Risk assessment models for venous thromboembolism in hospitalised adult patients: a systematic review

Abstract

Introduction: Hospital-acquired thrombosis accounts for a large proportion of all venous thromboembolism (VTE), with significant morbidity and mortality. This subset of VTE can be reduced through accurate risk assessment and tailored pharmacological thromboprophylaxis. This systematic review aimed to determine the comparative accuracy of risk assessment models (RAMs) for predicting VTE in patients admitted to hospital.

Methods: A systematic search was performed across five electronic databases (including MEDLINE, EMBASE and the Cochrane Library) from inception to February 2021. All primary validation studies were eligible if they examined the accuracy of a multivariable RAM (or scoring system) for predicting the risk of developing VTE in hospitalised inpatients. Two or more reviewers independently undertook study selection, data extraction and risk of bias assessments using the PROBAST (Prediction model Risk Of Bias ASsessment Tool) tool. We used narrative synthesis to summarise the findings.

Results: Among 6355 records, we included 51 studies, comprising 24 unique validated RAMs. The majority of studies included hospital inpatients who required medical care (21 studies), were undergoing surgery (15 studies) or receiving care for trauma (4 studies). The most widely evaluated RAMs were the Caprini RAM (22 studies), Padua prediction score (16 studies), IMPROVE models (8 studies), the Geneva risk score (4 studies) and the Kucher score (4 studies). C-statistics varied markedly between studies and between models, with no one RAM performing obviously better than other models. Across all models, C-statistics were often weak (<0.7), sometimes good (0.7-0.8) and a few were excellent (>0.8). Similarly, estimates for sensitivity and specificity were highly variable. Sensitivity estimates ranged from 12.0% to 100% and specificity estimates ranged from 7.2% to 100%.

Conclusion: Available data suggest that RAMs have generally weak predictive accuracy for VTE. There is insufficient evidence and too much heterogeneity to recommend the use of any particular RAM.

Prospero registration number: Steve Goodacre, Abdullah Pandor, Katie Sworn, Daniel Horner, Mark Clowes. A systematic review of venous thromboembolism RAMs for hospital inpatients. PROSPERO 2020 CRD42020165778. Available from https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=165778https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=165778.

Keywords: Anticoagulation; Haematology; Quality in health care; Vascular Medicine.

Figure 1

Study flowchart. RAM, risk assessment model; VTE, venous thromboembolism.

Figure 2

PROBAST (Prediction model Risk Of Bias ASsessment Tool) assessment summary graph—review authors’ judgements.

Figure 3

C-statistics by model for studies involving (a) medical, (b) surgical and (c) trauma inpatients. ACS NSQIP, American College of Surgeons National Surgical Quality Improvement Program; CI, confidence interval; DVT, deep vein thrombosis; NR, not reported; PE, pulmonary embolism; RAP, Risk Assessment Profile; TESS, Trauma Embolic Scoring System; VTE, venous thromboembolism.