Score (PPS).

Methods

Inpatients with AECOPD were prospectively enrolled from seven medical centers in China between December 2018 and June 2020. On admission, D-dimer was detected, PPS was calculated for each patient, and the incidence of 2-month VTE was investigated. The receiver operating characteristic (ROC) curve was used to evaluate the predictive value of D-dimer and PPS on VTE development, and the best cut-off value for both methods was evaluated through the Youden index.

Results

Among the 4468 eligible patients with AECOPD, 90 patients (2.01%) developed VTE within 2 months after admission. The area under the receiver operating characteristic curves (AUCs) of D-dimer for predicting VTE were significantly higher than those of the PPS both in the overall cohort (0.724, 95% CI 0.672–0.776 vs 0.620, 95% CI 0.562–0.679; P<0.05) and the subgroup of patients without thromboprophylaxis (0.747, 95% CI 0.695–0.799 vs 0.640, 95% CI 0.582–0.698; P<0.05). By calculating the Youden Index, the best cut-off value of D-dimer was determined to be 0.96 mg/L with an AUC of 0.689, which was also significantly better than that of the PPS with the best cut-off value of 2 (AUC 0.581, P=0.007). After the combination of D-dimer with PPS, the AUC (0.621) failed to surpass D-dimer alone (P=0.104).

Conclusion

D-dimer has a superior predictive value for VTE over PPS in inpatients with AECOPD, which might be a better choice to guide thromboprophylaxis in inpatients with AECOPD due to its effectiveness and convenience.

Clinical Trial Registration

Chinese Clinical Trail Registry NO. ChiCTR2100044625; URL: http://www.chictr.org.cn/showproj.aspx?proj=121626.

Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline 2022

No matter the practice setting, physical therapists work with patients who are at risk for or who have a history of venous thromboembolism (VTE). In 2016, the first clinical practice guideline (CPG) addressing the physical therapist management of VTE was published with support by the American Physical Therapy Association's Academy of Cardiovascular and Pulmonary Physical Therapy and Academy of Acute Care, with a primary focus on lower extremity deep vein thrombosis (DVT). This CPG is an update of the 2016 CPG and contains the most current evidence available for the management of patients with lower extremity DVT and new key action statements (KAS), including guidance on upper extremity DVT, pulmonary embolism, and special populations. This document will guide physical therapist practice in the prevention of and screening for VTE and in the management of patients who are at risk for or who have been diagnosed with VTE. Through a systematic review of published studies and a structured appraisal process, KAS were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms based on the KAS were developed that can assist with clinical decision-making. Physical therapists, along with other members of the health care team, should implement these KAS to decrease the incidence of VTE, improve the diagnosis and acute management of VTE, and reduce the long-term complications of VTE.

Risk stratification for hospital-acquired venous thromboembolism in medical patients (RISE): Protocol for a prospective cohort study

Background

Hospital-acquired venous thromboembolism (VTE) is one of the leading preventable causes of in-hospital mortality. However, its risk assessment in medically ill inpatients is complicated due to the patients’ heterogeneity and complexity of currently available risk assessment models (RAMs). The simplified Geneva score provides simplicity but has not yet been prospectively validated. Immobility is an important predictor for VTE in RAMs, but its definition is inconsistent and based on subjective assessment by nurses or physicians. In this study, we aim to prospectively validate the simplified Geneva score and to examine the predictive performance of a novel and objective definition of in-hospital immobilization using accelerometry.

Methods and analysis

RISE is a multicenter prospective cohort study. The goal is to recruit 1350 adult inpatients admitted for medical illness in three Swiss tertiary care hospitals. We collect data on demographics, comorbidities, VTE risk and thromboprophylaxis. Mobility from admission to discharge is objectively measured using a wrist-worn accelerometer. Participants are followed for 90 days for the occurrence of symptomatic VTE (primary outcome). Secondary outcomes are the occurrence of clinically relevant bleeding, and mortality. The evolution of autonomy in the activities of daily living, the length of stay, and the occurrence of readmission are also recorded. Time-dependent area under the curve, sensitivity, specificity, and positive and negative predictive values are calculated for each RAM (i.e. the simplified and original Geneva score, Padua, and IMPROVE score) with and without the objective mobility measures to assess their accuracy in predicting hospital-acquired VTE at 90 days.

