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  1. Article ; Online: Effectiveness and cost effectiveness of pharmacological thromboprophylaxis for medical inpatients: decision analysis modelling study.

    Davis, Sarah / Goodacre, Steve / Horner, Daniel / Pandor, Abdullah / Holland, Mark / de Wit, Kerstin / Hunt, Beverley J / Griffin, Xavier Luke

    BMJ medicine

    2024  Volume 3, Issue 1, Page(s) e000408

    Abstract: Objective: To determine the balance of costs, risks, and benefits for different thromboprophylaxis strategies for medical patients during hospital admission.: Design: Decision analysis modelling study.: Setting: NHS hospitals in England.: ... ...

    Abstract Objective: To determine the balance of costs, risks, and benefits for different thromboprophylaxis strategies for medical patients during hospital admission.
    Design: Decision analysis modelling study.
    Setting: NHS hospitals in England.
    Population: Eligible adult medical inpatients, excluding patients in critical care and pregnant women.
    Interventions: Pharmacological thromboprophylaxis (low molecular weight heparin) for all medical inpatients, thromboprophylaxis for none, and thromboprophylaxis given to higher risk inpatients according to risk assessment models (Padua, Caprini, IMPROVE, Intermountain, Kucher, Geneva, and Rothberg) previously validated in medical cohorts.
    Main outcome measures: Lifetime costs and quality adjusted life years (QALYs). Costs were assessed from the perspective of the NHS and Personal Social Services in England. Other outcomes assessed were incidence and treatment of venous thromboembolism, major bleeds including intracranial haemorrhage, chronic thromboembolic complications, and overall survival.
    Results: Offering thromboprophylaxis to all medical inpatients had a high probability (>99%) of being the most cost effective strategy (at a threshold of £20 000 (€23 440; $25 270) per QALY) in the probabilistic sensitivity analysis, when applying performance data from the Padua risk assessment model, which was typical of that observed across several risk assessment models in a medical inpatient cohort. Thromboprophylaxis for all medical inpatients was estimated to result in 0.0552 additional QALYs (95% credible interval 0.0209 to 0.1111) while generating cost savings of £28.44 (-£47 to £105) compared with thromboprophylaxis for none. No other risk assessment model was more cost effective than thromboprophylaxis for all medical inpatients when assessed in deterministic analysis. Risk based thromboprophylaxis was found to have a high (76.6%) probability of being the most cost effective strategy only when assuming a risk assessment model with very high sensitivity is available (sensitivity 99.9% and specificity 23.7%
    Conclusions: Offering pharmacological thromboprophylaxis to all eligible medical inpatients appears to be the most cost effective strategy. To be cost effective, any risk assessment model would need to have a very high sensitivity resulting in widespread thromboprophylaxis in all patients except those at the very lowest risk, who could potentially avoid prophylactic anticoagulation during their hospital stay.
    Language English
    Publishing date 2024-02-21
    Publishing country England
    Document type Journal Article
    ISSN 2754-0413
    ISSN (online) 2754-0413
    DOI 10.1136/bmjmed-2022-000408
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  2. Article ; Online: Estimating the value of future research into thromboprophylaxis for women during pregnancy and after delivery: a value of information analysis.

    Davis, Sarah / Pandor, Abdullah / Sampson, Fiona C / Hamilton, Jean / Nelson-Piercy, Catherine / Hunt, Beverley J / Daru, Jahnavi / Goodacre, Steve

    Journal of thrombosis and haemostasis : JTH

    2024  Volume 22, Issue 4, Page(s) 1105–1116

    Abstract: Background: Risk assessment models (RAMs) are used to select women at increased risk of venous thromboembolism (VTE) during pregnancy and the puerperium for thromboprophylaxis.: Objectives: To estimate the value of potential future studies that would ...

