A risk-stratification tool is a first step for hospitalists and others trying to identify patients with sufficient VTE risk to warrant pharmacological prophylaxis, according to a new Journal of Hospital Medicine report.
The authors of the retrospective cohort study noted that while both the American College of Chest Physicians (ACCP) and the Joint Commission mandate inpatients can be assessed for VTE risk, there are no validated risk-stratification tools. So a team of researchers from Baystate Medical Center in Springfield, Mass., and Tufts University School of Medicine in Boston reviewed patients with a primary diagnosis of pneumonia, heart failure, chronic obstructive pulmonary disease (COPD), stroke, and urinary tract infection. Length of stay had to be greater than three days.
The authors reported the strongest risk factors were inherited thrombophilia (OR 4.00), length of stay equal to or greater than six days (OR 3.22), inflammatory bowel disease (OR 3.11), central venous catheter (OR 1.87), and cancer. But more research needs to be done to determine exactly what risk levels should trigger the use of prophylaxis, says lead author Michael Rothberg, MD, MPH, associate professor of medicine at Tufts and Baystate's interim chief of the Division of General Medicine.
"I would hope people would use the model as a way to measure a patient's risk," says Dr. Rothberg, who also serves as Baystate's director of scholarly activities in the Internal Medicine Training Program. "The problem is, we don't know the threshold."
Dr. Rothberg and his colleagues are currently preparing a grant application to take the next step in the research, which would be an attempt to define just what risk levels in patients should trigger pharmacological prophylaxis. While such treatments, including the use of heparin, have relatively low risks for patients, "the costs are real," Dr. Rothberg says.
In the meantime, he says, the take-home message from his team's preliminary work is that without accepted risk thresholds in place, physicians should determine prophylaxis use on a patient-by-patient basis.
"There's a need for a more nuanced approach," he says. "It's a not a one-size-fits-all."