Ethics and expected impact

The ethics committee approved the protocol and the study was registered on ClinicalTrials.gov as NCT04439383. RISE has the potential to optimize VTE risk stratification, and thus to improve the quality of care of medically hospitalized patients.

Evaluation of the Padua Prediction Score ability to predict venous thromboembolism in Israeli non-surgical hospitalized patients using electronic medical records

Venous thromboembolism (VTE) is considered a leading safety concern during hospitalization. The Padua Predication Score (PPS) is a risk model conceived to predict VTE among non-surgical hospitalized patients. The study aim was to evaluate the PPS ability to predict VTE in Israeli non-surgical hospitalized patients using data from electronic medical records. A single center, large-scale, historic cohort study of hospitalized non-surgical patients was conducted. Outcomes included clinically diagnosed symptomatic VTE events, bleeding events, and mortality during hospitalization and up to 90 days thereafter, and readmission up to 90 days after discharge. 5117 patient records were analyzed after screening and validation. 1120 (22%) patients were defined per PPS as high-risk, of which 277 (24.7%) were prophylactically treated. The low-risk group included 3997 (78%) patients. Prevalence of symptomatic VTE was low. Overall, 14 (0.27%) VTE events were diagnosed: 3 cases in the high-risk group (0.27%) and 11 (0.28%) in the low-risk group, with no significant difference, p = 0.768. Prophylactic treatment among the high-risk patients did not significantly improve VTE incidence: 1/277 (0.36%) treated vs. 2/843 (0.24%), p = 0.343. There was no significant difference between the study groups regarding the rates of bleeding, unexplained mortality or readmission. PPS was not found to be an efficient tool for identification of non-surgical hospitalized patients with high risk for clinically significant VTE.

International consensus on the prevention of venous and arterial thrombotic events in patients with inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) are at increased risk of thrombotic events. Therapies for IBD have the potential to modulate this risk. The aims of this Evidence-Based Guideline were to summarize available evidence and to provide practical recommendations regarding epidemiological aspects, prevention and drug-related risks of venous and arterial thrombotic events in patients with IBD. A virtual meeting took place in May 2020 involving 14 international IBD experts and 3 thrombosis experts from 12 countries. Proposed statements were voted upon in an anonymous manner. Agreement was defined as at least 75% of participants voting as 'fully agree' or 'mostly agree' with each statement. For each statement, the level of evidence was graded according to the Scottish Intercollegiate Guidelines Network (SIGN) grading system. Consensus was reached for 19 statements. Patients with IBD harbour an increased risk of venous and arterial thrombotic events. Thromboprophylaxis is indicated during hospitalization of any cause in patients with IBD. Disease activity is a modifiable risk factor in patients with IBD, and physicians should aim to achieve deep remission to reduce the risk. Exposure to steroids should be limited. Antitumour necrosis factor agents might be associated with a reduced risk of thrombotic events.

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.

Derivation and Validation of a Risk Factor Model to Identify Medical Inpatients at Risk for Venous Thromboembolism

BACKGROUND

Venous thromboembolism (VTE) prophylaxis is recommended for hospitalized medical patients at high risk for VTE. Multiple risk assessment models exist, but few have been compared in large data sets.

METHODS

We constructed a derivation cohort using 6 years of data from 13 hospitals to identify risk factors associated with developing VTE within 14 days of admission. VTE was identified using a complex algorithm combining administrative codes and clinical data. We developed a multivariable prediction model and applied it to 2 validation cohorts: a temporal cohort, including two additional years and a cross-validation, in which we refit the model excluding one hospital at a time, and applied the refitted model to the holdout hospital. Performance was evaluated using the C-statistic.