    Abstract Background: Risk assessment models (RAMs) are used to select women at increased risk of venous thromboembolism (VTE) during pregnancy and the puerperium for thromboprophylaxis.
    Objectives: To estimate the value of potential future studies that would reduce the decision uncertainty associated with offering thromboprophylaxis according to available RAMs in the following groups: high-risk antepartum women (eg, prior VTE), unselected postpartum women, and postpartum women with risk factors (obesity or cesarean delivery).
    Methods: A decision-analytic model was developed to simulate clinical outcomes, lifetime costs, and quality-adjusted life-years for different thromboprophylaxis strategies, including thromboprophylaxis for all, thromboprophylaxis for none, and RAM-based thromboprophylaxis. The expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty. The value of future research studies was estimated using expected value of sample information analysis. Costs were assessed from a health and social services perspective.
    Results: The expected value of perfect information analysis identified high decision uncertainty for high-risk antepartum women (£21.8 million) and obese postpartum women (£13.4 million), which was largely attributable to uncertainty regarding the effectiveness of thromboprophylaxis in reducing VTE. A randomized controlled trial of thromboprophylaxis compared with none in obese postpartum women is likely to have substantial value (£2.8 million; 300 participants per arm). A trial in women with previous VTE would have higher value but would be less acceptable.
    Conclusion: Future research should focus on estimating the effectiveness of thromboprophylaxis in obese postpartum women with additional risk factors who have not had a previous VTE.
    MeSH term(s) Female ; Humans ; Pregnancy ; Anticoagulants/therapeutic use ; Obesity/complications ; Obesity/drug therapy ; Risk Assessment ; Risk Factors ; Venous Thromboembolism/diagnosis ; Venous Thromboembolism/prevention & control ; Venous Thromboembolism/drug therapy ; Randomized Controlled Trials as Topic
    Chemical Substances Anticoagulants
    Language English
    Publishing date 2024-01-11
    Publishing country England
    Document type Journal Article
    ZDB-ID 2112661-6
    ISSN 1538-7836 ; 1538-7933
    ISSN (online) 1538-7836
    ISSN 1538-7933
    DOI 10.1016/j.jtha.2023.12.035
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  3. Article ; Online: The Cost-Effectiveness of Expanding the UK Newborn Bloodspot Screening Programme to Include Five Additional Inborn Errors of Metabolism.

    Bessey, Alice / Chilcott, James / Pandor, Abdullah / Paisley, Suzy

    International journal of neonatal screening

    2020  Volume 6, Issue 4

    Abstract: Glutaric aciduria type 1, homocystinuria, isovaleric acidaemia, long-chain hydroxyacyl CoA dehydrogenase deficiency and maple syrup urine disease are all inborn errors of metabolism that can be detected through newborn bloodspot screening. This ... ...

    Abstract Glutaric aciduria type 1, homocystinuria, isovaleric acidaemia, long-chain hydroxyacyl CoA dehydrogenase deficiency and maple syrup urine disease are all inborn errors of metabolism that can be detected through newborn bloodspot screening. This evaluation was undertaken in 2013 to provide evidence to the UK National Screening Committee for the cost-effectiveness of including these five conditions in the UK Newborn Bloodspot Screening Programme. A decision-tree model with lifetable estimates of outcomes was built with the model structure and parameterisation informed by a systematic review and expert clinical judgment. A National Health Service/Personal Social Services perspective was used, and lifetime costs and quality-adjusted life years (QALYs) were discounted at 1.5%. Uncertainty in the results was explored using expected value of perfect information analysis methods together with a sensitivity analysis using the screened incidence rate in the UK from 2014 to 2018. The model estimates that screening for all the conditions is more effective and cost saving when compared to not screening for each of the conditions, and the results were robust to the updated incidence rates. The key uncertainties included the sensitivity and specificity of the screening test and the estimated costs and QALYs.
    Language English
    Publishing date 2020-11-20
    Publishing country Switzerland
    Document type Journal Article
    ISSN 2409-515X
    ISSN (online) 2409-515X
    DOI 10.3390/ijns6040093
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  4. Article ; Online: Cost-effectiveness of therapeutics for COVID-19 patients: a rapid review and economic analysis.

