Rate of lower-extremity ultrasonography in trauma patients is associated with rate of deep venous thrombosis but not pulmonary embolism

Abstract

Background Disparate lower extremity ultrasound (LUS) screening practices among trauma institutions reflect lack of consensus regarding screening indications and whether screening improves outcomes. We hypothesized that LUS screening for DVT is not associated with reduced incidence of pulmonary embolism (PE). Methods The 2012 ACS National Trauma Data Bank Research Data Set was queried to identify 442,108 patients treated at institutions reporting at least one LUS and at least one DVT. Institutions performing LUS on more than 2% of admitted patients were designated high screening (HS) facilities and remaining institutions were designated low screening (LS) facilities. Patient characteristics and risk factors were used to develop a logistic regression model to assess the independent associations between LUS and DVT, and between LUS and PE. Results Overall, DVT and PE were reported in 0.94% and 0.37% of the study population, respectively. DVT and PE were more commonly reported in HS than LS (DVT: 1.12% vs. 0.72%, p<0.0001; PE: 0.40% vs. 0.33%, p=0.0004). Multivariable logistic regression demonstrated that LUS was independently associated with DVT (OR=1.43, CI 1.34-1.53) but not PE (OR=1.01, CI 0.92-1.12) (c-statistic 0.86 and 0.85, respectively). Sensitivity analyses performed at various rates for designating HS facilities did not alter the significance of these relationships. Conclusions LUS in trauma patients is not associated with a change in the incidence of pulmonary embolism. Aggressive LUS DVT screening protocols appear to detect many clinically insignificant DVTs for which subsequent therapeutic intervention may be unnecessary, and the use of these protocols should be questioned.

Determining the magnitude of surveillance bias in the assessment of lower extremity deep venous thrombosis

“…Our results confirm the previous works of Haut et al 7 and of Dietch et al, 6 both of which used a large administrative data set derived from the National Trauma Data Bank. However, these studies likely underestimated the magnitude of surveillance bias.…”

“…3,4 Opponents argue that LEDUS identifies more DVTs but does not prevent or reduce the incidence of PE. 3,5,6 This dispute has led to a wide variation in the use of duplex ultrasound at trauma centers, resulting in significant differences in reported rates of DVT, raising concerns for "surveillance bias." 6,7 The magnitude of this surveillance bias or the percent increase in the number of asymptomatic DVTs identified by LEDUS compared with the number identified when duplex is only performed for symptoms is currently unknown.…”

“…3,5,6 This dispute has led to a wide variation in the use of duplex ultrasound at trauma centers, resulting in significant differences in reported rates of DVT, raising concerns for "surveillance bias." 6,7 The magnitude of this surveillance bias or the percent increase in the number of asymptomatic DVTs identified by LEDUS compared with the number identified when duplex is only performed for symptoms is currently unknown. Determining the magnitude of surveillance bias is important to trauma centers because DVT is a commonly monitored quality-of-care metric.…”

Venous thromboembolism in pediatric trauma patients: Ten‐year experience and long‐term follow‐up in a tertiary care center

“…The estimated incidence of venous thromboembolism (VTE) in pediatric trauma patients (0.0003–0.4%) is far lower than that in adult trauma patients (0.9%) . There is little enthusiasm for routine VTE prophylaxis or screening in a general pediatric trauma cohort given the low yield of such broadly applied interventions.…”

Prevention of Venous Thromboembolism in Individuals with Spinal Cord Injury: Clinical Practice Guidelines for Health Care Providers, 3rd ed.

“…In major trauma patients, screening for asymptomatic DVT has definitely been shown to detect more thrombi (Winemiller, 1999;Furlan, 2007;Pierce, 2008;Haut, 2009;Azarbal, 2011;Jawa, 2011;Dietch, 2015). Similarly, among acute SCI patients managed at the Mayo Clinic from 1976 to 1995, the use of DVT screening was the strongest predictor of a VTE diagnosis, with a risk ratio of 2.8-fold compared with patients not screened (Winemiller, 1999).…”