RESULTS

The derivation cohort included 160,928 patients with a 14-day VTE rate of 0.79%. The final multivariable model contained 13 patient risk factors. The model had an optimism corrected C-statistic of 0.80 and good calibration. The temporal validation cohort included 55,301 patients, with a VTE rate of 0.74%. Based on the c-statistic, the Cleveland Clinic Model (CCM) outperformed the Padua model (0.76 vs. 0.72, p<0.01). The CCM was more sensitive (65.8% vs. 60.4%, p=0.05) and more specific (74.9% vs. 71.4%, p<.001), with higher positive (1.9% vs. 1.5%, p<.001) and negative predictive values (99.7% vs. 99.6%, p=0.01). C-statistics for the CCM at individual hospitals ranged from 0.64 to 0.76.

CONCLUSION

A new VTE risk assessment model outperformed the Padua model. After further validation it could be recommended for widespread use.

Validation of risk assessment models predicting venous thromboembolism in inpatients with AECOPD: a multicenter cohort study

BACKGROUND

As inpatients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are at increased risk for venous thromboembolism (VTE), identifying high-risk patients requiring thromboprophylaxis is critical to reduce the mortality and morbidity associated with VTE. This study aimed to evaluate and compare the validities of the Padua Prediction Score and Caprini risk assessment model (RAM) in predicting the risk of VTE in inpatients with AECOPD.

METHODS

The inpatients with AECOPD were prospectively enrolled from seven medical centers of China between September 2017 and January 2020. Caprini and Padua scores were calculated on admission, and the incidence of 3-month VTE was investigated.

RESULTS

Among the 3277 eligible patients with AECOPD, 128 patients (3.9%) developed VTE within 3 months after admission. The distribution of the study population by the Caprini risk level was as follows: high, 53.6%; moderate, 43.0%; and low, 3.5%. The incidence of VTE increased by risk level as high, 6.1%; moderate, 1.5%; and low, 0%. According to the Padua RAM, only 10.9% of the study population was classified as high risk and 89.1% as low risk, with the corresponding incidence of VTE 7.9% and 3.4%, respectively. The Caprini RAM had higher area under curve (AUC) compared with the Padua RAM (0.713  0.021 vs 0.644 ± 0.023, P = 0.029).

CONCLUSION

The Caprini RAM was superior to the Padua RAM in predicting the risk of VTE in inpatients with AECOPD and might better guide thromboprophylaxis in these patients.

Validation of risk assessment models for venous thromboembolism and bleeding in critically ill adolescents

OBJECTIVE

To determine the performance of risk assessment models that were developed for adults, in predicting venous thromboembolism (VTE) and bleeding in critically ill adolescents.

STUDY DESIGN

We conducted a retrospective cohort study of adolescents 12 to 17 years old admitted to the pediatric intensive care unit who received cardiopulmonary support but did not have VTE on admission nor received anticoagulation. Discrimination, using areas under the receiver operating characteristic (AUROC) and precision-recall (AUPRC) curves, and calibration, using Hosmer-Lemeshow test, of the Geneva, Padua, IMPROVE VTE and IMPROVE Bleed models were calculated.

RESULTS

Of 536 adolescents analyzed, 7 (1.3%) developed VTE and 13 (2.4%) bled. AUROCs of the Geneva, Padua and IMPROVE VTE models ranged from 0.46 to 0.59, with 95% confidence intervals (CI) including 0.5. AUPRCs ranged from 0.011 to 0.017, with 95% CIs including 0.013. Only IMPROVE VTE model had non-statistically significant Hosmer-Lemeshow test. IMPROVE Bleed model had AUROC and AUPRC of 0.75 and 0.062, with 95% CIs excluding 0.5 and 0.024, respectively. Hosmer-Lemeshow test was not statistically significant.

CONCLUSION

Despite similarities in coagulation between adolescents and adults, risk assessment models for VTE in adults should not be used for critically ill adolescents. The model for bleeding may be useful.

