This pilot study found significant inter-rater and inter-RAM variability with use of RAMs from various US healthcare institutions. Based on this initial data, it is clear there is a probability that there will be considerable variation in the ordering practices of DVT prophylaxis with the use of traditional RAMs. It is also clear that there is variation in the type and number of risk factors associated with DVTs. The new ACCP guidelines now elucidate that the risk factors for VTE in medical patients include increasing age (especially > 70 years), previous VTE, known thrombophilia, active cancer, heart failure, or respiratory failure, reduced mobility, and hormonal medications. The guidelines also provide a scoring system for these risk factors which should theoretically result in consistent risk assessment for all patients. In order to maintain consistency, using the risk factor and scoring elucidated by the guidelines may reduce the variability in the provision of DVT prophylaxis however there may still be possibility of inter-rater variability especially in terms of ambiguous risk factors such as ‘reduced mobility, recent trauma/surgery’ as well as ‘heart and respiratory failure’. In addition, the ACCP guidelines, state that those patients who are deemed high risk for bleeding should receive mechanical prophylaxis. High risk patient are those with multiple risk factors for bleeding or those with an active gastroduodenal ulcer, bleeding in the 3 months before admission, or a platelet count <50 × 109/L. These contraindications for chemoprophylaxis leave room for provider interpretation especially with regard to ambiguous factors such as ‘bleeding in 3 months before admission’ or even interpretation of ‘multiple’ risk factors. As a case in point, would an 85 year old male who is immobile with a history of heart failure be considered high risk for bleeding? In this paper, we showed that there was considerable inter-rater variability even when the same RAM was utilized, this means that even though the guidelines have now clearly identified a risk scoring system, there still may be potential of missed prophylaxis for patients that would benefit from receiving prophylaxis. Individual institutions will have to identify the best way to determine risk for DVT. In this paper, we argue that RAMs may not be the best approach to identifying these patients.
Study strengths and limitations
This was a small exploratory study that highlights the limitations of traditional RAMs. This study has provided some preliminary data indicated significant inter-rater and inter-RAM variability and more importantly resulted in suboptimal DVT prophylaxis rates. However, more rigorous studies would have to be performed to establish or refute the routine use of RAMs in clinical practice. In addition, this study was conducted prior to the release of the 9th ACCP guidelines and it is possible that institutions have since updated their RAMs to include only those risk factors identified by ACCP as being significant for the development of a DVT.
The number of reviewers and types of reviewers was also small, which is a significant limitation of this study. The lack of inclusion of reviewers from the nursing profession is a limitation because sometimes nursing staff are responsible for performing risk assessment for DVT prophylaxis. More reviewers and RAMs would have improved the strength of the study.