Risk-assessment models for VTE and bleeding in hospitalized medical patients: an overview of systematic reviews

Abstract

Multiple risk-assessment models (RAMs) for venous thromboembolism (VTE) in hospitalized medical patients have been developed. To inform the 2018 American Society of Hematology (ASH) guidelines on VTE, we conducted an overview of systematic reviews to identify and summarize evidence related to RAMs for VTE and bleeding in medical inpatients. We searched Epistemonikos, the Cochrane Database, Medline, and Embase from 2005 through June 2017 and then updated the search in January 2020 to identify systematic reviews that included RAMs for VTE and bleeding in medical inpatients. We conducted study selection, data abstraction and quality assessment (using the Risk of Bias in Systematic Reviews [ROBIS] tool) independently and in duplicate. We described the characteristics of the reviews and their included studies, and compared the identified RAMs using narrative synthesis. Of 15 348 citations, we included 2 systematic reviews, of which 1 had low risk of bias. The reviews included 19 unique studies reporting on 15 RAMs. Seven of the RAMs were derived using individual patient data in which risk factors were included based on their predictive ability in a regression analysis. The other 8 RAMs were empirically developed using consensus approaches, risk factors identified from a literature review, and clinical expertise. The RAMs that have been externally validated include the Caprini, Geneva, IMPROVE, Kucher, and Padua RAMs. The Padua, Geneva, and Kucher RAMs have been evaluated in impact studies that reported an increase in appropriate VTE prophylaxis rates. Our findings informed the ASH guidelines. They also aim to guide health care practitioners in their decision-making processes regarding appropriate individual prophylactic management.

Conflict of interest statement

Conflict-of-interest disclosure: All authors were members of the 2018 ASH guideline panel, members of the overview of systematic review team, or both. A.J.D., I.E.-I., A.I., E.A.A., and H.J.S. reported that they are members of the GRADE Working Group. H.J.S. is cochair of the GRADE Working Group. A.J.D., F.A.S., M.C., N.A.Z., A.A., S.G.K., A.I., E.A.A., and H.J.S. were authors on a manuscript that conceptualized and tested a novel approach to selecting prognostic factors for the development or update of a RAM that has been accepted in the journal Blood Advances. H.J.S. reported being cochair of the ASH 2018 guidelines for prophylaxis for hospitalized and nonhospitalized medical patients and reported grant funding from the Centers for Disease Control and Prevention (CDC) for the project on identifying and selecting VTE and bleeding prognostic factors for the development or update of a RAM using a novel approach. M.C. reported being a former board director (2013-2017) of the American Heart Association and chairing the ASH 2018 guidelines for management of VTE: prophylaxis for hospitalized and nonhospitalized medical patients. F.A.S., A.B.R., K.A.B., A.E.B., F.D., S.R.K., S.M.R., and N.A.Z. reported participating as panel members for the ASH 2018 guidelines for management of VTE: prophylaxis for hospitalized and nonhospitalized medical patients, for which they disclosed their conflicts that are provided in the supplement of the published guideline. N.A.Z. also reported receiving honoraria in 2017 from ASH for the Highlights of ASH 2017 meeting (Dallas, New York, Latin America). N.A.Z. and M.C. reported intellectual conflicts as leads in the group that derived and validated the MITH RAM for VTE risk assessment in hospitalized medical patients. The remaining authors declare no competing financial interests.

© 2020 by The American Society of Hematology.

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Graphical abstract

Figure 1.

PRISMA flowchart.