Quality gap in venous thromboembolism prophylaxis practices in inpatients: Assessment of prophylaxis practices in a University Hospital

BACKGROUND

Venous thromboembolism (VTE) is a prevalent complication of inpatient care, causing high burden of morbidity and mortality. Prophylaxis reduces the events; thus, these practices are promoted. We aimed to assess the VTE prophylaxis practices in the general internal medicine wards of a tertiary-care university hospital and utilize these data to propose quality improvement projects.

OBJECTIVE

Assess the pharmacological venous thromboembolism prophylaxis utilization by using the Padua Prediction Score and demonstrate the main determinants of inappropriate prophylaxis use.

METHODS

Electronic medical records were used to collect data cross-sectionally from 1 January 2019 to 30 June 2019. Padua Prediction Score was used to assess the appropriateness of VTE prophylaxis. Underlying health conditions, hospitalization causes, anti-platelets and use of glucocorticoids were also assessed as confounding factors.

RESULTS

A total of 295 patients were included. Higher proportion of patients who received VTE prophylaxis were obese and had higher rates of diabetes and coronary artery disease. Prophylaxis was more commonly utilized among patients who were elderly, obese, having an acute infection and/or rheumatologic disorder and prolonged bed rest (P ≤ 0.001, P = 0.01, P = 0.22 and P ≤ 0.001, respectively). Thirty-five patients (11.8%) received VTE prophylaxis, despite 89 patients (30.2%) were high-risk patients. In the high-risk group (n = 89), 27 patients (30.3%) received appropriate pharmacological prophylaxis, while 8 patients (3.9%) received VTE prophylaxis in the low-risk group (total n = 206). A considerable percentage of the high-risk population (69.6%) did not receive VTE prophylaxis.

DISCUSSION

Underuse constitutes a major challenge in our hospital but differing from other institutions, overuse is not a significant issue. Further studies are needed whether VTE prophylaxis improvement implementations uniformly increase appropriate VTE use.

Risk assessment models for venous thromboembolism in hospitalised adult patients: a systematic review

INTRODUCTION

Hospital-acquired thrombosis accounts for a large proportion of all venous thromboembolism (VTE), with significant morbidity and mortality. This subset of VTE can be reduced through accurate risk assessment and tailored pharmacological thromboprophylaxis. This systematic review aimed to determine the comparative accuracy of risk assessment models (RAMs) for predicting VTE in patients admitted to hospital.

METHODS

A systematic search was performed across five electronic databases (including MEDLINE, EMBASE and the Cochrane Library) from inception to February 2021. All primary validation studies were eligible if they examined the accuracy of a multivariable RAM (or scoring system) for predicting the risk of developing VTE in hospitalised inpatients. Two or more reviewers independently undertook study selection, data extraction and risk of bias assessments using the PROBAST (Prediction model Risk Of Bias ASsessment Tool) tool. We used narrative synthesis to summarise the findings.

RESULTS

Among 6355 records, we included 51 studies, comprising 24 unique validated RAMs. The majority of studies included hospital inpatients who required medical care (21 studies), were undergoing surgery (15 studies) or receiving care for trauma (4 studies). The most widely evaluated RAMs were the Caprini RAM (22 studies), Padua prediction score (16 studies), IMPROVE models (8 studies), the Geneva risk score (4 studies) and the Kucher score (4 studies). C-statistics varied markedly between studies and between models, with no one RAM performing obviously better than other models. Across all models, C-statistics were often weak (<0.7), sometimes good (0.7-0.8) and a few were excellent (>0.8). Similarly, estimates for sensitivity and specificity were highly variable. Sensitivity estimates ranged from 12.0% to 100% and specificity estimates ranged from 7.2% to 100%.

CONCLUSION

Available data suggest that RAMs have generally weak predictive accuracy for VTE. There is insufficient evidence and too much heterogeneity to recommend the use of any particular RAM.

PROSPERO REGISTRATION NUMBER

Steve Goodacre, Abdullah Pandor, Katie Sworn, Daniel Horner, Mark Clowes. A systematic review of venous thromboembolism RAMs for hospital inpatients. PROSPERO 2020 CRD42020165778. Available from https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=165778https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=165778.

