Global use of RAM and Thromboprophylaxis in hospitalized patients

Global use of risk assessment models and thromboprophylaxis in hospitalized patients with medical illnesses: An update from the World Thrombosis Day steering committee

This systematic review and meta-analysis revealed that anticoagulants are effective and safe for Venous Thromboembolism (VTE) prevention; however, thromboprophylaxis prescriptions are still unsatisfactory among hospitalized medically ill patients globally, with marked geographical differences.

Key Takeaway

• This systematic review and meta-analysis of global studies indicates that:
  • In contrast to guideline recommendations, the frequency of thromboprophylaxis prescriptions was still unsatisfactory among hospitalized medically ill patients
  • Adequate thromboprophylaxis markedly varied across geographic regions
  • No major deviations were noted among risk assessment models
  • Most frequent reasons not to administer thromboprophylaxis: Active bleeding or a high risk of bleeding, including thrombocytopenia, and renal or liver dysfunction
  • The Padua Prediction score and the American College of Chest Physicians (ACCP) criteria were the most frequently adopted scores, followed by Caprini and Geneva scores
     
• The World Thrombosis Day is instrumental for increasing VTE awareness and reducing disease burden.

Why This Matters

• VTE is a leading cause of cardiovascular morbidity and mortality.

• In 2008, the Endorse study reported a substantial proportion of high-risk hospitalized patients, but a low use of appropriate thromboprophylaxis.

• This systematic review and meta-analysis aimed at providing updated figures for the use of thromboprophylaxis and use of risk assessment models in acutely medically ill patients during hospitalization.

Study Design

• Search strategy: Trials, cohort studies, case-control studies, and surveys (not limited to English) from the past decade (2010) were searched in PubMed and Web of Science
• Inclusion criteria: (a) Observational non-randomized studies or surveys focusing on medically ill patients (e.g., those hospitalized for medical, non-surgical, condition); and (b) reporting the prevalent use of risk assessment models (with number of patients for each risk class) and of thromboprophylaxis
• Outcomes: (a) Patients with an indication for thromboprophylaxis based on individual risk assessment models or classifiers; (b) thromboprophylaxis use; and (c) reasons for not giving thromboprophylaxis to patients with another indication

Key Results

• In total, 27 studies from 20 countries (N = 137,288 patients) were included.
• Models used: Padua Prediction score (10 studies, n = 71,649); ACCP guideline-recommended scheme (10 studies, n = 4914); Caprini score (7 studies, n = 61,258); and Geneva score (1 study, n = 1478)
• Based on these models, 50.5% (95% confidence interval [CI]: 41.9–59.1, I² = 99%) hospitalized medically ill patients were found to have high VTE risk.

  • Padua Prediction score: 30.4% (95% CI: 27.4–33.5, I²= 97%), Caprini score: 59.5% (95% CI: 34.9–81.8, I² = 99%), ACCP criteria: 63.1% (95% CI: 52.3–73.4, I²= 98%)
     

• Overall, 54.5% (95% CI: 46.2–62.6, I2 = 99%) of patients with high VTE risk received adequate thromboprophylaxis.
  • The frequency of thromboprophylaxis use was similar across groups: 56.9% (95% CI: 39.6–73.4, I² = 99%) for Padua Prediction score, 53.8% (95% CI: 40.1–67.2, I² = 98%) for ACCP criteria, and 50.5% (95% CI: 29.4–71.5, I² = 99%) for Caprini score
  • Use of adequate thromboprophylaxis: Europe = 66.8% (95% CI: 50.7–81.1, I² = 98%), Africa = 44.9% (95% CI: 31.8–58.4, I² = 96%), Asia = 37.6% (95% CI: 25.7–50.3, I² = 97%), South America = 58.3% (95% CI: 31.1–83.1, I²= 99%), North America = 68.6% (95% CI: 64.9–72.6, I² = 96%)
     
• Overall, 14 studies reported the frequency of relative and absolute contraindications to thromboprophylaxis.
  • Active bleeding was considered a contraindication in all studies.
  • Following active bleeding, the most prevalent contraindication was thrombocytopenia.
  • A bleeding disorder was reported as a contraindication in 7/11 studies.
  • In five studies, patients presenting with renal failure did not receive thromboprophylaxis.

Limitations

• Analysis only included observational studies.
• Some important studies were possibly not included.
• Risk assessment methods used for revaluating VTE risk were diverse.
• Cutoff for high-risk VTE and exclusion criteria was not homogeneously defined.
• High clinical and statistical heterogeneity were observed across studies.