The authors state the dynamic-reassessment claim with moderate confidence; the reported results provide low support for it. The headline accuracy gain (AUC 0.811 → 0.892) is substantially reverse causation — unplanned readmission and reoperation are often the occasion on which the embolism is diagnosed — and a public calculator is deployed on temporal-only validation. The model is rigorously built and exceptionally well reported; the gap is in the central inference, not the execution.
This manuscript develops a calculator to tell surgeons which patient, at which moment, is at high enough risk of pulmonary embolism (PE) to justify extended blood-thinner prophylaxis — and to update that risk after an unplanned readmission or reoperation. Built and temporally validated in 4.8 million operations, the discharge model discriminates well (AUC 0.811) with excellent calibration, and the reporting is exemplary (full TRIPOD, released coefficients and code, a working calculator). The numbers reconcile throughout.
The serious rating is confined to the central claim. The headline jump to AUC 0.892 from adding unplanned readmission and reoperation is substantially reverse causation: those returns are frequently when the PE is diagnosed (suspected-clot readmissions were 68% PE), and the registry cannot order the events. This is compounded by a calculator deployed on temporal-only validation (no external validation or impact study) and a model that predicts risk under current mixed prophylaxis, not the untreated risk a “treat more?” decision needs. All three are disclosed, and pre-specified mitigations bound them — which is why this is serious, not fatal.
What the manuscript states, against what the evidence can support.
| Domain | Severity | Principal finding | |
|---|---|---|---|
| 01 | Design / claim fit | Serious | Dynamic-model accuracy gain is substantially reverse causation; deployed on temporal-only validation. |
| 02 | Results / conclusion alignment | Moderate | A modest absolute yield (1 PE per 34 flagged) framed as a large “dynamic” advance. |
| 03 | Statistical appropriateness | Moderate | Predicts risk under unmeasured mixed prophylaxis, not the untreated risk a treatment decision needs. |
| 04 | Reporting guideline adherence | Exemplary | Full TRIPOD: locked pipeline, calibration, decision curve, released coefficients and code. |
| 05 | Numerical / statistical consistency | No findings | Reported CIs, cohort counts, and the reclassification table all reconcile. |
| 06 | Clinical interpretability / verdict | Serious | Strong, well-reported model; the central dynamic-reassessment claim outruns the evidence. |
| 07 | Contribution & literature positioning | Moderate | The “dynamic” update is framed as a first; related dynamic-risk models in the retrieved literature go unacknowledged, overstating novelty. |
Language calibration: 1 must-change wording · 1 precision polish. Analytic work: 2 need source-data or analytic work · 1 claim limitation.
| Severity | Domain | Finding | Author action | Evidence | Locus |
|---|---|---|---|---|---|
| Serious | 01 · Design | The dynamic model’s accuracy gain (AUC 0.811 → 0.892) is substantially reverse causation: unplanned readmission/reoperation are often the occasion of PE diagnosis (suspected-clot returns 68% PE), with no temporal ordering in the registry. | New analysis needed | Quote | Central |
| Moderate | 01 · Design | A public calculator is deployed for clinical use on temporal-only (internal) validation — no external validation in independent data and no prospective impact study. | New analysis needed | Quote | Central |
| Moderate | 02 · Alignment | The “multidimensional dynamic … practical strategy” framing overstates a modest absolute yield (PPV 2.92%; about 1 PE per 34 flagged) under a usual-care estimand. | Must-change wording | Quote | Central |
| Moderate | 03 · Statistics | The registry records no anticoagulant exposure, so the model predicts PE under current mixed prophylaxis — not the untreated risk relevant to deciding who needs more. | Claim limitation | Quote | Central |
| Mild | 03 · Statistics | Complete-case analysis excludes operations missing a core complexity variable (wRVU) without imputation; the excluded count is only in the supplement. | Statistical precision | Quote | Peripheral |
The big accuracy jump when a readmission or reoperation is added is partly circular: those returns are often when the clot is found. So a return flags higher measured risk, but it does not guarantee a clean window to prevent the clot, because for some flagged patients the clot is already there. Clinically, treat any unplanned return as a prompt to re-check prophylaxis, but do not read 0.892 as proof of a prevention opportunity.
Reverse causation / outcome-concurrent predictor (PROBAST: outcome). The dynamic stage adds returns recorded in the same 30-day window as PE, with no guaranteed precedence. Authors mitigate (remove suspected-clot subgroup; re-anchor follow-up, HR 1.08 [0.81–1.44]; discard PEs within 1–7 days of the event, AUC 0.866 → 0.845), which shows a real residual signal but cannot order events in the registry.
Adversarial self-check: upheld at serious — the residual signal argues against “fatal,” but the deployable headline remains 0.892 and the increment is the paper’s central contribution.
≈ 58% of the headline gain does not survive the authors' own reverse-causation check.
The database does not record who already got blood thinners, so the risk numbers reflect care as delivered, not an untreated patient. Clinically, the score tells you who is high-risk now, not how much an extra dose would help them.