Inter-observer reliability of a risk assessment model for venous thromboembolism in acutely-ill medical hospitalized patients: Results from a prospective cohort study

OBJECTIVES

To analyze the inter-observer reliability of risk for venous thromboembolism (VTE) in a population of adult acutely-ill medical patients.

METHODS

In this prospective cohort study, we collected risk factors and risk classification for VTE using RAM IMPROVE7. Kappa statistics was used to evaluate inter-observer reliability between lead clinicians and trained researchers. We evaluated occurrence of VTE in patients with mismatched classification.

RESULTS

We included 2,380 patients, median age 70 years (interquartile range [IQR], 58-79), 56.2% female. Adjusted Kappa for VTE risk factors ranged from substantial (0.64, 95% confidence interval [CI], 0.61-0.67) for "immobilization", to almost perfect (0.98; 95% CI 0.97-0.99) for "thrombophilia"; risk classification was 0.64 (95% CI 0.60-0.67). Divergent risk classification occurred in 434 patients (18.2%) of whom seven (1.6%) developed VTE.

CONCLUSION

Despite substantial to almost perfect reliability between observers for risk factors and risk classification, lead clinicians tended to underestimate the risk for VTE.

Pharmacologic venous thromboembolism prophylaxis is not associated with post sphincterotomy bleeding after endoscopic retrograde cholangiopancreatography

BACKGROUND/AIM

Endoscopic sphincterotomy is considered high risk for post-procedure bleeding. Sphincterotomy in patients on therapeutic anticoagulation is avoided given increased bleeding risk. There is minimal data on the risk of post-sphincterotomy bleeding (PSB) among those on prophylactic anticoagulation for venous thromboembolism (VTE) prophylaxis.

METHODS

We performed a retrospective case control study of all inpatient endoscopic retrograde cholangiopancreatographies (ERCPs) with a sphincterotomy at our institution between July 2016 to February 2020. Cases were divided into two groups based on administration of peri‑procedural pharmacologic VTE prophylaxis. The outcomes were the rates of PSB and VTE within 30-days of the ERCP.

RESULTS

A total of 369 inpatient ERCPs with a sphincterotomy were identified. 151 cases received peri‑procedural pharmacologic VTE prophylaxis and 218 did not. The mean Padua score and American Society of Anesthesiologists physical status classification were significantly greater in the prophylaxis group. PSB was statistically similar between both groups (3.3% vs. 5.5%, p=.32). VTE was statistically similar (0.7% vs. 0.5%, p=.79). Multivariate analysis did not reveal an association between PSB and peri‑procedural pharmacologic VTE prophylaxis.

CONCLUSION

Peri-procedural pharmacologic VTE prophylaxis is not associated with increased rates of PSB. These findings suggest that pharmacologic VTE prophylaxis can be safely continued in those undergoing an endoscopic sphincterotomy.

Risk-assessment models for VTE and bleeding in hospitalized medical patients: an overview of systematic reviews

Multiple risk-assessment models (RAMs) for venous thromboembolism (VTE) in hospitalized medical patients have been developed. To inform the 2018 American Society of Hematology (ASH) guidelines on VTE, we conducted an overview of systematic reviews to identify and summarize evidence related to RAMs for VTE and bleeding in medical inpatients. We searched Epistemonikos, the Cochrane Database, Medline, and Embase from 2005 through June 2017 and then updated the search in January 2020 to identify systematic reviews that included RAMs for VTE and bleeding in medical inpatients. We conducted study selection, data abstraction and quality assessment (using the Risk of Bias in Systematic Reviews [ROBIS] tool) independently and in duplicate. We described the characteristics of the reviews and their included studies, and compared the identified RAMs using narrative synthesis. Of 15 348 citations, we included 2 systematic reviews, of which 1 had low risk of bias. The reviews included 19 unique studies reporting on 15 RAMs. Seven of the RAMs were derived using individual patient data in which risk factors were included based on their predictive ability in a regression analysis. The other 8 RAMs were empirically developed using consensus approaches, risk factors identified from a literature review, and clinical expertise. The RAMs that have been externally validated include the Caprini, Geneva, IMPROVE, Kucher, and Padua RAMs. The Padua, Geneva, and Kucher RAMs have been evaluated in impact studies that reported an increase in appropriate VTE prophylaxis rates. Our findings informed the ASH guidelines. They also aim to guide health care practitioners in their decision-making processes regarding appropriate individual prophylactic management.

