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Horner DE, Davis S, Pandor A, Shulver H, Goodacre S, Hind D, Rex S, Gillett M, Bursnall M, Griffin X, Holland M, Hunt BJ, de Wit K, Bennett S, Pierce-Williams R. Evaluation of venous thromboembolism risk assessment models for hospital inpatients: the VTEAM evidence synthesis. Health Technol Assess 2024; 28:1-166. [PMID: 38634415 PMCID: PMC11056814 DOI: 10.3310/awtw6200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
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.
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Affiliation(s)
- Daniel Edward Horner
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Oxford Road, Manchester, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Shulver
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Saleema Rex
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michael Gillett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matthew Bursnall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Xavier Griffin
- Barts Bone and Joint Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, UK
| | - Beverley Jane Hunt
- Thrombosis & Haemophilia Centre, St Thomas' Hospital, King's Healthcare Partners, London, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queens University, Kingston, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shan Bennett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Harvard S, Guh D, Bansback N, Richette P, Saraux A, Fautrel B, Anis AH. Adherence to Antitumor Necrosis Factor Use Recommendations in Spondyloarthritis: Measurement and Effect in the DESIR Cohort. J Rheumatol 2017; 44:1436-1444. [PMID: 28668809 DOI: 10.3899/jrheum.161399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To evaluate a classification system to define adherence to axial spondyloarthritis (axSpA) anti-tumor necrosis factor (anti-TNF) use recommendations and examine the effect of adherence on outcomes in the DESIR cohort (Devenir des Spondylarthropathies Indifférenciées Récentes). METHODS Using alternate definitions of adherence, patients were classified as adherent "timely" anti-TNF users, nonadherent "late" anti-TNF users, adherent nonusers ("no anti-TNF need"), non-adherent nonusers ("unmet anti-TNF need"). Multivariate models were fitted to examine the effect of adherence on quality-adjusted life-years (QALY), total costs, and nonbiologic costs 1 year following an index date. Generalized linear regression models assuming a γ-distribution with log link were used for costs outcomes and linear regression models for QALY outcomes. RESULTS Using the main definition of adherence, there were no significant differences between late anti-TNF users and timely anti-TNF users in total costs (RR 0.86, 95% CI 0.54-1.36, p = 0.516) or nonbiologic costs (RR 0.72, 95% CI 0.44-1.18, p = 0.187). However, in the sensitivity analysis, late anti-TNF users had significantly increased nonbiologic costs compared with timely users (RR 1.58, 95% CI 1.06-2.36, p = 0.026). In the main analysis, there were no significant differences in QALY between timely anti-TNF users and late anti-TNF users, or between timely users and patients with unmet anti-TNF need. In the sensitivity analysis, patients with unmet anti-TNF need had significantly lower QALY than timely anti-TNF users (-0.04, 95% CI -0.07 to -0.01, p = 0.016). CONCLUSION The effect of adherence to anti-TNF recommendations on outcomes was sensitive to the definition of adherence used, highlighting the need to validate methods to measure adherence.
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Affiliation(s)
- Stephanie Harvard
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences
| | - Daphne Guh
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences
| | - Nick Bansback
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences
| | - Pascal Richette
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences
| | - Alain Saraux
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences
| | - Bruno Fautrel
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences
| | - Aslam H Anis
- From the School of Population and Public Health, University of British Columbia; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; University Paris Diderot, Faculty of Medicine; AP-HP, Rheumatology Department, Lariboisiere University Hospital; AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital, Paris; Rheumatology Unit, Hôpital de la Cavale Blanche; EA2216, INSERM ESPRI, ERI29, Université de Brest, LabEx IGO, Brest, France.
- S. Harvard, MSc, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences, and Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health; D. Guh, MSc, Centre for Health Evaluation and Outcome Sciences; N. Bansback, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences; P. Richette, MD, PhD, University Paris Diderot, Faculty of Medicine, and AP-HP, Rheumatology Department, Lariboisiere University Hospital; A. Saraux, MD, PhD, Rheumatology Unit, Hôpital de la Cavale Blanche, and EA2216, INSERM ESPRI, ERI29, Université de Brest; B. Fautrel, MD, PhD, Sorbonne Universités, UPMC - GRC08, Pierre Louis Institute for Epidemiology and Public Health, and AP-HP, Rheumatology Department, Pitié Salpétrière University Hospital; A.H. Anis, PhD, School of Population and Public Health, University of British Columbia, and Centre for Health Evaluation and Outcome Sciences.
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