Venous thromboembolism prevention guidelines for medical inpatients: Mind the (implementation) Gap

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. Journal of Hospital Medicine 2013;8:582–588. © 2013 Society of Hospital Medicine

Multifaceted Intervention to Prevent Venous Thromboembolism in Patients Hospitalized for Acute Medical Illness: A Multicenter Cluster-Randomized Trial

“…A simpler and more reliable risk assessment model may be more effective for a system-wide intervention. [ 26 ]…”

“…Firstly, some of our criteria for adequate prophylaxis based on 2008 guidelines may today be debatable. [ 26 , 28 ] Secondly, we focused our analysis on antithrombotic treatment and did not assess mechanical thromboprophylaxis. Thirdly, due to the lack of stratification by the centers’ activities, there were some differences in the number of patients and patients’ characteristics between the two groups.…”

Assessment of the Risk of Venous Thromboembolism in Medical Inpatients using the Padua Prediction Score and Caprini Risk Assessment Model

“…The American College of Chest Physicians guidelines for antithrombotic therapy and prevention of thrombosis 9 th edition (ACCP-9) adopted the Padua Prediction Score (PPS), which was based only on a single cohort study carried out in Italy 15 ) , to estimate the VTE risk for medical inpatients 9 ) . Questions regarding the representativeness of the included patients in the study and the failure to incorporate some important risk factors (e.g., family history of VTE) were raised subsequently by some researchers 22 ) . In addition, studies aimed at validation of this RAM in medical inpatients in other centers are rare.…”

Impact of a Multicenter, Mentored Quality Collaborative on Hospital‐Associated Venous Thromboembolism

“…17,18 The selection of a VTE protocol conducive to implementation and provider use was a key strategy. The ideal approach to VTE risk assessment is not known, 12,26 but guidelines either offer no specific guidance 7 or would require implementation of 3 different systems per hospital. 4,5 Several of these are point scoring systems, which may have lower clinician acceptance or require programming to improve real-world use 18,26,27 ; the Padua score was derived from a patient population that differs significantly from those in the United States.…”

“…The ideal approach to VTE risk assessment is not known, 12,26 but guidelines either offer no specific guidance 7 or would require implementation of 3 different systems per hospital. 4,5 Several of these are point scoring systems, which may have lower clinician acceptance or require programming to improve real-world use 18,26,27 ; the Padua score was derived from a patient population that differs significantly from those in the United States. 12 Our study provides more practical experience with a "3-bucket" model, which has previously shown high interobserver reliability, good clinician acceptance, and meaningful reductions of VTE, including in American patient populations.…”