Severity Scoring and Outcomes Measurement

Historical Background

The past few decades have marked a change of focus in reporting outcomes for venous disease and therapy. Although treatments were regularly being offered for many venous conditions, the outcomes were only sporadically evaluated, and reporting methods were not standardized, preventing comparison trials and confounding reported results. The realization that the language of diagnostic and treatment information needs to be universal has shifted the focus of physicians to organize information to provide a framework for clinical practice and research. Reporting standards to address important elements of assessment, including clinical classification of disease, a grading system for risk factors, categorization of operations and interventions, complications encountered with grades for severity or outcomes, and criteria for improvement, deterioration, and failure has become a priority. Results should be evaluated alongside other options, such as the natural course of the disease itself, nonsurgical therapies, additional surgical interventions, or alternative ways of performing an intervention.

Developing and using proper venous severity and outcomes assessment tools should be paramount to those treating venous disease. The assessment of outcomes in chronic venous disease is multifactorial and is more complicated than in other vascular conditions. The end points of comparison must be objective usable measures that reflect signs, symptoms, and patient quality of life. This chapter will review current venous assessment tools to determine severity of venous disease for both thrombotic and chronic venous insufficiency, which forms the core of outcome measurements used to determine quality benchmarking and comparative analysis. A general algorithm for use of these venous severity scoring systems will be recommended, highlighting the pearls and pitfalls of these outcome measurement tools.

Venous Severity Assessment Tools

Venous Thromboembolism Risk Assessment—Caprini Score

Prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE) is important because initial diagnosis is challenging, treatment is not always successful, long-term sequelae can include postthrombotic syndrome (PTS), and PE can cause sudden death. Using a venous thromboembolism (VTE) risk assessment will allow for more precise risk stratification of surgical and nonsurgical patients at potential risk for VTE, compared with risk of bleeding before instituting pharmacologic thromboprophylaxis prevention strategies. The Caprini score was introduced in 2005 to evaluate patient risk of developing VTE if placed into a high-risk situation (such as surgical procedure, major injury or other hospitalizations, malignancy, or prolonged immobility). The Caprini score ( Table 26.1 ) weighs out VTE risk factors with 1 to 5 points for each. The total risk factor score then is used to group patients into one of four categories (low, moderate, high, and highest risk), each of which corresponds to a recommended prophylactic regimen. Practitioners should weigh in prophylactic safety against increased risks of bleeding in prophylactic decision making.

TABLE 26.1

Venous Thromboembolism Risk Assessment—Caprini Score

1 Point	2 Points	3 Points	5 Points
Age 41–60 years	Age 61–74 years	Age ≥ 75 years	Stroke (<1 month)
Minor surgery	Arthroscopic surgery	History of VTE	Elective arthroplasty
BMI ≥ 25 a	Major open surgery (≥45 minutes)	Family history of VTE	Hip, pelvis, or leg fracture
History of major surgery (<1 month)	Laparoscopic surgery (>45 minutes)	Positive factor V Leiden	Multiple trauma (<1 month)
Varicose veins	Cancer (past or present)	Positive prothrombin 20210A	Acute spinal cord injury (<1 month)
Swollen legs	Patient confined to bed (>72 hours)	Elevated serum homocysteine
Acute myocardial infarction	Immobilizing plaster cast (<1 month)	Positive lupus anticoagulant
Congestive heart failure (<1 month	Central venous access	Elevated anticardiolipin antibodies
Sepsis (<1 month)		Heparin-induced thrombocytopenia
Serious lung disease, such as pneumonia (<1 month)		Other congenital or acquired thrombophilia
Chronic obstructive pulmonary disease
Medical patient on bed rest
Recommended Prophylactic Strategy Based on Caprini Thrombosis Risk Factor Assessment Score b
Number of Risk Factors	Risk Category	Recommended Regimen
1	Low	Early ambulation plus elastic compression stockings
2–4	Moderate	Early ambulation plus elastic compression stockings plus sequential compression device anticoagulant
>4	High	Early ambulation plus elastic compression stockings plus sequential compression device plus LMWH, heparin, or warfarin

BMI, Body mass index; LMWH, low-molecular-weight heparin; VTE, venous thromboembolism.

a From Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon . 2005;52:70–78.

b From Caprini JA. Risk assessment as a guide for the prevention of the many faces of venous thromboembolism. Am J Surg 2010;S3–10.