key: cord-0835715-2goxa4f4 authors: Spyropoulos, Alex C.; Cohen, Stuart L.; Gianos, Eugenia; Kohn, Nina; Giannis, Dimitrios; Chatterjee, Saurav; Goldin, Mark; Lesser, Marty; Coppa, Kevin; Hirsch, Jamie S.; McGinn, Thomas; Barish, Matthew A. title: Validation of the IMPROVE‐DD risk assessment model for venous thromboembolism among hospitalized patients with COVID‐19 date: 2021-02-24 journal: Res Pract Thromb Haemost DOI: 10.1002/rth2.12486 sha: c7d5da027445d6a1307685be6b136333e159c13b doc_id: 835715 cord_uid: 2goxa4f4 BACKGROUND: Antithrombotic guidance statements for hospitalized patients with coronavirus disease 2019 (COVID‐19) suggest a universal thromboprophylactic strategy with potential to escalate doses in high‐risk patients. To date, no clear approach exists to discriminate patients at high risk for venous thromboembolism (VTE). OBJECTIVES: The objective of this study is to externally validate the IMPROVE‐DD risk assessment model (RAM) for VTE in a large cohort of hospitalized patients with COVID‐19 within a multihospital health system. METHODS: This retrospective cohort study evaluated the IMPROVE‐DD RAM on adult inpatients with COVID‐19 hospitalized between March 1, 2020, and April 27, 2020. Diagnosis of VTE was defined by new acute deep venous thrombosis or pulmonary embolism by Radiology Department imaging or point‐of‐care ultrasound. The receiver operating characteristic (ROC) curve was plotted and area under the curve (AUC) calculated. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using standard methods. RESULTS: A total of 9407 patients were included, with a VTE prevalence of 2.9%. The VTE rate was 0.4% for IMPROVE‐DD score 0‐1 (low risk), 1.3% for score 2‐3 (moderate risk), and 5.3% for score ≥ 4 (high risk). Approximately 45% of the total population scored high VTE risk, while 21% scored low VTE risk. IMPROVE‐DD discrimination of low versus medium/high risk showed sensitivity of 0.971, specificity of 0.218, PPV of 0.036, and NPV of 0.996. ROC AUC was 0.702. CONCLUSIONS: The IMPROVE‐DD VTE RAM demonstrated very good discrimination to identify hospitalized patients with COVID‐19 as low, moderate, and high VTE risk in this large external validation study with potential to individualize thromboprophylactic strategies. | 297 SPYROPOULOS et aL. • No clear approach exists to discriminate high-risk hospitalized patients with coronavirus disease 2019 (COVID-19) for venous thromboembolism (VTE). • Our study included a large hospitalized COVID-19 population within a multihospital health system. • The IMPROVE-DD VTE risk score classified approximately 45% of the population into high VTE risk. • The IMPROVE-DD score has the potential to individualize strategies to prevent VTE in this population. The coronavirus disease 2019 (COVID-19) pandemic has been associated with elevated rates of thrombotic events. The majority of events represent venous thromboembolism (VTE) and include classic macrovessel disease such as deep vein thrombosis (DVT) or pulmonary embolism (PE), as well as microvessel disease and in situ fatal thrombosis. 1,2 Although initial reports suggested VTE rates of 46% or higher in hospitalized patients -especially those with critical illness -subsequent larger US studies have shown much lower VTE rates of 1.7% to 3.6%. [3] [4] [5] Antithrombotic guidance statements on hospitalized patients with COVID-19 suggest a universal thromboprophylactic strategy with potential to escalate doses in high-risk groups, though identifying and discriminating these groups remains a challenge. 6 The International Medical Prevention Registry on Venous Thromboembolism and D-Dimer (IMPROVE-DD) risk assessment model (RAM) expands upon a well-validated RAM -the IMPROVE VTE RAM -and incorporates a novel biomarker, an elevated d-dimer (Dd). 7, 8 Elevated Dd appears to be highly predictive of increased thrombotic risk and poor outcomes in patients hospitalized with COVID-19. 9 Our aim was to externally validate the IMPROVE-DD RAM for VTE in a large cohort of hospitalized patients with COVID-19. International guidelines are moving toward an individualized, risk-adapted approach to thromboprophylaxis in hospitalized medically ill patients, 6 which would include the subset of hospitalized patients with COVID-19. Pre-COVID-era studies in medically ill patients, including those with pneumonia and sepsis, have suggested a much lower percentage (10% to ~ 25%) of high-VTE-risk patients compared to our study's findings. 12 Although nearly 80% of hospitalized patients with COVID-19 in our study were at moderate or high VTE risk, a sizable proportion (~21%) were at a low VTE risk of ~ 0.4%; such patients may be subject to potential harms in a universal anticoagulant thromboprophylaxis policy. 6 Hospitalized COVID-19 patients and venous thromboembolism: A perfect storm Autopsy findings and venous thromboembolism in patients with COVID-19: A prospective cohort study Thrombotic complications and anticoagulation in COVID-19 pneumonia: a New York City hospital experience Thrombosis in hospitalized patients with COVID-19 in a New York City health system Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy Subcommittee on Perioperative, Critical Care Thrombosis, Haemostasis of the Scientific, Standardization Committee of the International Society on Thrombosis, Haemostasis+. Scientific and Standardization Committee Communication: clinical guidance on the diagnosis, prevention and treatment of venous thromboembolism in hospitalized patients with COVID-19 The IMPROVEDD VTE Risk Score: Incorporation of D-Dimer into the IMPROVE Score to Improve Venous Thromboembolism Risk Stratification Predictive and associative models to identify hospitalized medical patients at risk for VTE Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach External validation of a risk assessment model for venous thromboembolism in the hospitalised acutely-ill medical patient Prevention of venous thromboembolism in hospitalized medically ill patients: A U.S. perspective Rivaroxaban for thromboprophylaxis among patients recently hospitalized for acute infectious diseases: a subgroup analysis of the MAGELLAN study Development and validation of a predictive model for chemotherapy-associated thrombosis The validation of the original and modified Caprini score in COVID-19 patients Association of Padua prediction score with in-hospital prognosis in COVID-19 patients On Behalf of the COVID-19 Consortium Group. Validation of the IMPROVE-DD risk assessment model for venous thromboembolism among hospitalized patients with COVID-19