Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland.
JAMA Netw Open. 2024 May 1;7(5):e249980. doi: 10.1001/jamanetworkopen.2024.9980.
Thromboprophylaxis is recommended for medical inpatients at risk of venous thromboembolism (VTE). Risk assessment models (RAMs) have been developed to stratify VTE risk, but a prospective head-to-head comparison of validated RAMs is lacking.
To prospectively validate an easy-to-use RAM, the simplified Geneva score, and compare its prognostic performance with previously validated RAMs.
DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study was conducted from June 18, 2020, to January 4, 2022, with a 90-day follow-up. A total of 4205 consecutive adults admitted to the general internal medicine departments of 3 Swiss university hospitals for hospitalization for more than 24 hours due to acute illness were screened for eligibility; 1352 without therapeutic anticoagulation were included.
At admission, items of 4 RAMs (ie, the simplified and original Geneva score, the Padua score, and the IMPROVE [International Medical Prevention Registry on Venous Thromboembolism] score) were collected. Patients were stratified into high and low VTE risk groups according to each RAM.
Symptomatic VTE within 90 days.
Of 1352 medical inpatients (median age, 67 years [IQR, 54-77 years]; 762 men [55.4%]), 28 (2.1%) experienced VTE. Based on the simplified Geneva score, 854 patients (63.2%) were classified as high risk, with a 90-day VTE risk of 2.6% (n = 22; 95% CI, 1.7%-3.9%), and 498 patients (36.8%) were classified as low risk, with a 90-day VTE risk of 1.2% (n = 6; 95% CI, 0.6%-2.6%). Sensitivity of the simplified Geneva score was 78.6% (95% CI, 60.5%-89.8%) and specificity was 37.2% (95% CI, 34.6%-39.8%); the positive likelihood ratio of the simplified Geneva score was 1.25 (95% CI, 1.03-1.52) and the negative likelihood ratio was 0.58 (95% CI, 0.28-1.18). In head-to-head comparisons, sensitivity was highest for the original Geneva score (82.1%; 95% CI, 64.4%-92.1%), while specificity was highest for the IMPROVE score (70.4%; 95% CI, 67.9%-72.8%). After adjusting the VTE risk for thromboprophylaxis use and site, there was no significant difference between the high-risk and low-risk groups based on the simplified Geneva score (subhazard ratio, 2.04 [95% CI, 0.83-5.05]; P = .12) and other RAMs. Discriminative performance was poor for all RAMs, with an area under the receiver operating characteristic curve ranging from 53.8% (95% CI, 51.1%-56.5%) for the original Geneva score to 58.1% (95% CI, 55.4%-60.7%) for the simplified Geneva score.
This head-to-head comparison of validated RAMs found suboptimal accuracy and prognostic performance of the simplified Geneva score and other RAMs to predict hospital-acquired VTE in medical inpatients. Clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies.
重要性：对于有静脉血栓栓塞症（VTE）风险的住院内科患者，建议进行血栓预防。已经开发了风险评估模型（RAM）来对 VTE 风险进行分层，但缺乏对经过验证的 RAM 进行前瞻性头对头比较的研究。
目的：前瞻性验证一种易于使用的 RAM，即简化版日内瓦评分，并比较其与之前验证的 RAM 的预后性能。
设计、地点和参与者：这是一项前瞻性队列研究，于 2020 年 6 月 18 日至 2022 年 1 月 4 日进行，随访 90 天。共有 3 家瑞士大学医院的普通内科部门连续筛查了 4205 例因急性疾病住院超过 24 小时的成年患者，以确定是否符合入选标准；其中 1352 例患者未接受治疗性抗凝治疗。
暴露：入院时收集了 4 种 RAM （即简化版和原版日内瓦评分、帕多瓦评分和 IMPROVE[国际静脉血栓栓塞预防注册]评分）的项目。根据每个 RAM 将患者分为高和低 VTE 风险组。
主要结果和措施：90 天内有症状的 VTE。
结果：在 1352 例内科住院患者中（中位数年龄 67 岁[IQR，54-77 岁]；762 名男性[55.4%]），有 28 例（2.1%）发生 VTE。根据简化版日内瓦评分，854 例（63.2%）患者被归类为高风险，90 天 VTE 风险为 2.6%（n=22；95%CI，1.7%-3.9%），498 例（36.8%）患者被归类为低风险，90 天 VTE 风险为 1.2%（n=6；95%CI，0.6%-2.6%）。简化版日内瓦评分的敏感性为 78.6%（95%CI，60.5%-89.8%），特异性为 37.2%（95%CI，34.6%-39.8%）；简化版日内瓦评分的阳性似然比为 1.25（95%CI，1.03-1.52），阴性似然比为 0.58（95%CI，0.28-1.18）。在头对头比较中，原始日内瓦评分的敏感性最高（82.1%；95%CI，64.4%-92.1%），而 IMPROVE 评分的特异性最高（70.4%；95%CI，67.9%-72.8%）。在调整了血栓预防使用和部位对 VTE 风险的影响后，根据简化版日内瓦评分（亚危险比，2.04[95%CI，0.83-5.05]；P=0.12）和其他 RAM 没有发现高风险和低风险组之间存在显著差异。所有 RAM 的判别性能均较差，接受者操作特征曲线下面积范围为 53.8%（95%CI，51.1%-56.5%），用于原始日内瓦评分，58.1%（95%CI，55.4%-60.7%）用于简化版日内瓦评分。
结论和相关性：这项对经过验证的 RAM 进行的头对头比较发现，简化版日内瓦评分和其他 RAM 预测内科住院患者获得性 VTE 的准确性和预后性能欠佳。现有 RAM 的临床实用性值得怀疑，这突出表明需要更准确的 VTE 预测策略。
