Risk‐prediction tool for identifying hospitalized children with a predisposition for development of venous thromboembolism: Peds‐Clot clinical Decision Rule

Abstract

Summary. Background: The prevalence of VTE is increasing in tertiary pediatric hospitals. Identification of high-risk populations using uniform criteria is required to develop evidence-based VTE prevention guidelines. Objective: To develop a VTE risk prediction rule, the Peds-Clot clinical Decision Rule (PCDR), to identify high-risk children who were at increased risk of developing VTE. Methods: This retrospective case-control study developed the PCDR using a derivation cohort (173 cases, 346 controls) and validated it on a separate validation cohort (100 cases, 100 controls). A uniform data collection strategy was applied to derive both the samples. Conditional logistic regression analyses were used to develop a risk-prediction model. Each significant predictor was assigned a score based on its beta coefficient and the PCDR was developed. ROC curves were derived to test the performance of the PCDR. Results: Characteristics of derivation and validation cohorts were comparable. Six risk factors (positive blood stream infection, central venous catheter, direct admission to ICU/ NICU, hospitalization for ‡ 7 days, immobilization for > 72 h, and use of birth control pills) formed the final risk prediction model (risk score range, 0.5-9.5). A risk score of 3 or more identified high-risk children at a sensitivity of 70% and specificity of 80% and AUC of 0.852 (95% confidence interval, 0.814-0.890). The application of a risk score to the validation sample showed sensitivity 57% and specificity 88% and an AUC of 0.875 (95% confidence interval, 0.82-0.924). Conclusion: Incorporation of the PCDR in routine clinical care can be an attractive strategy to identify high-risk hospitalized children with a predisposition for VTE. The clinical utility of the PCDR needs validation in prospective studies.

Hospital-associated venous thromboembolism in pediatrics: a systematic review and meta-analysis of risk factors and risk assessment models

“…23 Our meta-analysis helps to confirm previous singleinstitution work to define risk of individual pediatric patients with risk-assessment models. 2,18,21 A recent study by Atchison et al, 24 published after the date range for this review, demonstrated independent risk through multivariate analyses for CVC (5 points), infection (2 points), and LOS ≥4 days (1 point) specifically in non-critically ill children. The risk score demonstrated that with 8, 7, or ≤6 points, the risk of HA-VTE was 12.5%, 1.1%, and 0.1%, respectively.…”

“…In a single institution case-control study, Branchford et al 18 demonstrated statistically significant independent risk for mechanical ventilation, systemic infection, and hospital stay ≥5 days and that this combination in a risk-model yielded a posttest probability of 3.6% for HA-VTE development. By contrast, Sharathkumar et al 2 found six statistically independent risk factors, with associated "points" determined from the β coefficient from a logistic regression model: immobilization (3 points), LOS ≥7 days (2 points), oral contraceptive pills (2 points), CVC (1 point), bacteremia (1 point), and direct admission to critical care (0.5 points).…”

“…In addition, age was not found to be a risk factor in a meta-analysis. However, age, particularly adolescents and neonates, had been shown to be a risk factor in some individual case-control studies, 2,18 and as noted below, adolescents and neonates were the most common age groups represented in non-case-control studies. Lastly, we could not conduct any quantitative analyses for publication bias in risk factors among case-control studies because of the paucity of studies available for each risk factor.…”

“…A fourth study was excluded from these analyses as it only reported LOS as a dichotomous variable (specifically, <7 versus ≥7 days). 2 Obesity, thrombophilic conditions and systemic infection as putative risk factors were not evaluable by metaanalysis, due to a lack of at least three studies with OR for each individual thrombophilic condition. One retrospective case-control study evaluated obesity.…”

“…1,2 This is attributed to improved survival of pediatric subspecialty patients as well as increased utilization of life-saving measures, e.g. central venous catheters (CVC).…”