    Metry, Andrew / Pandor, Abdullah / Ren, Shijie / Shippam, Andrea / Clowes, Mark / Dark, Paul / McMullan, Ronan / Stevenson, Matt

    Health technology assessment (Winchester, England)

    2023  Volume 27, Issue 14, Page(s) 1–92

    Abstract: Background: Severe acute respiratory syndrome coronavirus 2 is the virus that causes coronavirus disease 2019. Over six million deaths worldwide have been associated with coronavirus disease 2019.: Objective: To assess the cost-effectiveness of ... ...

    Abstract Background: Severe acute respiratory syndrome coronavirus 2 is the virus that causes coronavirus disease 2019. Over six million deaths worldwide have been associated with coronavirus disease 2019.
    Objective: To assess the cost-effectiveness of treatments used for the treatment of coronavirus disease 2019 in hospital or used in the community in patients with coronavirus disease 2019 at high risk of hospitalisation.
    Setting: Treatments provided in United Kingdom hospital and community settings.
    Methods: Clinical effectiveness estimates were taken from the coronavirus disease-network meta-analyses initiative and the metaEvidence initiative. A mathematical model was constructed to explore how the interventions impacted on patient health, measured in quality-adjusted life-years gained. The costs associated with treatment, including those of hospital care, were also estimated and used to form a cost per quality-adjusted life-year gained value which was compared with thresholds published by the National Institute for Health and Care Excellence. Estimates of cost-effectiveness compared against current standard of care were produced in both the hospital and community settings at three different levels of efficacy: mean, low and high. Public list prices were used for interventions with neither confidential patient access schemes nor confidential list prices considered. Results incorporating confidential pricing data were provided to the National Institute for Health and Care Excellence appraisal committee.
    Results: The treatments were estimated to be clinically effective although not all reached statistical significance. All treatments in the hospital setting, or community, were estimated to plausibly have a cost per quality-adjusted life-year gained value below National Institute for Health and Care Excellence's thresholds when compared with standard of care. However, almost all drugs could plausibly have cost per quality-adjusted life-years above National Institute for Health and Care Excellence's thresholds. However, there is considerable uncertainty in the results as the prevalent severe acute respiratory syndrome coronavirus 2 variant, vaccination status, history of being infected with severe acute respiratory syndrome coronavirus 2 and standard of care have all evolved since the pivotal studies were conducted which could have significant impact on the efficacy of each drug. For drugs used in high-risk patients in the community setting, the proportion of people at high risk who need hospital admission was a large driver of the cost per quality-adjusted life-year.
    Limitations: No studies were identified that were conducted in current conditions. This may be a large limitation as the severe acute respiratory syndrome coronavirus 2 variant changes. No head-to-head studies of interventions were identified.
    Conclusions: The results produced could be informative to decision-makers, although conclusions regarding the most clinical - and cost-effectiveness of each intervention should be tentative due to the evolving nature of the decision problem and, in this report, the use of list prices only. Comparisons between interventions should also be treated with caution due to potentially large heterogeneity between studies.
    Future work: Research assessing the relative clinical effectiveness of interventions within head-to-head studies in current conditions would be beneficial. Contemporary information related to the probability of hospital admission and death for patients at high risk in the community would improve the precision of the estimates generated.
    Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR135564) and will be published in full in
    MeSH term(s) Humans ; SARS-CoV-2 ; Cost-Benefit Analysis ; COVID-19 ; United Kingdom ; Quality-Adjusted Life Years
    Language English
    Publishing date 2023-10-16
    Publishing country England
    Document type Review ; Journal Article ; Research Support, Non-U.S. Gov't
    ZDB-ID 2006765-3
    ISSN 2046-4924 ; 1366-5278
    ISSN (online) 2046-4924
    ISSN 1366-5278
    DOI 10.3310/NAFW3527
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  5. Article ; Online: Decision-analysis modeling of effectiveness and cost-effectiveness of pharmacologic thromboprophylaxis for surgical inpatients using variable risk assessment models or other strategies.

