Screening and Diagnosis of VTE: The More You Look, The More You Find?
Screening and Diagnosis of VTE: The More You Look, The More You Find?
复制标题
DOI：
10.1007/s40719-016-0038-y
复制
发表时间：
2016-03-01
影响因子：
0.7
通讯作者：
Haut, Elliott R.
中科院分区：
文献类型：
--
作者：
Kodadek, Lisa M.;Haut, Elliott R.
目前还没有关于常规筛查高风险无症状创伤患者静脉血栓栓塞症（VTE）的共识。VTE是指存在深静脉血栓形成（DVT）和/或肺栓塞（PE）。外科医生在无症状患者中筛查VTE的相关实践可能差异很大。常规筛查的支持者认为进行相对便宜和无创的检查（双功超声检查）是有益的，以便在无症状DVT进展为症状性或致命性PE之前诊断和治疗无症状DVT。其他人认为，增加无症状性VTE的医学检查和治疗不仅会带来与抗凝治疗相关的风险，而且还会产生不必要的费用。VTE结局报告中的监测偏倚（“看得越多，发现的越多”）可能是不同筛查实践的意外结果。研究清楚地表明，增加筛查与VTE诊断率的增加有关，主要是在创伤患者中。这引起了严重的关注，因为较低的VTE发病率被认为是较高质量卫生保健的标志。国家机构，包括医疗保险和医疗补助服务中心，当一些住院患者发生静脉血栓栓塞时，会实施经济处罚。此外，医疗保健消费者可以使用VTE结果数据来决定在哪里寻求更高质量的护理。由于静脉血栓栓塞的发病率与筛查实践有关，通过对无症状患者进行更多双功超声检查来进行更积极筛查的提供者可能会发现更多的静脉血栓栓塞病例，并且矛盾的是，与不进行筛查或订购较少筛查测试的提供者相比，他们提供的护理质量更低。因此，一些专家认为，患者安全和优质护理的标准不应仅关注VTE的发生率（结果测量），还应考虑根据最佳实践指南（过程测量），患者接受VTE预防性治疗的频率。纯粹的过程测量方法或结合过程和结果测量可能更有效地识别更高质量的护理，并最终减轻与VTE相关的可预防的伤害。
There is no current consensus regarding routine screening of high-risk asymptomatic trauma patients for venous thromboembolism (VTE). VTE refers to the presence of deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Practices among surgeons related to screening for VTE in asymptomatic patients may vary significantly. Supporters of routine screening see benefit in performing a relatively inexpensive and noninvasive test (Duplex ultrasonography), in order to diagnose and treat asymptomatic DVT before it progresses to symptomatic or fatal PE. Others suggest that increased medical testing and treatment of asymptomatic VTE incurs not only the risk associated with anticoagulation treatment, but also unnecessary costs. Surveillance bias ("the more you look, the more you find") in VTE outcome reporting is perhaps an unintended consequence of varying screening practices. Studies have clearly shown that increasing screening is associated with increasing rates of VTE diagnosis, primarily in trauma patients. This poses significant concern because lower incidence of VTE is considered a marker for higher quality health care. National bodies, including the Centers for Medicare and Medicaid Services, impose financial penalties when some hospitalized patients develop VTE. Furthermore, healthcare consumers may use VTE outcomes data to make decisions about where to seek higher quality care. Since the incidence of VTE is related to screening practices, providers who screen more aggressively by performing more Duplex ultrasounds on asymptomatic patients may identify more cases of VTE and will appear, paradoxically, to provide lower quality care than providers who do not screen or order fewer screening tests. For this reason, some experts argue that the standard of patient safety and quality care should not only focus on the incidence of VTE alone (outcome measure) but should also consider how frequently patients are prescribed and administered VTE prophylaxis according to best-practice guidelines (process measure). A pure process measure approach or combined process and outcome measure may be more effective to identify higher quality care and to ultimately mitigate preventable harm related to VTE.