evaluating the performance of a previously reported risk score to predict venous thromboembolism: a...
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Evaluating the Performance of a Previously Reported Risk Score to
Predict Venous Thromboembolism: A VERITY Registry Study
Denise O'Shaughnessy, Peter Rose, Fran Pressley, Nicholas Scriven, Tim Farren, Tim
Nokes, and Roopen Arya for the VERITY Investigators
Disclosures for Dr. Roopen Arya
Presentation includes discussion of the following off-label use of a drug or medical device: N/A
Research Support/P.I. Sanofi-aventis
Employee No relevant conflicts of interest to declare
Consultant No relevant conflicts of interest to declare
Major Stockholder No relevant conflicts of interest to declare
Speakers Bureau No relevant conflicts of interest to declare
Honoraria Sanofi-aventis
Scientific Advisory Board No relevant conflicts of interest to declare
In compliance with ACCME policy, ASH requires the following disclosures to the session audience:
48th A
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What is VERITY?
A UK, multi-centre observational registry of clinical management practices & patient outcomes in the treatment of venous thromboembolism (VTE).
What is VERITY?
• Launched December 2001 in 39 NHS centre
• Now has ~80 NHS centres in the UK
• Independent Steering Committee
Current data - patient numbers
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
50000
55000
60000
2002/01 2002/09 2003/05 2004/01 2004/09 2005/05 2006/01 2006/09
Time
No
. of
pat
ien
ts
Total entries 58,737
DVT 11,893
PE 849
No VTE 45,793
91 Study Sites in 14 Countries
Unique Features of VERITY
• National registry – outpatient VTE treatment
• Full spectrum of VTE – DVT and PE
• Records information on patients presenting with suspected VTE
• Expanded data on demographics, presentation, management & outcomes
• Annual analysis of data
Objective
To evaluate a simple score for estimating risk of VTE using a registry (VERITY) of patients presenting to hospital with suspected VTE.
Why the need for risk assessment?
Identifying at-risk patientIdentifying at-risk patient
Counselling at-risk Counselling at-risk patientpatient
PrescribingPrescribingthromboprophylaxisthromboprophylaxis
Venous thromboembolism risk score
Kucher, N. et al. N Engl J Med 2005;352:969-977
Risk score for VTE
Kucher, N. et al. N Engl J Med 2005;352:969-977
Risk score for VTE
Kucher, N. et al. N Engl J Med 2005;352:969-977
Clinical Feature Score
Active cancer (treatment ongoing or within 6 months or palliative) 3
Personal history of VTE 3
Thrombophilia 3
Recent major surgery 2
Advanced age (≥ 75 years) 1
Obesity (BMI >29) 1
Bed rest (medical inpatient/immobilized >3d in last 4 wks/paralysis) 1
Hormonal therapy (OCP/HRT) 1
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.
Patient Cohort
• 27,179 - presented with suspected VTE
• 6,124 - had a positive diagnosis of DVT, PE or both
• All 8 risk factors known for 5,692 cases
• 1872 with VTE (31% of VTE cases)
• 3820 VTE-negative cases (24% of not VTE cases)
Baseline characteristics
VTE cohort (n=1872)
Control cohort (n=3820)
Female sex 896 (48%) 2385 (62%)
Age ≥ 75 433 (23%) 912 (24%)
Medical illness/ immobility
203 (11%) 374 (10%)
Recent surgery 229 (12%) 494 (13%)
Cancer 224 (12%) 148 (4%)
Final diagnosis of VTE and risk score (n=5,692)
0
10
20
30
40
50
60
70
80%
pat
ien
ts w
ith
VT
E
0,1 2,3 4,5 6,7 >7
Risk score
Final diagnosis of VTE and risk score threshold (n=5,692)
0
10
20
30
40
50
60
70
80
% p
atie
nts
wit
h V
TE
<4 >/=4
Risk score
P<0.01
VTE patients – RISK SCORE 0,1
0 20 40 60 80 100
Medical
Surgical
>75
Obesity
Cancer
Thrombophilia
Hormone
VTE history
% of patients
VTE patients – RISK SCORE 2,3
0 20 40 60 80 100
Medical
Surgical
>75
Obesity
Cancer
Thrombophilia
Hormone
VTE history
% of patients
VTE patients – RISK SCORE 4,5
0 20 40 60 80 100
Medical
Surgical
>75
Obesity
Cancer
Thrombophilia
Hormone
VTE history
% of patients
VTE patients – RISK SCORE 6,7
0 20 40 60 80 100
Medical
Surgical
>75
Obesity
Cancer
Thrombophilia
Hormone
VTE history
% of patients
VTE patients – RISK SCORE >7
0 20 40 60 80 100
Medical
Surgical
>75
Obesity
Cancer
Thrombophilia
Hormone
VTE history
% of patients
Risk score threshold in VTE patients – medical and surgical
0 20 40 60 80 100
>/=4
<4
Ris
k sc
ore
% of patients
Medical Surgical
Thromboprophylaxis & risk score – medical & surgical
01020304050607080
% r
ecei
ved
p'la
xis
0,1 2,3 4,5 6,7 >7
Risk score
Medical Surgical
Results – risk score & VTE
• An increasing risk score was associated with linear rise in confirmed VTE
• 51% of patients with a risk score ≥4 were diagnosed with VTE
– significantly higher than risk score <4 • 26% vs. 51%; p<0.01
• 71% of patients with a risk score >7 were diagnosed with VTE
Results – risk score & prophylaxis
• Significantly more medical patients with a risk score ≥4 received VTE prophylaxis– Medical patients – 22% (<4) vs. 33% (≥4), p=0.02
• Risk score did not seem to influence prophylaxis provision in surgical patients– Surgical patients – 34% (<4) vs. 32% (≥4)
Conclusion
• Confirmed utility of risk scoring system in defining those at risk for VTE in VERITY cohort.
• Cases of suspected VTE managed in community rather than hospitalised patient population.
• Retrospective analysis of risk factor profile and thromboprophylaxis behaviour.
• Further refinement of such scoring systems to increase the accuracy of VTE prediction might be valuable.