    Davis, Sarah / Goodacre, Steve / Horner, Daniel / Pandor, Abdullah / Griffin, Xavier L / de Wit, Kerstin / Hunt, Beverley J / Holland, Mark

    Journal of thrombosis and haemostasis : JTH

    2023  Volume 21, Issue 6, Page(s) 1580–1591

    Abstract: Background: Surgical inpatients are at a risk of venous thromboembolism (VTE), which can be life-threatening or result in chronic complications. Thromboprophylaxis reduces the VTE risk but incurs costs and may increase bleeding risk. Risk assessment ... ...

    Abstract Background: Surgical inpatients are at a risk of venous thromboembolism (VTE), which can be life-threatening or result in chronic complications. Thromboprophylaxis reduces the VTE risk but incurs costs and may increase bleeding risk. Risk assessment models (RAMs) are currently used to target thromboprophylaxis at high-risk patients.
    Objectives: To determine the balance of cost, risk, and benefit for different thromboprophylaxis strategies in adult surgical inpatients, excluding patients who underwent major orthopedic surgery or were under critical care and pregnant women.
    Methods: Decision analytic modeling was performed to estimate the following outcomes for alternative thromboprophylaxis strategies: thromboprophylaxis usage; VTE incidence and treatment; major bleeding; chronic thromboembolic complications; and overall survival. Strategies compared were as follows: no thromboprophylaxis; thromboprophylaxis for all; and thromboprophylaxis given according to RAMs (Caprini and Pannucci). Thromboprophylaxis is assumed to be given for the duration of hospitalization. The model evaluates lifetime costs and quality-adjusted life-years (QALYs) within England's health and social care services.
    Results: Thromboprophylaxis for all surgical inpatients had a 70% probability of being the most cost-effective strategy (at a £20 000 per QALY threshold). RAM-based prophylaxis would be the most cost-effective strategy if a RAM with a higher sensitivity (99.9%) were available for surgical inpatients. QALY gains were mainly due to reduced postthrombotic complications. The optimal strategy was sensitive to several other factors such as the risk of VTE, bleeding and postthrombotic syndrome, duration of prophylaxis, and patient age.
    Conclusion: Thromboprophylaxis for all eligible surgical inpatients seemed to be the most cost-effective strategy. Default recommendations for pharmacologic thromboprophylaxis, with the potential to opt-out, may be superior to a complex risk-based opt-in approach.
    MeSH term(s) Pregnancy ; Female ; Humans ; Venous Thromboembolism/epidemiology ; Anticoagulants/adverse effects ; Cost-Benefit Analysis ; Inpatients ; Risk Assessment
    Chemical Substances Anticoagulants
    Language English
    Publishing date 2023-03-01
    Publishing country England
    Document type Journal Article ; Research Support, Non-U.S. Gov't
    ZDB-ID 2112661-6
    ISSN 1538-7836 ; 1538-7933
    ISSN (online) 1538-7836
    ISSN 1538-7933
    DOI 10.1016/j.jtha.2023.02.018
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  6. Article ; Online: Cervical spine immobilisation following blunt trauma in pre-hospital and emergency care: A systematic review.

    Pandor, Abdullah / Essat, Munira / Sutton, Anthea / Fuller, Gordon / Reid, Stuart / Smith, Jason E / Fothergill, Rachael / Surendra Kumar, Dhushy / Kolias, Angelos / Hutchinson, Peter / Perkins, Gavin D / Wilson, Mark H / Lecky, Fiona

    PloS one

    2024  Volume 19, Issue 4, Page(s) e0302127

    Abstract: ... PROSPERO REGISTRATION Fiona Lecky, Abdullah Pandor, Munira Essat, Anthea Sutton, Carl Marincowitz, Gordon ...

