Agreement of four competing guidelines on prevention of venous thromboembolism and comparison with observed physician practices

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Abstract
OBJECTIVE: To assess the degree of agreement between four competing guidelines regarding the recommendation for prophylactic heparin therapy and to report to what extent actual practice agreed with or differed from the recommendations made before these guidelines were disseminated. DESIGN: Four French guidelines were applied to data from a cross-sectional study conducted before their dissemination. SETTING: Twenty-six medical units of a teaching and a non-teaching hospital. PATIENTS: One thousand thirty-two medical inpatients. MAIN MEASUREMENTS: Interguideline agreement rated by the κ coefficient and percentage of patients receiving prophylactic heparin treatment. RESULTS: The percentage of patients requiring prophylactic treatment ranged from 35.4% to 54.6% (overall κ coefficient, 0.65 [0.63 to 0.68]), depending on the guideline. The four guidelines agreed in recommending prophylactic heparin treatment in 330 patients (32.0%). The corresponding rate of prophylactic treatment use was 57.0% (188/330). None of the guidelines recommended prophylactic heparin treatment in 385 patients (37.3%). The physicians did not order prophylactic treatment in 80.3% of these patients (309/385). The guidelines disagreed in recommending prophylactic treatment in 317 patients (30.7%). The corresponding rate of prophylactic treatment use was 32.8% (104/317). CONCLUSION: The four guidelines agreed in 69.3% of patients but physician practices were already quite appropriate in these patients before the guidelines were disseminated. Active dissemination of the guidelines can be expected to improve physician practices in the treatment of these patients, but likely with limited impact. In contrast, the four guidelines disagreed in 30.7% of patients. Further clinical trials are needed in this subgroup of patients.