Risk Assessment for VTE

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Risk Assessment for VTE
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Which of the following best describes you?
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Which of the following best describes your
institution?
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Do surgical patients in your hospital receive
thromboprophylaxis?
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Do medical patients receive thromboprophylaxis in
your hospital?
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Which risk-assessment tool does your hospital use?
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If used, is the risk-assessment tool
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Which of the following are used for
thromboprophylaxis in your hospital?
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Does your hospital provide extended-duration
thromboprophylaxis?
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Risk assessment for VTE

• Risk
• Risk assessment
• Thromboprophylaxis risk assessment strategies

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Risk assessment for VTE

• Risk
• Risk assessment
• Thromboprophylaxis risk assessment strategies

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What is risk?
Risk can be defined as the probability of an
unwanted event occurring and the severity of
potential loss Risks exist because things
considered to have value are placed at risk
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Risk assessment for VTE

• Risk
• Risk assessment
• Thromboprophylaxis risk assessment strategies

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What is Risk Assessment?

• Risk assessment consists of an objective
  evaluation of risk in which assumptions and
  uncertainties are clearly considered and
  presented.
• Part of the difficulty of risk management is that
  the measurement of the quantities in which risk
  assessment is concerned - potential loss and
  probability of occurrence - can be very difficult
  to measure.

Wikipedia
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Risk Assessment for VTE

• Potential losses
• Morbidity or mortality from VTE (including
  complications of therapy)
• Financial cost of investigating and treating VTE
• Increased future risk of VTE
• Probability of occurrence
• Likelihood of patient developing VTE

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Potential Losses from VTE

• Morbidity
• Post thrombotic syndrome in 30, severe in 3-51
• Chronic thromboembolic pulmonary hypertension in
  4-8 of patients following PE2
• Bleeding from anticoagulant therapies (1 major
  bleeding)
• Mortality
• 25,000 patients each year are thought to die of
  VTE in UK hospitals
• Mortality from DVT 1-6
• Mortality from PE 10-30
• Mortality from anticoagulant therapies
  (0.3/year)
• Costs to healthcare system
• Investigation and treatment of thrombotic episode
• Prolongation of inpatient stay
• Treatment of long term complications

1 Khan SR et al. Ann Int Med 2008 2 Dentali F et
al. Thr Res Feb 2009
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Probability of occurrence of VTE in hospitalised
patients
From ACCP Guidelines on prevention VTE Chest 2008
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Most VTE cases are not detected
20 symptomatic
80 asymptomatic
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Likelihood of symptomatic VTE in hospitalised
patients
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Risk Factors for VTE
Patient characteristics
Disease related
Age
Surgical therapy
Trauma
Obesity
Cancer/ cancer therapies
Varicose veins
Cardiac/respiratory failure
Immobility
Myocardial infarction
Pregnancy
Paralysis of lower limb(s)
Thrombophilia
Infection
Hormone therapy
Inflammatory bowel disease
Previous VTE
Nephrotic syndrome
Polycythaemia
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Proportion of hospital inpatients at risk of VTE
Endorse study Lancet 2008
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Thromboprophylaxis strategies are required

• It is, as yet, impossible to identify those
  individuals who will develop VTE
• Screening using imaging techniques is of low
  sensitivity, expensive, time consuming
• Asymptomatic DVT can cause fatal PE

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Potential losses risk of intervention

• Adverse effects of prophylactic therapies
• Bleeding
• Dependent on surgical procedure
• Intracerebral haemorrhage/ GI bleeding
• Heparin Induced Thrombocytopenia
• Dependent on prophylactic agent chosen
• Higher with unfractionated heparin
• Costs to healthcare system of adverse events

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Risk assessment for VTE

• Risk
• Risk assessment
• Thromboprophylaxis risk assessment strategies

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Why Risk Assessment for VTE?
Improve the use of appropriate thromboprophylaxis
Identify patients at significant risk of VTE
Objectives of RAM
Simplify decision making
Cost containment
Reduce the burden of VTE
Cohen AT et al. J Thromb Haemost 20031 (Suppl
1)OC437
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Thromboprophylaxis Risk Assessment Strategies

• Opt-in
• Surgical only
• Medical only
• Hybrid models
• Opt-out
• Electronic risk assessment (opt in or opt out)

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Autar risk assessment
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Sheffield surgical risk assessment
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Hunt BJH March 2009
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Hunt BJH March 2009
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Opt-out model

• Little evidence base
• Advantages
• Patients at risk of VTE possibly more likely to
  receive thromboprophylaxis
• Disadvantages
• Patients not at risk will receive prophylaxis
• Patients are likely to be given prophylaxis even
  if at increased risk of side-effects

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Information Technology helps
Kucher, N. et al. N Engl J Med 2005352969-977
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Endorse study Lancet 2008
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Amended ACCP guidance
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• We recommend the use of strategies shown to
  increase thromboprophylaxis adherence, including
  the use of computer decision support systems,
  preprinted orders, and periodic audit and
  feedback.
• Passive methods such as distribution of
  educational materials or educational meetings are
  not recommended as sole strategies to increase
  adherence to thromboprophylaxis

Geerts et al, ACCP, Chest 2008
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Risk assessment for VTE

• Identify patients who would benefit from
  thromboprophylaxis
• Strategy chosen will be dependent on
• Culture of organisation
• Local opinion
• Information Technology
• For strategy to work- needs to be simple

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Rhona Maclean
Sheffield Teaching Hospitals
Consultant Haematologist
Rhona.maclean_at_sth.nhs.uk