    Abstract Objectives: To assess whether different cervical spine immobilisation strategies (full immobilisation, movement minimisation or no immobilisation), impact neurological and/or other outcomes for patients with suspected cervical spinal injury in the pre-hospital and emergency department setting.
    Design: Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
    Data sources: MEDLINE, EMBASE, CINAHL, Cochrane Library and two research registers were searched until September 2023.
    Eligibility criteria: All comparative studies (prospective or retrospective) that examined the potential benefits and/or harms of immobilisation practices during pre-hospital and emergency care of patients with a potential cervical spine injury (pre-imaging) following blunt trauma.
    Data extraction and synthesis: Two authors independently selected and extracted data. Risk of bias was appraised using the Cochrane ROBINS-I tool for non-randomised studies. Data were synthesised without meta-analysis.
    Results: Six observational studies met the inclusion criteria. The methodological quality was variable, with most studies having serious or critical risk of bias. The effect of cervical spine immobilisation practices such as full immobilisation or movement minimisation during pre-hospital and emergency care did not show clear evidence of benefit for the prevention of neurological deterioration, spinal injuries and death compared with no immobilisation. However, increased pain, discomfort and anatomical complications were associated with collar application during immobilisation.
    Conclusions: Despite the limited evidence, weak designs and limited generalisability, the available data suggest that pre-hospital cervical spine immobilisation (full immobilisation or movement minimisation) was of uncertain value due to the lack of demonstrable benefit and may lead to potential complications and adverse outcomes. High-quality randomised comparative studies are required to address this important question.
    Trial registration: PROSPERO REGISTRATION Fiona Lecky, Abdullah Pandor, Munira Essat, Anthea Sutton, Carl Marincowitz, Gordon Fuller, Stuart Reid, Jason Smith. A systematic review of cervical spine immobilisation following blunt trauma in pre-hospital and emergency care. PROSPERO 2022 CRD42022349600 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022349600.
    MeSH term(s) Humans ; Cervical Vertebrae/injuries ; Immobilization ; Emergency Medical Services ; Wounds, Nonpenetrating/therapy ; Spinal Injuries/therapy ; Emergency Service, Hospital
    Language English
    Publishing date 2024-04-25
    Publishing country United States
    Document type Journal Article ; Systematic Review ; Research Support, Non-U.S. Gov't
    ZDB-ID 2267670-3
    ISSN 1932-6203 ; 1932-6203
    ISSN (online) 1932-6203
    ISSN 1932-6203
    DOI 10.1371/journal.pone.0302127
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  7. Article ; Online: Thromboprophylaxis during pregnancy and the puerperium: a systematic review and economic evaluation to estimate the value of future research.

    Davis, Sarah / Pandor, Abdullah / Sampson, Fiona C / Hamilton, Jean / Nelson-Piercy, Catherine / Hunt, Beverley J / Daru, Jahnavi / Goodacre, Steve / Carser, Rosie / Rooney, Gill / Clowes, Mark

    Health technology assessment (Winchester, England)

    2024  Volume 28, Issue 9, Page(s) 1–176

    Abstract: Background: Pharmacological prophylaxis to prevent venous thromboembolism is currently recommended for women assessed as being at high risk of venous thromboembolism during pregnancy or in the 6 weeks after delivery (the puerperium). The decision to ... ...

