Can increased incidence of deep vein thrombosis (DVT) be used as a marker of quality of care in the absence of standardized screening? The potential effect of surveillance bias on reported DVT rates after trauma
Can increased incidence of deep vein thrombosis (DVT) be used as a marker of quality of care in the absence of standardized screening? The potential effect of surveillance bias on reported DVT rates after trauma
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DOI：
10.1097/ta.0b013e31814856ad
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发表时间：
2007-11-01
影响因子：
--
通讯作者：
Pronovost, Peter J.
中科院分区：
文献类型：
--
作者：
Haut, Elliott R.;Noll, Kathy;Pronovost, Peter J.
背景：即使采取了适当的预防措施，深静脉血栓（DVT）也是创伤患者发病和死亡的一个重要原因。许多国家机构（医疗保健研究与质量机构、联合委员会、国家质量论坛）建议将深静脉血栓发生率作为医疗保健质量的衡量标准，但没有一个机构推荐标准化的筛查方法。双功超声作为 DVT 检测的无创诊断工具发挥着重要作用。然而，对无症状患者 DVT 的筛查存在一定争议，而且创伤中心之间的做法差异很大。我们假设，随着创伤患者筛查双重检查次数的增加，DVT 的识别率也会增加。方法：对来自城市大学一级创伤中心的 21,961 名患者进行了超过 11 年（1995-2005 年）的回顾性队列研究。我们根据 1998 年实施 DVT 预防和双重超声监测的书面实践管理指南之前或之后在创伤服务机构入院的情况对患者进行分组。我们使用 Fisher 精确检验比较了每 1,000 名创伤入院患者的双重、DVT 和肺栓塞发生率。结果：接受双功能超声检查的创伤患者比例显着增加（每 1,000 名创伤入院患者中 20.9-81.5 例，p < 0.0001）。报告的 DVT 发生率在两个时期之间显着增加了 10 倍（每 1,000 名入院患者 0.7-7.0，p = 0.0024）。肺栓塞发生率几乎增加了五倍（每 1,000 名入院患者 0.7-3.2 例，p = 0.15），但这种差异并不具有统计学意义。结论：增加双重筛查检查次数可提高 DVT 识别率。在缺乏标准化监测的情况下，DVT 发生率可能更多地受到护理人员查找这些事件的频率的影响，而不是所提供护理质量的影响。
Background: Deep vein thrombosis (DVT) is a significant cause of morbidity and mortality in trauma patients, even with appropriate prophylaxis. Many national agencies (Agency for Healthcare Research and Quality, Joint Commission, National Quality Forum) have suggested DVT incidence as a measurement of health care quality, but none has recommended a standardized screening approach. Duplex ultrasound serves an important role as a noninvasive diagnostic tool for detection of DVT. However, screening of asymptomatic patients for DVT is somewhat controversial and these practices vary widely among trauma centers. We hypothesized that as the number of screening duplex examinations in trauma patients increases, the rate of DVT identification will also increase. Methods: Retrospective cohort study of 21,961 patients from an urban, university-based Level I trauma center for more than 11 years (1995-2005). We grouped patients according to admission at the trauma service either before or after implementation of a written practice management guideline for DVT prophylaxis and duplex ultrasound surveillance in 1998. We compared duplex, DVT, and pulmonary embolism rates per 1,000 trauma admissions using Fisher's exact test. Results: The proportion of trauma patients having a duplex ultrasound increased significantly (20.9-81.5 per 1,000 trauma admissions, p < 0.0001). The rate of DVT reported increased 10-fold (0.7-7.0 per 1,000 admissions, p = 0.0024), significantly, between the two periods. The pulmonary embolism rate increased almost fivefold (0.7-3.2 per 1,000 admissions, p = 0.15), although this difference was not statistically significant. Conclusions: Increasing the number of duplex screening exams resulted in an increased rate of DVT identification. In the absence of standardized surveillance, DVT rates may be more influenced by how often caregivers look for these events rather than the quality of care provided.