Greg Maynard1, Ian H Jenkins, Geno J Merli. 1. Division of Hospital Medicine, Center for Innovation and Improvement Science, University of California, San Diego, San Diego, California.
Abstract
BACKGROUND: Hospital-associated nonsurgical venous thromboembolism (VTE) is an important problem addressed by new guidelines from the American College of Physicians (ACP) and American College of Chest Physicians (AT9). METHODS: Narrative review and critique. RESULTS: Both guidelines discount asymptomatic VTE outcomes and caution against overprophylaxis, but have different methodologies and estimates of risk/benefit. Guideline complexity and lack of consensus on VTE risk assessment contribute to an implementation gap. Methods to estimate prophylaxis benefit have significant limitations because major trials included mostly screening-detected events. AT9 relies on a single Italian cohort study to conclude that those with a Padua score ≥4 have a very high VTE risk, whereas patients with a score <4 (60% of patients) have a very small risk. However, the cohort population has less comorbidity than US inpatients, and over 1% of patients with a score of 3 suffered pulmonary emboli. The ACP guideline does not endorse any risk-assessment model. AT9 includes the Padua model and Caprini point-based system for nonsurgical inpatients and surgical inpatients, respectively, but there is no evidence they are more effective than simpler risk-assessment models. CONCLUSIONS: New VTE prevention guidelines provide varied guidance on important issues including risk assessment. If Padua is used, a threshold of 3, as well as 4, should be considered. Simpler VTE risk-assessment models may be superior to complicated point-based models in environments without sophisticated clinical decision support.
BACKGROUND: Hospital-associated nonsurgical venous thromboembolism (VTE) is an important problem addressed by new guidelines from the American College of Physicians (ACP) and American College of Chest Physicians (AT9). METHODS: Narrative review and critique. RESULTS: Both guidelines discount asymptomatic VTE outcomes and caution against overprophylaxis, but have different methodologies and estimates of risk/benefit. Guideline complexity and lack of consensus on VTE risk assessment contribute to an implementation gap. Methods to estimate prophylaxis benefit have significant limitations because major trials included mostly screening-detected events. AT9 relies on a single Italian cohort study to conclude that those with a Padua score ≥4 have a very high VTE risk, whereas patients with a score <4 (60% of patients) have a very small risk. However, the cohort population has less comorbidity than US inpatients, and over 1% of patients with a score of 3 suffered pulmonary emboli. The ACP guideline does not endorse any risk-assessment model. AT9 includes the Padua model and Caprini point-based system for nonsurgical inpatients and surgical inpatients, respectively, but there is no evidence they are more effective than simpler risk-assessment models. CONCLUSIONS: New VTE prevention guidelines provide varied guidance on important issues including risk assessment. If Padua is used, a threshold of 3, as well as 4, should be considered. Simpler VTE risk-assessment models may be superior to complicated point-based models in environments without sophisticated clinical decision support.
Authors: Michael B Streiff; Jeffrey P Brady; Althea M Grant; Scott D Grosse; Betty Wong; Tanja Popovic Journal: MMWR Morb Mortal Wkly Rep Date: 2014-03-07 Impact factor: 17.586
Authors: Pierre-Marie Roy; Antoine Rachas; Guy Meyer; Grégoire Le Gal; Pierre Durieux; Dominique El Kouri; Didier Honnart; Jeannot Schmidt; Catherine Legall; Pierre Hausfater; Jean-Marie Chrétien; Dominique Mottier Journal: PLoS One Date: 2016-05-26 Impact factor: 3.240