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

Abstract

IntroductionHospital-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.MethodsA 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.ResultsAmong 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%.ConclusionAvailable 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 numberSteve 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

An update on the global use of risk assessment models and thromboprophylaxis in hospitalized patients with medical illnesses from the World Thrombosis Day steering committee: Systematic review and meta‐analysis

“…1,2 VTE impairs patient prognosis and causes patient discomfort, longer hospitalizations, and higher health care costs. [3][4][5] The majority of VTE events are hospital-associated, occurring during hospitalization or within 90 days of hospital discharge 6 :…”

“…with more than 20 million hospital admissions in the European Union and around 35 million in the United States per year, 7,8 there is an urgent need to tackle this issue on a global scale. 5,9 Several risk assessment models, scores, and classifiers have been developed to identify high-risk medical patients who would benefit from in-hospital and postdischarge thromboprophylaxis on the basis of a risk-benefit principle. 5 This means avoiding exposing patients with a low risk to unnecessary anticoagulation and consequent bleeding risk, but, and conversely, promoting the use of thromboprophylaxis among patients estimated to have a substantial VTE risk.…”

“…5,9 Several risk assessment models, scores, and classifiers have been developed to identify high-risk medical patients who would benefit from in-hospital and postdischarge thromboprophylaxis on the basis of a risk-benefit principle. 5 This means avoiding exposing patients with a low risk to unnecessary anticoagulation and consequent bleeding risk, but, and conversely, promoting the use of thromboprophylaxis among patients estimated to have a substantial VTE risk. 10,11 In several countries, national health care strategies and a systematic approach to prevention of hospital-associated VTE have been integrated into routine care, resulting in a reduction of deaths and costs.…”

Internal Validation of a Risk Scoring System for Venous Thromboembolism After Total hip or Knee Arthroplasty

“…However, further research is required to determine the relationship between VTE risk level and the period that patients remain at risk. 34 …”

Electronic health record risk-stratification tool reduces venous thromboembolism events in surgical patients

“…Inappropriate chemoprophylaxis including erroneous dose prescription or failure to order any chemoprophylaxis occurs for up to 40%–50% of surgical patients [ 6 , 15 , 16 ]. There has been increasing use of risk assessment models to aid in identification and stratification of at-risk patients [ 17 ]. Additionally, the use of electronic clinical decision-making tools has evolved as a promising modality in standardizing and improving appropriate prophylaxis and reduction of VTE events [ 15 , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] ].…”