Patient-Centered approach to reducing harm from VTE

描述(由申请人提供)：静脉血栓栓塞症(VTE)是医院发病率和死亡率的严重来源。肝素的化学预防已被证明可以减少VTE的发生，但它增加了出血的风险，接受治疗也不舒服。因此，静脉血栓栓塞术的预防应保留给中、高度VTE风险和低出血风险的患者。然而，识别低风险的VTE患者可能很困难，因为大多数患者至少有一个VTE风险因素，而且没有经过验证的风险预测工具可供美国医院使用。取而代之的是，许多医院选择了一种一刀切的方法，几乎是全民预防，这让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可以用来估计个人 病人的风险。其次，没有经过验证的风险计算器来估计出血的风险。因此，尚未确定静脉血栓栓塞术或出血的适当治疗阈值(即，没有人定义什么是低风险，或者在什么风险水平下治疗的好处大于危害)。最后，风险计算器在护理时不是现成的。作为一名 结果有些机构的预防覆盖率居高不下，有些机构的预防覆盖率较高，但预防不当的比率也较高。这个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工具，医生可以使用这些工具来评估单个患者的VTE和出血的风险，并对这些风险进行权衡。一个经验丰富的团队将开发和测试这些工具，然后将它们以智能医嘱集的形式整合到广泛使用的商业电子健康记录中，如果医生的医嘱似乎与患者的RICK不符，就会触发警报。然后，我们将使用随机试验设计评估顺序设置对医生行为和患者结果的影响。在常规临床实践中检查嵌入EHR中的电子决策辅助工具的有效性，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。这一应用程序建立在我们跨学科团队创建风险评估工具并将其纳入EHR的坚实基础上。将获得的知识将成为每年数百万住院内科患者预防VTE的最佳实践，并导致涉及以患者为中心的决策的复杂决策的其他干预措施。

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.