Abstract
BackgroundRisk assessment models (RAMs) may allow the clinician to determine need for deep vein thrombosis (DVT) prophylaxis. Individual healthcare facilities often develop their own RAMs. The purpose of this study was to determine: 1.) inter-RAM variability in DVT risk factors and contraindications; 2.) inter-rater variability and inter-RAM variability when applying a RAM to a standard case; and 3.) inter-rater and inter-RAM variability in outcome as far as type of prophylaxis. A convenience sample of RAMs was obtained from various institutions and ten reviewers were recruited to apply the RAMs to three patient cases.FindingThe review resulted in 390 separate assessments. Patient 1 did not receive any chemoprophylaxis in 67% of the evaluations, patient 2 in 27% of the evaluations and patient 3 in 2.3% of the evaluations. There was statistically significant variation in the provision of chemoprophylaxis per RAM for patient 1 (p=0.001) and no significant variation for patients 2 and 3. When analyzing the rate of chemoprophylaxis per reviewer, there was statistically significant variation for patients 1 and 2 (p=0.026 and <0.0001 respectively) but not for patient 3 (p=0.123).ConclusionThere may be significant inter-RAM and inter-reviewer variability when utilizing RAMs for assessing DVT risk.
Highlights
Risk assessment models (RAMs) may allow the clinician to determine need for deep vein thrombosis (DVT) prophylaxis
The 9th American College of Chest Physicians (ACCP) guidelines favor risk recognition/assessment over universal prophylaxis. (Kahn et al 2012) RAMs may allow the clinician to assess the need for thromboprophylaxis and determine appropriate prophylaxis based on individual risk factors
This study focused on medical patients as this patient population has the greatest variability in terms of risk factors for DVT
Summary
Risk assessment models (RAMs) may allow the clinician to determine need for deep vein thrombosis (DVT) prophylaxis. Given the high morbidity and mortality associated with this disease, the American College of Chest Physicians (ACCP) calls for preventive strategies and risk assessment for all admitted patients. According to the 9th ACCP guidelines, all medical patients on bed-rest with at least one additional risk factor should receive chemoprophylaxis while those at a high risk of bleeding should receive mechanical prophylaxis with graduated compression stockings (GCS) or intermittent pneumatic compression devices (IPCs). There are several strategies for improving the provision of VTE prophylaxis including: 1.) Risk assessment models (RAMs); 2.) Risk recognition strategies; and 3.) Universal prophylaxis (Nutescu 2007). (Kahn et al 2012) RAMs may allow the clinician to assess the need for thromboprophylaxis and determine appropriate prophylaxis based on individual risk factors. RAMs for identifying patients at risk for VTE have been described in the literature (Arcelus et al 1991; Cohen & Alikhan 2001; Thromboembolic Risk Factors (THRIFT)
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