    Abstract Background: Pharmacological prophylaxis to prevent venous thromboembolism is currently recommended for women assessed as being at high risk of venous thromboembolism during pregnancy or in the 6 weeks after delivery (the puerperium). The decision to provide thromboprophylaxis involves weighing the benefits, harms and costs, which vary according to the individual's venous thromboembolism risk. It is unclear whether the United Kingdom's current risk stratification approach could be improved by further research.
    Objectives: To quantify the current decision uncertainty associated with selecting women who are pregnant or in the puerperium for thromboprophylaxis and to estimate the value of one or more potential future studies that would reduce that uncertainty, while being feasible and acceptable to patients and clinicians.
    Methods: A decision-analytic model was developed which was informed by a systematic review of risk assessment models to predict venous thromboembolism in women who are pregnant or in the puerperium. Expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty and should be the target of future research. To find out whether future studies would be acceptable and feasible, we held workshops with women who have experienced a blood clot or have been offered blood-thinning drugs and surveyed healthcare professionals. Expected value of sample information analysis was used to estimate the value of potential future research studies.
    Results: The systematic review included 17 studies, comprising 19 unique externally validated risk assessment models and 1 internally validated model. Estimates of sensitivity and specificity were highly variable ranging from 0% to 100% and 5% to 100%, respectively. Most studies had unclear or high risk of bias and applicability concerns. The decision analysis found that there is substantial decision uncertainty regarding the use of risk assessment models to select high-risk women for antepartum prophylaxis and obese postpartum women for postpartum prophylaxis. The main source of decision uncertainty was uncertainty around the effectiveness of thromboprophylaxis for preventing venous thromboembolism in women who are pregnant or in the puerperium. We found that a randomised controlled trial of thromboprophylaxis in obese postpartum women is likely to have substantial value and is more likely to be acceptable and feasible than a trial recruiting women who have had a previous venous thromboembolism. In unselected postpartum women and women following caesarean section, the poor performance of risk assessment models meant that offering prophylaxis based on these models had less favourable cost effectiveness with lower decision uncertainty.
    Limitations: The performance of the risk assessment model for obese postpartum women has not been externally validated.
    Conclusions: Future research should focus on estimating the efficacy of pharmacological thromboprophylaxis in pregnancy and the puerperium, and clinical trials would be more acceptable in women who have not had a previous venous thromboembolism.
    Study registration: This study is registered as PROSPERO CRD42020221094.
    Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR131021) and is published in full in
    MeSH term(s) Humans ; Pregnancy ; Female ; Anticoagulants ; Venous Thromboembolism/prevention & control ; Cost-Benefit Analysis ; Cesarean Section ; Postpartum Period ; Obesity ; Randomized Controlled Trials as Topic
    Chemical Substances Anticoagulants
    Language English
    Publishing date 2024-04-03
    Publishing country England
    Document type Systematic Review
    ZDB-ID 2006765-3
    ISSN 2046-4924 ; 1366-5278
    ISSN (online) 2046-4924
    ISSN 1366-5278
    DOI 10.3310/DFWT3873
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  8. Article ; Online: Risk assessment models for venous thromboembolism in pregnancy and in the puerperium: a systematic review.

    Pandor, Abdullah / Daru, Jahnavi / Hunt, Beverley J / Rooney, Gill / Hamilton, Jean / Clowes, Mark / Goodacre, Steve / Nelson-Piercy, Catherine / Davis, Sarah

    BMJ open

    2022  Volume 12, Issue 10, Page(s) e065892

    Abstract: Objectives: To assess the comparative accuracy of risk assessment models (RAMs) to identify women during pregnancy and the early postnatal period who are at increased risk of venous thromboembolism (VTE).: Design: Systematic review following ... ...

