Patient-Centered approach to reducing harm from VTE

以患者为中心的方法减少 VTE 伤害

• 批准号: 9042938
• 负责人: MICHAEL B ROTHBERG
• 金额: $ 24.97万
• 依托单位: CLEVELAND CLINIC FOUNDATION
• 依托单位国家: 美国
• 财政年份: 2014
• 资助国家: 美国
• 起止时间: 2014-04-01 至 2018-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9042938
• 关键词: Patient; Centered; approach; reducing; harm

DESCRIPTION (provided by applicant): Venous thromboembolism (VTE) is a serious source of hospital morbidity and mortality. Chemoprophylaxis with heparin has been shown to reduce the occurrence of VTE, but it increases the risk of bleeding and it is uncomfortable to receive. For that reason, VTE prophylaxis should be reserved for patients at moderate to high risk of VTE and low risk of bleeding. However, identifying patients at low risk for VTE can be difficult, because most patients have at least one risk factor for VTE and there are no validated risk prediction tools for use in US hospitals. Instead, many hospitals have opted for a one-size-fits-all approach with near-universal prophylaxis, putting many patients at unnecessary risk of bleeding. However, to provide care that is truly patient-centered, US physicians face several challenges. First, there is no accepted risk calculator that they can use to estimate an individual patient's risk. Second, there is no validated risk calculator to estimate the risk of bleeding. Thid, the appropriate treatment thresholds for VTE or bleeding have not been identified (i.e. no one has defined what it means to be at low risk or at what level of risk the benefits of treatment outweigh the harms). Finally, risk calculators are not readily available at the point of care. As a result, prophylaxis rates have remained stubbornly low in some institutions, while in others the rate of prophylaxis is high, but the rate of inappropriate prophylaxis is also high. The aim of thi application is to use data from a large number of patients at the Cleveland Clinic to create tools that physicians can use to assess an individual patient's risk of both VTE and bleeding and to weigh those risks. An experienced team will develop and test these tools, and then incorporate them into a widely-used commercially available electronic health record in the form of a smart order set that will trigger an alert if the physician's order appears not to match the patient's rik. We will then assess the effects of the order set on physician behavior and patient outcomes using a randomized trial design. Examining the effectiveness of an electronic decision aid embedded in an EHR in routine clinical practice will test whether a smart order set can improve patient care by incorporating patient-specific factors into a complex decision process. This application builds upon our inter-disciplinary team's strong foundation of creating risk assessment tools and incorporating them into the EHR. Knowledge to be gained will inform best practices for VTE prophylaxis for millions of hospitalized medical patients each year and lead to other interventions for complex decision making involving patient-centered decisions.

描述（由申请方提供）：静脉血栓栓塞（VTE）是医院发病率和死亡率的严重来源。已证明肝素化学预防可减少静脉血栓栓塞的发生，但它会增加出血的风险，而且使用起来不舒服。出于这个原因，静脉血栓栓塞预防应保留给中度至高度风险的静脉血栓栓塞和低出血风险的患者。然而，识别VTE低风险患者可能很困难，因为大多数患者至少有一个VTE风险因素，并且在美国医院中没有经过验证的风险预测工具。相反，许多医院选择了一刀切的方法，几乎普遍预防，使许多患者面临不必要的出血风险。然而，要提供真正以患者为中心的护理，美国医生面临着几个挑战。首先，没有公认的风险计算器，他们可以用来估计个人 患者的风险。其次，没有经过验证的风险计算器来估计出血风险。因此，尚未确定VTE或出血的适当治疗阈值（即，没有人定义低风险意味着什么，或在什么风险水平下治疗的获益大于危害）。最后，风险计算器在护理点不容易获得。作为 结果，一些机构的预防率仍然很低，而另一些机构的预防率很高，但不适当的预防率也很高。该应用程序的目的是使用克利夫兰诊所大量患者的数据来创建医生可以用来评估个体患者的VTE和出血风险并权衡这些风险的工具。一个经验丰富的团队将开发和测试这些工具，然后将它们以智能订单集的形式整合到广泛使用的商业电子健康记录中，如果医生的订单与患者的风险不匹配，就会触发警报。然后，我们将使用随机试验设计评估顺序集对医生行为和患者结局的影响。在常规临床实践中检查嵌入在EHR中的电子决策辅助的有效性，将测试智能订单集是否可以通过将患者特定因素纳入复杂的决策过程来改善患者护理。该应用程序建立在我们的跨学科团队创建风险评估工具并将其纳入EHR的强大基础之上。获得的知识将为每年数百万住院医疗患者的VTE预防提供最佳实践，并导致涉及以患者为中心的复杂决策的其他干预措施。