Population-based analysis of perioperative chemotherapy use, interventions requiring hospitalization and atheroembolic events among patients with non-metastatic muscle-invasive bladder cancer

Introduction

Utilization of neoadjuvant chemotherapy (NC) in muscle invasive bladder cancer (MIBC) is increasingly recognized as standard of care but trends of use in Ontario remain unknown. Currently, there remains knowledge gaps regarding the effects of perioperative chemotherapy on the rates of interventions requiring hospitalization (IRH) and atheroembolic events (ATEs).

Methods

We conducted a population‐based retrospective study within the province of Ontario over 16 years. Patients with non‐metastatic MIBC receiving surgery only or planned for perioperative chemotherapy were included. Primary outcomes included 2‐year IRH and ATE rates. Univariate/multivariate analysis was used to identify predictors associated with IRHs and ATEs. Cochrane‐Armitage was used to assess treatment trends over time.

Results

Our study included 3281 patients. RC alone occurred in 2030 (60.9%), NC in 974 (29.6%) and adjuvant chemotherapy in 8.4% (n = 277). A total of 490/974 (50.3%) patients whom initiated NC with RC intent failed to undergo RC. This improved to 20.5% by 2015 (p < 0.001). Use of NC increased by an absolute value of 33% (p < 0.001). Overall, 4.2% of patients experienced IRHs and 11.5% ATEs. On multivariate analysis, advanced age and Charlson index score (CI) were strong predictors of outcomes, not timing of perioperative chemotherapy (p < 0.05.)

Conclusion

A total of 29.6% of MIBC patients are planned for NC with 20.5% not progressing to their surgery. Use of NC has substantially increased over time. IRHs and ATEs remain stubbornly high at 4.2% and 11.5% respectively. Older age and higher CI scores are the strongest predictors of IRHs and ATEs (p < 0.05), not perioperative chemotherapy.

Underuse of medical thromboprophylaxis in mobile elderly inpatients: The SWITCO65+ cohort

BACKGROUND

Hospital-associated venous thromboembolism (HA-VTE) can be prevented by pharmacologic thromboprophylaxis. Thrombotic risk assessment models (RAMs) are essential tools to improve inadequately prescribed thromboprophylaxis. Among cases of HA-VTE, our study objectives are to explore the classifications of available thrombosis RAMs, the adequacy of thromboprophylaxis and risk factors for inadequate thromboprophylaxis.

METHODS

We identified cases of HA-VTE occurring during medical hospitalizations within a multicenter Swiss venous thromboembolism (VTE) cohort (2009-2013). We calculated the proportion of VTE cases deemed at high risk with 4 VTE RAMs (Geneva, Simplified Geneva, Padua, and Improve) and the adequacy of administered pharmacologic thromboprophylaxis, and explored risk factors for underprescription of thromboprophylaxis in high-risk inpatients.

RESULTS

Among 66 medical inpatients with HA-VTE, 60.6% had pulmonary embolism. The sensitivities of the Geneva, Simplified Geneva, Padua, and Improve RAMs were 86.4%, 80.3%, 72.7%, and 57.6%, respectively. The proportion of inadequate thromboprophylaxis was high, as 62.5%-71.1% of high-risk inpatients had not received it. Among the high-risk group according to the Simplified Geneva RAM, absence of immobilization was the only variable significantly associated with an inadequate use of thromboprophylaxis (odds ratio, 3.59; 95% confidence interval, 1.08-11.88).

CONCLUSIONS

We found a dramatically high proportion of inadequate medical thromboprophylaxis among inpatients who suffered from HA-VTE. This reinforces the need for global and local quality-improvement efforts to promote adequate use of thromboprophylaxis in elderly inpatients. Mobility may favor the underuse of thromboprophylaxis, and clinicians should stay alert to other thrombotic risk factors in mobile inpatients.