    Abstract Objectives: To assess the comparative accuracy of risk assessment models (RAMs) to identify women during pregnancy and the early postnatal period who are at increased risk of venous thromboembolism (VTE).
    Design: Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
    Data sources: MEDLINE, Embase, Cochrane Library and two research registers were searched until February 2021.
    Eligibility criteria: All validation studies that examined the accuracy of a multivariable RAM (or scoring system) for predicting the risk of developing VTE in women who are pregnant or in the puerperium (within 6 weeks post-delivery).
    Data extraction and synthesis: Two authors independently selected and extracted data. Risk of bias was appraised using PROBAST (Prediction model Risk Of Bias ASsessment Tool). Data were synthesised without meta-analysis.
    Results: Seventeen studies, comprising 19 externally validated RAMs and 1 internally validated model, met the inclusion criteria. The most widely evaluated RAMs were the Royal College of Obstetricians and Gynaecologists guidelines (six studies), American College of Obstetricians and Gynecologists guidelines (two studies), Swedish Society of Obstetrics and Gynecology guidelines (two studies) and the Lyon score (two studies). In general, estimates of sensitivity and specificity were highly variable with sensitivity estimates ranging from 0% to 100% for RAMs that were applied to antepartum women to predict antepartum or postpartum VTE and 0% to 100% for RAMs applied postpartum to predict postpartum VTE. Specificity estimates were similarly diverse ranging from 28% to 98% and 5% to 100%, respectively.
    Conclusions: Available data suggest that external validation studies have weak designs and limited generalisability, so estimates of prognostic accuracy are very uncertain.
    Prospero registration number: CRD42020221094.
    MeSH term(s) Anticoagulants/adverse effects ; Bias ; Female ; Humans ; Postpartum Period ; Pregnancy ; Prognosis ; Risk Assessment ; Venous Thromboembolism/chemically induced ; Venous Thromboembolism/diagnosis
    Chemical Substances Anticoagulants
    Language English
    Publishing date 2022-10-12
    Publishing country England
    Document type Journal Article ; Systematic Review ; Research Support, Non-U.S. Gov't
    ZDB-ID 2599832-8
    ISSN 2044-6055 ; 2044-6055
    ISSN (online) 2044-6055
    ISSN 2044-6055
    DOI 10.1136/bmjopen-2022-065892
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  9. Article ; Online: Evaluation of venous thromboembolism risk assessment models for hospital inpatients: the VTEAM evidence synthesis.

    Horner, Daniel Edward / Davis, Sarah / Pandor, Abdullah / Shulver, Helen / Goodacre, Steve / Hind, Daniel / Rex, Saleema / Gillett, Michael / Bursnall, Matthew / Griffin, Xavier / Holland, Mark / Hunt, Beverley Jane / de Wit, Kerstin / Bennett, Shan / Pierce-Williams, Robin

    Health technology assessment (Winchester, England)

    2024  Volume 28, Issue 20, Page(s) 1–166

    Abstract: Background: Pharmacological prophylaxis during hospital admission can reduce the risk of acquired blood clots (venous thromboembolism) but may cause complications, such as bleeding. Using a risk assessment model to predict the risk of blood clots could ... ...

    Abstract Background: Pharmacological prophylaxis during hospital admission can reduce the risk of acquired blood clots (venous thromboembolism) but may cause complications, such as bleeding. Using a risk assessment model to predict the risk of blood clots could facilitate selection of patients for prophylaxis and optimise the balance of benefits, risks and costs.
    Objectives: We aimed to identify validated risk assessment models and estimate their prognostic accuracy, evaluate the cost-effectiveness of different strategies for selecting hospitalised patients for prophylaxis, assess the feasibility of using efficient research methods and estimate key parameters for future research.
    Design: We undertook a systematic review, decision-analytic modelling and observational cohort study conducted in accordance with Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines.
    Setting: NHS hospitals, with primary data collection at four sites.
    Participants: Medical and surgical hospital inpatients, excluding paediatric, critical care and pregnancy-related admissions.
    Interventions: Prophylaxis for all patients, none and according to selected risk assessment models.
    Main outcome measures: Model accuracy for predicting blood clots, lifetime costs and quality-adjusted life-years associated with alternative strategies, accuracy of efficient methods for identifying key outcomes and proportion of inpatients recommended prophylaxis using different models.
    Results: We identified 24 validated risk assessment models, but low-quality heterogeneous data suggested weak accuracy for prediction of blood clots and generally high risk of bias in all studies. Decision-analytic modelling showed that pharmacological prophylaxis for all eligible is generally more cost-effective than model-based strategies for both medical and surgical inpatients, when valuing a quality-adjusted life-year at £20,000. The findings were more sensitive to uncertainties in the surgical population; strategies using risk assessment models were more cost-effective if the model was assumed to have a very high sensitivity, or the long-term risks of post-thrombotic complications were lower. Efficient methods using routine data did not accurately identify blood clots or bleeding events and several pre-specified feasibility criteria were not met. Theoretical prophylaxis rates across an inpatient cohort based on existing risk assessment models ranged from 13% to 91%.
    Limitations: Existing studies may underestimate the accuracy of risk assessment models, leading to underestimation of their cost-effectiveness. The cost-effectiveness findings do not apply to patients with an increased risk of bleeding. Mechanical thromboprophylaxis options were excluded from the modelling. Primary data collection was predominately retrospective, risking case ascertainment bias.
    Conclusions: Thromboprophylaxis for all patients appears to be generally more cost-effective than using a risk assessment model, in hospitalised patients at low risk of bleeding. To be cost-effective, any risk assessment model would need to be highly sensitive. Current evidence on risk assessment models is at high risk of bias and our findings should be interpreted in this context. We were unable to demonstrate the feasibility of using efficient methods to accurately detect relevant outcomes for future research.
    Future work: Further research should evaluate routine prophylaxis strategies for all eligible hospitalised patients. Models that could accurately identify individuals at very low risk of blood clots (who could discontinue prophylaxis) warrant further evaluation.
    Study registration: This study is registered as PROSPERO CRD42020165778 and Researchregistry5216.
    Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127454) and will be published in full in
    MeSH term(s) Female ; Pregnancy ; Humans ; Child ; Inpatients ; Anticoagulants ; Retrospective Studies ; Venous Thromboembolism ; Risk Assessment ; Thrombosis ; Cost-Benefit Analysis ; Observational Studies as Topic
    Chemical Substances Anticoagulants
    Language English
    Publishing date 2024-04-18
    Publishing country England
    Document type Systematic Review
    ZDB-ID 2006765-3
    ISSN 2046-4924 ; 1366-5278
    ISSN (online) 2046-4924
    ISSN 1366-5278
    DOI 10.3310/AWTW6200
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  10. Article ; Online: Individual risk factors predictive of major trauma in pre-hospital injured older patients: a systematic review.

