PURPOSE: Recent literature reveals a gap between guidelines and implementation of deep vein thrombosis (DVT) preventive strategies. Risk assessment models (RAMs) may allow the clinician to determine need for DVT prophylaxis based on individual risk factors. However, currently there is no widely accepted standardized RAM in the United States. Individual institutions have developed RAMs based on published literature regarding DVT risk factors.We sought to determine inter-reviewer and inter-protocol reliability when applying RAMs to a standard case.
METHODS: A convenience sample of 13 RAMs was obtained from various institutions through e-mail requests to the American College of Clinical Pharmacy list serve. Ten reviewers were recruited to apply the RAMs to three standardized cases of varying acuity (2 General Medicine and 1 intensive care unit cases). Reviewers were asked to use each of the 13 RAMs to determine the patient’s DVT risk score and to recommend prophylaxis based on each protocol.
RESULTS: Reviewers consisted of five pharmacists, four physicians and one medical student resulting in 390 separate assessments. Patient 1(lowest risk) did not receive any chemoprophylaxis in 67% of the evaluations (range 0-80%), patient 2 (moderate risk) in 27% of the evaluations (range 10-50%) and patient 3 (highest risk) in 2.3% of the evaluations (range 0-10%). There was statistically significant variation in the provision of chemoprophylaxis per protocol 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). The simplified protocols (< 23 risk factors) resulted in higher rates of chemoprophylaxis than the more complicated ones (>23 risk factors).
CONCLUSION: There may be significant inter-protocol and inter-reviewer variability when utilizing RAMs for low and moderate risk patients.
CLINICAL IMPLICATIONS: Variation in RAMs may result in missed opportunities for providing appropriate prophylaxis to medical patients. This study suggests a need to develop a simplified validated RAM based on proven DVT risk factors.
DISCLOSURE: Ousama Dabbagh, Consultant fee, speaker bureau, advisory committee, etc. Ousama Dabbagh is on the speaker bureau : SANOFI -AVENTIS; No Product/Research Disclosure Information