Prescribing patterns and outcomes of venous thromboembolism prophylaxis in hospitalized medical and cancer patients: Observations from the Ottawa Hospital

Guidelines suggest broad use of pharmacologic prophylaxis to prevent venous thromboembolism (VTE) in hospitalized medical patients, however little 'real-world' data exists to support this. Our goal was to describe the use of thromboprophylaxis among general medical and cancer patients admitted to hospital, compare VTE and bleeding outcomes according to use of thromboprophylaxis, and to determine what variables influence prescribing patterns and outcomes. Patients admitted to the general medical and oncology services at The Ottawa Hospital between 2010 and 2015 were retrospectively reviewed and classified according to whether they received initial, delayed, or no pharmacologic thromboprophylaxis during their first hospitalization. Patients with an alternate indication for anticoagulation or those admitted with a bleeding event were excluded from analysis. The primary efficacy outcome was any symptomatic VTE during index hospitalization or within 90 days of discharge, and the primary safety outcome was clinically relevant bleeding during the index hospitalization. 17,262 patients were included in our final analysis. General medical patients selected to receive no, initial, or delayed thromboprophylaxis had 0.4%, 0.7%, and 2.4% rates of VTE; and 0.2%, 0.7%, and 1.5% rates of clinically relevant bleeding complications, respectively. Cancer patients had significantly higher rates of VTE: 3.3%, 3.9%, and 5.0%; and 0.9%, 0.7%, and 3.0% rates of clinically relevant bleeding among those selected to receive no, initial, or delayed thromboprophylaxis, respectively. Overall, our study suggests that broad use of pharmacologic thromboprophylaxis may be unnecessary in select low-risk general medical patients and may be less effective in cancer patients in whom new studies are indicated.

Acute Kidney Injury During Hospitalization Increases the Risk of VTE

BACKGROUND

Kidney disease has been linked to risk for hospitalization-related (HR) VTE, but the effect size and differences across types of kidney disease are described poorly.

RESEARCH QUESTION

Can the risk for HR VTE among patients with acute kidney injury (AKI) and chronic kidney disease be quantified, and if so, how?

STUDY DESIGN AND METHODS

We prospectively collected data on hospitalized adult patients and documented HR VTE events. We recorded creatinine clearance (CrCl) daily throughout hospitalization and modeled the effects that admission CrCl, peak CrCl, average CrCl, and AKI had on HR VTE. We controlled for known VTE risk factors and daily administration of chemoprophylaxis.

RESULTS

Of the 6,552 admissions that met our inclusion criteria, 184 (2.81%) patients experienced an HR VTE. Surgery, AKI, chemical prophylaxis, and admission albumin all were associated with HR VTE in univariate analysis, but neither admission CrCl nor average CrCl (throughout the hospitalization) increased the odds of HR VTE. Kaplan-Meier curves showed AKI, whether it occurred before or during the hospitalization, was associated significantly with time to HR VTE. Cox regression analysis found that AKI was associated independently with HR VTE, as was surgery during admission, enoxaparin dose, and admission albumin. Sensitivity analyses showed that AKI lost significance when only patients with traumatic injuries were assessed.

INTERPRETATION

We found that AKI increases the risk for HR VTE in a large, heterogeneous population that included medical and surgical patients. However, this relationship was not seen in patients with traumatic injuries.

Prevention, Diagnosis, and Treatment of VTE in Patients With Coronavirus Disease 2019: CHEST Guideline and Expert Panel Report

BACKGROUND

Emerging evidence shows that severe coronavirus disease 2019 (COVID-19) can be complicated by a significant coagulopathy, that likely manifests in the form of both microthrombosis and VTE. This recognition has led to the urgent need for practical guidance regarding prevention, diagnosis, and treatment of VTE.

