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Wells DVT score for inpatients inadequate to alter management approach
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In hospitalized patients with suspected deep vein thrombosis, the Wells score was only slightly more useful than chance in stratifying risk and showed higher failure and lower efficiency than rates among outpatients in the medical literature, according to research published in JAMA Internal Medicine.
“The Wells score risk stratification is not sufficient to rule out DVT or influence management decisions in the inpatient setting,” the researchers wrote.
Patricia C. Silveira, MD, of the department of radiology, Brigham and Women’s Hospital, Harvard Medical School, and colleagues prospectively analyzed Wells score clinical predictor findings from a computerized physician order system entered when lower-extremity venous duplex ultrasounds were requested.
Patricia C.
Silveira
Adult inpatients (n = 1,135) from the 793-bed quaternary care, academic hospital suspected of having lower-extremity DVT who underwent the ultrasound studies between Nov. 1, 2012, and Dec. 31, 2013, were included. Patients diagnosed with DVT in the 3 months preceding were excluded, and for those with multiple lower-extremity ultrasounds, only the first was considered.
Proximal DVT was experienced by 137 (12.1%) patients; incidence rates in the low, moderate and high pretest probability groups were 5.9% (8 of 135), 9.5% (48 of 506) and 16.4% (81 of 494), respectively (P < .001).
The Wells score accuracy in discriminating risk for proximal DVT on lower-extremity venous duplex ultrasounds was 0.6, based on area under the receiver operating characteristics curve. The Wells score failure rate in classifying patients who had a low pretest probability was 5.9%
(95% CI, 3-11.3) and the efficiency rate was 11.9% (95% CI, 10.1-13.9).
“Potential explanations rely on differences in characteristics of inpatients compared with the outpatient population,” the researchers wrote. “Inpatients are also more likely to have heart failure, chronic obstructive pulmonary disease, acute infection, and atherosclerosis, all of which increase the risk for DVT and none of which are part of the Wells score.”
In an accompanying commentary, Erika Leemann Price, MD, MPH, and Tracy Minichiello, MD, both of the department of medicine, University of California, San Francisco, highlight the need for further assessment to determine how risk factors specific to hospitalized patients changes DVT probability.
Among the risk factors are comorbidities, body mass, recent chemotherapy and use or nonuse of pharmacologic or mechanical prophylaxis, according to the authors. In surgical patients, type and duration of procedure and timing of postoperative pharmacologic prophylaxis represent other factors, they added.
“Some of these risk factors are incorporated into existing models for risk stratification of patients for venous thromboembolism prophylaxis, but a comprehensive model to help with diagnosis of inpatients with suspected venous thromboembolism has yet to be developed,” the authors wrote. – by Allegra Tiver
Disclosure: Silveira reports no relevant financial disclosures. Please see the full study for a list of all other researchers’ relevant financial disclosures. Price and Minichiello report no relevant financial disclosures.
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