Thrombosis and Bleeding Risk Assessment in Medical Inpatients

摘要 每年，美国有超过1000万人接受非手术治疗，这引发了 大约三分之一的静脉血栓栓塞症(VTE)事件-或每年约200,000个VTE。全国 质量措施和专业协会建议在入学时评估VTE风险，并提供 适当的VTE预防措施，包括移动、顺序压缩设备和/或 预防性剂量抗凝药物(即依诺肝素)。除了减少VTE外，药物性VTE 预防也会增加出血的风险。在过去的几年里，在 临床医生对VTE的预防；一方面，鼓励医生评估非VTE患者的VTE风险 手术患者和提供静脉血栓栓塞症预防，另一方面，越来越多的证据表明 静脉血栓栓塞术中死亡的好处可能会被出血增加所抵消。医院获得性疾病的前期研究 (HA)静脉血栓栓塞术和出血受到以下事实的阻碍：这是一种常见事件的罕见并发症 (住院)。数以万计的住院治疗需要进行评估，以获得足够数量的 事件以确定谁患有HA-VTE和HA-出血。以前的研究不得不依赖于耗时的 或仅依靠行政数据来研究HA-VTE或HA-VTE 在流血。随着电子健康记录的引入，我们现在可以评估数以万计的非 手术入院，并确定谁有静脉血栓栓塞和出血的风险。这项提议的目的有三个方面， 在两个不同的机构(佛蒙特州大学和华盛顿大学)：(I)发展风险 HA-VTE和HA-出血的模型(Ii)验证HA-VTE和HA-出血的风险模型，以及(Iii) 确定出院后VTE和出血的发生率和危险因素。有了这些目标，我们将 通过允许提供商针对VTE风险最高的人群定制VTE预防策略，使医疗保健更加安全 出血的风险也最低。我们的创新在于利用电子健康记录的潜力来 在超过140,000名入院患者中有效地研究HA-VTE和HA-出血事件，并在推进临床 通过开发经过验证的风险模型来实践，以允许提供商高效和合理地确定 风险：入院时药物预防VTE的益处，并开始了解VTE和 出院时有出血风险。

SUMMARY Each year, there are over 10 million non-surgical hospitalizations in the United States which trigger approximately 1 in 3 venous thromboembolism (VTE) events – or about 200,000 VTEs per year. National quality measures and professional societies recommend assessing VTE risk at admission and provide appropriate VTE prevention measures which include ambulation, sequential compression devices, and/or prophylactic dose anticoagulant medications (i.e. enoxaparin). In addition to reducing VTE, pharmacologic VTE prophylaxis also increases bleeding risk. Over the past few years there have been divergent pressures on clinicians regarding VTE prevention; on the one hand physicians are encouraged to assess VTE risk in non- surgical patients and provide VTE prophylaxis, and on the other a growing body of evidence suggests that the benefits of deceases in VTE may be outweighed by increased bleeding. Prior research of hospital-acquired (HA) VTE and bleeding has been hampered by the fact that it is a rare complication of a common event (hospitalization). Tens of thousands of hospitalizations need to be evaluated to obtain sufficient numbers of events to characterize who suffers HA-VTE and HA-bleeding. Prior studies have had to rely on time-consuming chart abstraction of thousands of hospitalizations or rely only on administrative data to study HA-VTE or HA- bleeding. With the introduction of the electronic health record, we can now assess tens of thousands of non- surgical admissions and determine who is at risk for VTE and bleeding. The aims of this proposal are threefold, at two diverse institutions (The University of Vermont and the University of Washington): (i) to develop risk models for HA-VTE and HA-bleeding (ii) to validate risk models for HA-VTE and HA-bleeding, and (iii) to determine the incidence of and risk factors for post-discharge VTE and bleeding. With these aims, we will make healthcare safer by allowing providers to tailor VTE prevention strategies to those at highest risk of VTE and lowest risk of bleeding. Our innovation lies in leveraging the potential of the electronic health record to efficiently study HA-VTE and HA-bleeding events in over 140,000 admissions, and in advancing clinical practice by developing validated risk models to allow providers to efficiently and rationally determine the risk:benefit of pharmacologic VTE prophylaxis at the time of admission and begin to understand the VTE and bleeding risks at discharge.