Division of Plastic Surgery, Division of Health Services Research, University of Utah, Salt Lake City, Utah; Division of Plastic Surgery, University of Utah, Salt Lake City, Utah.
Division of Plastic Surgery, University of Utah, Salt Lake City, Utah.
J Vasc Surg Venous Lymphat Disord. 2018 May;6(3):304-311. doi: 10.1016/j.jvsv.2017.10.016. Epub 2018 Feb 13.
Perioperative venous thromboembolism (VTE) risk can be quantified with the 2005 Caprini score. The Caprini score has previously been validated by review of the electronic medical record (EMR) in >3000 plastic surgery patients. However, the accuracy of Caprini-based risk stratification using the EMR, as opposed to face-to-face contact with the patient, remains unknown.
Plastic and reconstructive surgery patients who had surgery under general anesthesia, required postoperative admission, and were started on enoxaparin prophylaxis were identified. The 2005 Caprini scores were calculated retrospectively using EMR review only (no direct contact with the patients) to establish cohort 1. The 2005 Caprini scores were calculated prospectively using face-to-face interaction with the patients, followed by EMR review, to establish cohort 2. For all included patients, EMR review or face-to-face screening was personally performed by the authors. We compared the proportions of patients with identified Caprini risk factors and the aggregate risk scores of patients between cohorts.
Complete data were available for 536 unique patients in the EMR review cohort and 207 unique patients in the face-to-face cohort. Patients whose risk scores were calculated face to face had higher Caprini scores than those calculated by EMR review alone. The face-to-face cohort had a higher proportion of patients risk stratified as Caprini 7-8 (29.5% vs 24.8%) and Caprini >8 (26.6% vs 10.5%) compared with the EMR review cohort. Patients risk stratified by face-to-face discussion were significantly more likely to be stratified into a higher risk Caprini stratum. Face-to-face discussion identified a 2-fold increase in patients with personal history of deep venous thrombosis (12.6% vs 6.3%; P = .005), a 3-fold increase in patients with family history of VTE (16.9% vs 5.2%; P < .001), and a 20-fold increase in patients with personal history of multiple lost pregnancies (13.6% vs 0.6%; P < .001) compared with EMR review. Observed differences for family history of VTE and history of pregnancy loss persisted after propensity score analysis, created using component variables in the 2005 Caprini score plus gender; this supports the conclusion that observed differences were not due to site variation or case mix.
When it is used in isolation, the EMR may provide inaccurate estimation of patient-level VTE risk using the 2005 Caprini score. This study demonstrates that EMR review may miss key VTE risk factors, such as personal or family history of VTE, history of pregnancy loss, and others; this omission results in lower estimates of perioperative VTE risk. The importance of provider-patient interaction for accurate VTE risk stratification cannot be overstated.
围手术期静脉血栓栓塞症 (VTE) 风险可以通过 2005 年卡普里尼评分来量化。卡普里尼评分此前已通过对 3000 多名整形外科患者的电子病历 (EMR) 进行审查得到验证。然而，使用 EMR 而非与患者面对面接触来进行基于卡普里尼的风险分层的准确性仍不清楚。
确定接受全身麻醉、需要术后住院和开始使用依诺肝素预防的整形外科患者。使用 EMR 回顾（不与患者直接接触）仅回顾性计算 2005 年卡普里尼评分，以建立队列 1。前瞻性地使用与患者的面对面互动并随后进行 EMR 回顾来建立队列 2。对于所有纳入的患者，由作者亲自进行 EMR 回顾或面对面筛查。我们比较了队列 1 和队列 2 中确定的卡普里尼风险因素的患者比例和总风险评分。
在 EMR 回顾队列中，有 536 名患者和在面对面队列中有 207 名患者具有完整的数据。面对面评估风险评分的患者的卡普里尼评分高于仅通过 EMR 回顾评估的患者。与 EMR 回顾队列相比，面对面队列中被风险分层为卡普里尼 7-8（29.5%比 24.8%）和卡普里尼>8（26.6%比 10.5%）的患者比例更高。通过面对面讨论进行风险分层的患者更有可能被分层为更高风险的卡普里尼层。面对面讨论发现深静脉血栓形成个人史的患者增加了 2 倍（12.6%比 6.3%；P=.005），静脉血栓栓塞家族史的患者增加了 3 倍（16.9%比 5.2%；P<.001），并且多次不明原因流产的患者增加了 20 倍（13.6%比 0.6%；P<.001），与 EMR 回顾相比。在使用 2005 年卡普里尼评分的组成变量加上性别创建倾向评分分析后，静脉血栓栓塞家族史和妊娠丢失史的观察到的差异仍然存在；这支持这样的结论，即观察到的差异不是由于站点差异或病例组合造成的。
当单独使用时，EMR 可能会使用 2005 年卡普里尼评分对患者的静脉血栓栓塞症风险进行不准确的估计。本研究表明，EMR 审查可能会遗漏关键的静脉血栓栓塞症风险因素，如个人或家族静脉血栓栓塞症史、妊娠丢失史等；这会导致围手术期静脉血栓栓塞症风险的估计值降低。强调提供者与患者之间的互动对于准确的静脉血栓栓塞症风险分层非常重要。
