Risk assessment for VTE Dr Roopen Arya

VERITY & VTE risk VERITY risk factor data VERITY thromboprophylaxis data Thrombosis prevention in the NHS Risk assessment & risk scores The way forward

VERITY and thromboprophylaxis Most cases present after discharge Data highlight risk in medical and surgical patients Variation in thromboprophylaxis

Thrombosis prevention in the NHS House of Common Health Committee Report March 2005 Government response July 2005 CMO publishes Independent Expert Working Group report April 2007 NICE guidance re: surgical patients April 2007

Health Committee: Key themes Awareness National guidelines NICE guidelines (2007) Education Implementation Risk assessment Thrombosis Committees Thrombosis Teams

Government response to Health Committee report July 2005 CMO communication re: existing guidance Independent VTE experts working group: review evidence & guidelines framework for implementation make recommendations to CMO Discuss with NICE a separate clinical guideline covering patients excluded from the scope of current guidance. CMO to write to relevant bodies involved in medical education regarding necessary changes in curricula.

Independent VTE Expert Group Quickly assess available guidance Consider use of mechanical devices and clarify the role of aspirin Consider VTE awareness and education Better monitoring systems to improve data on VTE outcome and mortality Make recommendations regarding implementation of thrombosis prevention

CMO Recommendations April 2007 CMO communication: published VTE Expert Working Group’s guidance in full 1. Systems, processes and knowledge base Documented mandatory risk assessment (all hospitalised patients) VTE risk assessment embedded in CNST Improved public/professional understanding of VTE (communication, information, education)

CMO Recommendations April 2007 1. Systems, processes and knowledge base (cont) VTE demo sites (strategy, educational material, develop national risk assessment strategy, advice) Core Standards from DOH to ensure compliance with risk assessment HCC monitors standards Evaluate impact on patient: systematic approach to ensure compliance, communication strategy, better outcome measures, raise awareness)

CMO Recommendations April 2007 2. Thromboprophylaxis Strategy (Medical) All medical patients considered for thrombo-prophylaxis as part of mandatory risk assessment Particularly > 4 days in hospital, Reduced mobility Heart failure, Resp failure, Acute infection, Inflammatory illness, Cancer Regimen: UFH/LMWH(preferred) Aspirin not recommended Mechanical not recommended (no current evidence)

CMO Recommendations April 2007 2. Thromboprophylaxis Strategy (Surgical) All high risk surgical/orthopaedic patients managed according to NICE guidance Intermediate risk surgical: mandatory risk assessment GCS+heparin Not aspirin Low risk surgical: early mobilisation only

NICE clinical guideline 46: VTE Key priorities for implementation Risk assessment Patient information Thigh-length graduated compression / anti-embolism stockings Patients shown to wear them correctly Intermittent pneumatic compression or foot impulse devices may be used as alternatives or in addition to AES.

NICE clinical guideline 46: VTE Key priorities for implementation In addition to mechanical prophylaxis, patient at increased risk of VTE because they have individual risk factors and patients having orthopaedic surgery should be offered LMWH. Fondaparinux, within its licensed indications, may be used as an alternative. LMWH or fondaparinux continued for 4 weeks after hip fracture surgery. Suitability of regional anaesthesia considered. Early mobilisation after surgery.

Risk Assessment & Clinical Governance The highest ranking safety practice was the appropriate use of prophylaxis to prevent VTE in patients at risk. AHRQ “Making Health Safer: A Critical Analysis of Patient Safety Practices” 2001 We recommend that every hospital develop a formal strategy that addresses prevention of thromboembolic complications. This should generally be in the form of a written thromboprophylaxis policy especially for high risk groups. ACCP guidelines “ Prevention of VTE” 2004

Risk Assessment & Clinical Governance Identifying at-risk patient Counselling at-risk patient Prescribing thromboprophylaxis

Individual Risk Assessment for Internal Medicine Patients Ischaemic stroke with paralysis Acute decompensation of COPD with ventilation MI Heart failure NYHA III + IV Acute decompensation of COPD without ventilation Sepsis Infection/acute inflammatory disease: bed rest Infection/acute inflammatory disease: non-strict bed rest Central venous lines or port system No acute risk Class of exposing risk 3 3 Increased risk 2 2 1 Low risk 1 1 2 3 Class of predisposing risk No basic risk Dehydration Polycythaemia or thrombocytosis Varicosis VTE in family HRT Obesity Age 65 years Pregnancy Oral contraception Nephrotic syndrome Myeloproliferative syndrome 2 risks from category 1 Thrombophilia History of VTE Active malignancy or 3 risks from category 1 2 risks from category 2 1 2 3 COPD: chronic obstructive pulmonary disease HRT: hormone replacement therapy Lutz L et al. Med Welt 2002;53:231–4

KCH guidelines for medical thromboprophylaxis

Venous thromboembolism risk score Kucher, N. et al. N Engl J Med 2005;352:969-977

Risk score for VTE Clinical Feature Score Active cancer (treatment ongoing or within 6 months or palliative) 3 Personal history of VTE Thrombophilia Recent major surgery 2 Advanced age (≥ 75 years) 1 Obesity (BMI >29) Bed rest Hormonal therapy (OCP/HRT) Kucher, N. et al. N Engl J Med 2005;352:969-977

Risk score for VTE The computer program alerted physicians to the increased risk for VTE and more than doubled the rate of prophylaxis (14.5% to 33.5%) Overall rate of VTE at 90 days was reduced by 41% Kucher, N. et al. N Engl J Med 2005;352:969-977

Risk score analysis using VERITY Retrospective analysis of risk score in VERITY population aiming to validate this as a decision aid to enable use of thromboprophylaxis. Risk score applied to complete population (VTE +ve and VTE –ve patients) Examine risk factor profiles in our patients and reveal existing levels of thromboprophylaxis.

The way forward Implementation of VTE Expert working group & NICE guidance National: Implementation working group Develop a national risk assessment tool Provide leadership Local: thrombosis committees local guidelines 100% risk assessment Role of VERITY