    Pandor, Abdullah / Fuller, Gordon / Essat, Munira / Sabir, Lisa / Holt, Chris / Buckley Woods, Helen / Chatha, Hridesh

    British paramedic journal

    2021  Volume 6, Issue 4, Page(s) 26–40

    Abstract: Background: Older adults with major trauma are frequently under-triaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to identify which individual risk factors and predictors are likely to increase ... ...

    Abstract Background: Older adults with major trauma are frequently under-triaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to identify which individual risk factors and predictors are likely to increase the risk of major trauma in elderly patients presenting to emergency medical services (EMS) following injury, to inform future elderly triage tool development.
    Methods: Several electronic databases (including Medline, EMBASE, CINAHL and the Cochrane Library) were searched from inception to February 2021. Prospective or retrospective diagnostic studies were eligible if they examined a prognostic factor (often termed predictor or risk factor) for, or diagnostic test to identify, major trauma. Selection of studies, data extraction and risk of bias assessments using the Quality in Prognostic Studies (QUIPS) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarise the findings.
    Results: Nine studies, all performed in US trauma networks, met review inclusion criteria. Vital signs (Glasgow Coma Scale (GCS) score, systolic blood pressure, respiratory rate and shock index with specific elderly cut-off points), EMS provider judgement, comorbidities and certain crash scene variables (other occupants injured, occupant not independently mobile and head-on collision) were identified as significant pre-hospital variables associated with major trauma in the elderly in multi-variable analyses. Heart rate and anticoagulant were not significant predictors. Included studies were at moderate or high risk of bias, with applicability concerns secondary to selected study populations.
    Conclusions: Existing pre-hospital major trauma triage tools could be optimised for elderly patients by including elderly-specific physiology thresholds. Future work should focus on more relevant reference standards and further evaluation of novel elderly relevant triage tool variables and thresholds.
    Language English
    Publishing date 2021-07-10
    Publishing country England
    Document type Journal Article ; Review
    ISSN 1478-4726
    ISSN (online) 1478-4726
    DOI 10.29045/14784726.2022.03.6.4.26
    Database MEDical Literature Analysis and Retrieval System OnLINE

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