METHODS

A group of approved panelists developed key clinical questions by using the PICO (Population, Intervention, Comparator, Outcome) format that addressed urgent clinical questions regarding the prevention, diagnosis, and treatment of VTE in patients with COVID-19. MEDLINE (via PubMed or Ovid), Embase, and Cochrane Controlled Register of Trials were systematically searched for relevant literature, and references were screened for inclusion. Validated evaluation tools were used to grade the level of evidence to support each recommendation. When evidence did not exist, guidance was developed based on consensus using the modified Delphi process.

RESULTS

The systematic review and critical analysis of the literature based on 13 Population, Intervention, Comparator, Outcome questions resulted in 22 statements. Very little evidence exists in the COVID-19 population. The panel thus used expert consensus and existing evidence-based guidelines to craft the guidance statements.

CONCLUSIONS

The evidence on the optimal strategies to prevent, diagnose, and treat VTE in patients with COVID-19 is sparse but rapidly evolving.

Low venous thromboembolism incidence in high risk medical patients in an Israeli hospital. Can risk assessment be extrapolated to different populations?

BACKGROUND

Guidelines recommend venous thromboembolism (VTE) prophylaxis in hospitalized medical patients with Padua prediction score (PPS) ≥4 points. This recommendation is based on the high risk of symptomatic VTE observed among these patients in the Italian PPS derivation study, and the fivefold risk reduction with VTE-prophylaxis. This study aims to assess the incidence of VTE in high risk medical patients in a medium sized hospital in Israel.

METHOD

In this retrospective cohort study, data was collected of all medical patients hospitalized between January and June 2014. Patients were classified into low and high risk groups according to their PPS score, and according to whether they received anticoagulant thromboprophylaxis for VTE. Patients were further randomly selected to compare high risk patients that did or did not receive anticoagulant thromboprophylaxis. We further compared VTE incidence in high and low risk patients not treated with thromboprophylaxis. A search was conducted for diagnoses of venous thromboembolism and death during hospitalization and the following 90 days.

RESULTS

568 high risk patients (PPS ≥4 points) were included, 284 treated with prophylactic anticoagulation and 284 not. There were no VTE events in either group. There was no difference in mortality. A total of 642 non anticoagulated patients were randomly selected, 474 low risk and 168 high risk. There were no VTE events in either group.

CONCLUSIONS

The risk of VTE appears to be very low in our study, suggesting that among medical patients with PPS ≥4, the risk of VTE may differ dramatically between populations.

Predicting postdischarge hospital-associated venous thromboembolism among medical patients using a validated mortality risk score derived from common biomarkers

BACKGROUND

Discharged medical patients are at risk for venous thromboembolism (VTE). It is difficult to identify which discharged patients would benefit from extended duration thromboprophylaxis. The Intermountain Risk Score is a prediction score derived from discrete components of the complete blood cell count and basic metabolic panel and is highly predictive of 1-year mortality. We sought to ascertain if the Intermountain Risk Score might also be predictive of 90-day postdischarge hospital-associated VTE (HA-VTE).

METHODS

We applied the Intermountain Risk Score to 60 064 medical patients who survived 90 days after discharge and report predictiveness for HA-VTE. Area under the receiver operating curve analyses were performed. We then assessed whether the Intermountain Risk Score improved prediction of 2 existing VTE risk assessment models.

RESULTS

The Intermountain Risk Score poorly predicted HA-VTE (area under the curve = 0.58; 95% confidence interval [CI], 0.56-0.60). Each clinical risk assessment model was superior to the Intermountain Risk Score (UTAH area under the curve, 0.63; Kucher area under the curve, 0.62; Intermountain Risk Score area under the curve, 0.58; P < .001 for each comparison). Adding the Intermountain Risk Score to these scores did not substantially improve the performance of either risk assessment model (UTAH + Intermountain Risk Score, 0.65; Kucher + Intermountain Risk Score, 0.64).

CONCLUSION

The Intermountain Risk Score demonstrated poor predictiveness for HA-VTE when compared to existing risk assessment models. Adding the Intermountain Risk Score to existing risk assessment models did not improve upon either risk assessment model alone to justify the added complexity.