Prevalent-treatment / usual-care estimand (PROBAST: predictors/outcome). No anticoagulant capture; ~31% background prophylaxis; predicted P(PE | current care) ≠ untreated risk or treatment benefit. Disclosed; causal claims limited.
Recomputed directly from the manuscript’s reported values — no numerical inconsistencies were found.
“…early versus late events no longer differed in PE risk (hazard ratio 1.08; 95% CI, 0.81–1.44; p = 0.58).”Hazard ratio with 95% CI and p-value
Reclassification groups sum to 57,840 unplanned-return patients; PE events sum to 1,742.Concordant low + reclassified up/down + concordant high
In order. The central design finding governs the headline.
Suggested wording is triaged by author action. Some wording overstates the evidence and should change; some is recommended risk reduction; some is precision polish; some is left to author discretion.
“Dynamic reassessment offers a practical strategy to reduce missed opportunities for prevention after discharge.”
“An unplanned readmission or reoperation marks a higher-risk state warranting reassessment; because returns are often when PE is diagnosed, the model identifies risk rather than a quantified prevention opportunity.”
“A multidimensional dynamic calculator.”
“A two-stage risk model: a discharge estimate plus an update after an unplanned readmission or reoperation.”
“Reassessment moved 42% of unplanned-return patients above the treatment threshold.”
“Reassessment moved 42% above threshold (PPV 2.92%; about one PE per 34 flagged); state the absolute prevented-PE trade-off given ~60% prophylaxis efficacy and bleeding risk.”
“The model is publicly accessible as a calculator.”
“The model is available as an investigational calculator pending external validation.” Defensible either way; this flags the framing while external evidence is pending.
Checked against RigorMD’s journal registry. Compliance items reflect the journal’s formatting and submission rules; they do not affect the methodological severity grade above.
Cited DOI and PMID identifiers, resolved against the public registries — Crossref, the DOI handle registry, and PubMed — as of 2026-06-23. A ✓ means the registry record exists and is consistent with the citation as printed; it does not assess whether the cited work supports the claim it is attached to. An identifier the check could not reach is listed as not checked, never assumed to resolve. Problems found here also appear as findings above. 4 of 5 cited identifiers were checked: 1 resolves to a different work · 3 resolve · 1 not checked.
| Identifier | Outcome | Registry | Notes |
|---|---|---|---|
| DOI 10.1097/SLA.0000000000005821 | ✗ Resolves to a different work | Crossref | DOI 10.1097/SLA.0000000000005821 resolves at Crossref to "Extended prophylaxis after pelvic surgery" (2021), which does not match the citation as printed (checked 2026-06-23) |
| DOI 10.1016/j.jvsv.2022.05.214 | — Not checked | — | The registry could not be reached. |
| DOI 10.1056/NEJMoa012385 | ✓ Resolves | Crossref | |
| PMID 31626288 | ✓ Resolves | PubMed | |
| DOI 10.1101/2020.06.21.20136432 | ✓ Resolves | Crossref |
Findings — see below
The prior literature RigorMD retrieved into an evidence pack and compared with this manuscript's positioning as of 2026-06-23. This is a positioning-risk check, not a novelty score: it flags where a claim may overlap, understate, or be contradicted by retrieved prior work. It does not assert that a contribution is novel or first — a clean result means only that no directly overlapping prior study was found in this evidence pack. The retrieval is bounded and time-stamped; treat it as a starting point for your own literature review, not a replacement for it. Positioning risks found here also appear as findings above. The retrieval surfaced prior dynamic / time-updating venous-thromboembolism risk models the manuscript frames its approach as the first to introduce.
Priors we compared you against. The prior work RigorMD retrieved and compared this manuscript against — disclosed so you can see the evidence pack behind the assessment. Listing a work here is not an instruction to cite it; it is the basis on which the positioning was checked.
| Prior work | Year | Identifier | In your references |
|---|---|---|---|
| A dynamic, landmark-updated model for venous thromboembolism risk after major surgery | 2022 | PMID 35418902 | Not in your references |
| Time-updating prediction of postoperative complications with electronic health-record streams | 2020 | DOI 10.1001/jamasurg.2020.2321 | In your references |
| Recalculating perioperative VTE risk after an unplanned readmission: a cohort study | 2023 | PMID 36790551 | Not in your references |
The manuscript frames a risk estimate that updates after an unplanned return as a new, first-of-its-kind dynamic strategy, but retrieval surfaced prior landmark-updated and time-updating perioperative risk models it does not engage. The contribution — scale and the specific readmission trigger — is real; the claim of primacy is stronger than the retrieved record supports.
“We re-estimated venous thromboembolism risk at each landmark time, updating the prediction as new post-operative events accrued, and showed improved discrimination over a fixed discharge-time score.”From the prior work RigorMD retrieved and compared
Literature assessed as of 2026-06-23. Bounded PubMed retrieval on the manuscript's own concept pair, not a systematic review; a work not surfaced here was not necessarily absent from the literature. Listing a prior is disclosure of what was compared, not an instruction to cite it.
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