Leveraging Health IT to Avoid Unnecessary Asymptomatic Carotid Revascularization

描述（由申请人提供）：老年患者经常面临血管疾病的高风险医疗保健决策，需要知情决策以获得最佳结果。颈动脉血管重建术，通过外科颈动脉内膜切除术或颈动脉支架植入术，是最常用的血管手术之一，被广泛推荐用于预防未来的中风。这种治疗通常用于无症状性狭窄，在无干预的情况下，未来卒中的风险很低，因此干预的潜在益处远小于有症状患者。当考虑无症状颈动脉狭窄的血管重建术时，患者和提供者必须在患者预期寿命的背景下权衡手术的前期风险和中风的长期风险。在这种临床情况下，最好的决定是对低风险患者进行血运重建术，这些患者将活得足够长，可以从手术中获益，而对预期寿命较短的高风险患者进行药物治疗。然而，提供者和政策制定者发现，无论是在动脉内膜切除术的短期风险方面，还是在中风或死亡的长期风险方面，都很难确定为这些决定提供信息的关键变量。医疗信息技术可用于支持这一医疗保健决策的两个关键方面：(1)通过使用详细的患者和程序变量（如临床登记中的变量）进行短期手术风险分层；(2)纵向随访以评估在患者剩余生命中血管重建术预防中风的有效性。我们的小组已经证明，第一个组成部分可以使用来自区域注册中心的真实世界数据来建立，第二个组成部分可以通过使用行政索赔数据以广泛的、具有成本效益的方式实现。在目前的应用中，我们将开发和实施一个合并的临床登记和索赔健康IT工具，该工具将支持无症状颈动脉疾病患者在门诊环境下的临床决策。这种方法利用了注册表中存在的临床细节，并从行政索赔中获得了完整的随访。具体来说，我们将：(1)使用合并的注册-索赔数据集确定哪些无症状患者可能接受不必要的颈动脉重建术，并设计一个健康IT工具将这些发现传达给提供者；(2)确定避免无症状患者不必要的颈动脉内膜切除术相关的潜在成本节约。这一健康信息技术工具将识别出最不可能从颈动脉血管重建术中获益的患者，并允许患者和提供者做出决定

DESCRIPTION (provided by applicant): Elderly patients often face high-risk health care decisions about vascular disease, and informed decisions are needed to obtain the best results. Carotid revascularization, via surgical carotid endarterectomy or carotid artery stenting, is among the most frequently performed vascular procedures, and is widely recommended to prevent future stroke. Such treatment is commonly performed for asymptomatic stenosis, where the risk of future stroke is low without intervention, so the potential benefit of intervention is much less than in symptomatic patients. When considering revascularization for asymptomatic carotid stenosis, patients and providers must weigh the up-front risk of surgery against the long-term risk of stroke, taken in the context of the patient's life expectancy. The best decision in ths clinical scenario is revascularization for low-risk patients who will live long enough to benefit from surgery, and medical treatment for higher risk patients with shorter life expectancy. However, providers and policymakers have found it difficult to identify the key variables to inform these decisions, both in terms of the short-term risks of endarterectomy, as well as the long- term risks of stroke or death. Health IT can be leveraged to support two key facets of this health care decision: (1) short-term surgical risk stratification by using detailed patient and procedural variables, such as those present in a clinical registry, and (2) longitudinal follow-up o assess the effectiveness of the revascularization in preventing stroke during the patient's remaining life. Our group has demonstrated that the first component can be established using real world data from a regional registry, and the second can be achieved in a broad, cost-effective manner by using administrative claims data. In the present application, we will develop and implement a merged clinical registry and claims health IT tool that will support clinical decision-making, in the ambulatory setting, for patients with asymptomatic carotid artery disease. This approach leverages the clinical detail present in registries with the complete follow-up available from administrative claims. Specifically, we will: (1) identify which asymptomatic patients are likely to receive unnecessary carotid revascularization, using a merged registry-claims dataset, and design a Health IT tool to convey these findings to providers, and (2) determine the potential cost savings associated with avoiding unnecessary carotid endarterectomy in asymptomatic patients. This health IT tool will identify patients who are least likely to benefit from carotid revascularization and allow patients and providers to make more informed choices in the ambulatory setting regarding medical management versus revascularization. This tool will also serve as a model for broader implementation, through the Society for Vascular Surgery Vascular Quality Initiative, and will inform policy makers about opportunities for reducing health care expenditures by reducing unnecessary care.