Low agreement for assessing the risk of postoperative deep venous thrombosis when deciding prophylaxis strategies: a study using clinical vignettes.

Martin O'Flaherty,Kaja Lerum,Daniel Grassi,Paula Martin

doi:10.1186/1472-6963-2-16

Martin O'Flaherty, Kaja Lerum + Show 2 more

Open Access

https://doi.org/10.1186/1472-6963-2-16

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Abstract

BackgroundSeveral clinical practice guidelines (CPG) on antithrombotic prophylaxis in surgical patients help to decide about the prophylaxis strategy based on the patient risk of deep venous thrombosis (DVT). However, the physician risk estimates of DVT could have little inter-observer reproducibility, which could lead to different individual prophylaxis practices.MethodsPhysicians were asked to evaluate DVT risk in eight clinical vignettes, describing actual patients cared for in our hospital. The vignettes included all possible levels of DVT risk.ResultsThe degree of prophylaxis strategies accuracy was 63% (95% CI 523–75%). Overall agreement was 0.32 (z = 7.61, p < 0.001) and for each level of risk kappa was 0.38 (z = 6.50, p < 0.001); 0.1 (z = 1.65, p < 0.049) and 0.5 (z = 8.45, p < 0.001) for small, moderate and high risk group respectivelyConclusionsOur results showed that there is poor agreement when physicians have to evaluate the risk for postoperative DVT, and in the cases of low and moderate risks of DVT there is the smallest agreement. In addition, the data also showed that the overall accuracy of DVT prophylaxis strategy was only moderate and the risk evaluation did not correlate to the selection of the strategy. The issue of inter-observers variability should be taken into account when CPG performance are analysed, especially when considering the risk-evaluation to choose the appropriate actions.

Highlights

Several clinical practice guidelines (CPG) on antithrombotic prophylaxis in surgical patients help to decide about the prophylaxis strategy based on the patient risk of deep venous thrombosis (DVT)
High-risk patients received nadroparin but when it was deemed inappropriate due to a high haemorrhagic risk, intermittent pneumatic calf compression (IPCC) was indicated. Both nadroparin and IPCC may be used in selected high-risk patients
A standardised way of risk evaluation could improve the quality of a key point in the decision process of the CPG, such as risk assessment

Summary

Introduction

Several clinical practice guidelines (CPG) on antithrombotic prophylaxis in surgical patients help to decide about the prophylaxis strategy based on the patient risk of deep venous thrombosis (DVT). Several clinical practice guidelines (CPG) on the topic have been published, with the aim to increase the utilisation and appropriateness of this practice. These guidelines established the choice of the prophylaxis strategies based on the type of surgery, as well as on the presence of specific patient's risk factors [1,2]. In order to determine if there are variations in the postoperative DVT risk perception among physicians, we performed a study using clinical vignettes The integration of several cognitive inputs and patient data under real work pressures is a task where the physicians' performance is sub-optimal [3].

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