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。通过颈动脉内膜切除术或颈动脉支架植入术进行的颈动脉血运重建是最常进行的血管手术之一，并被广泛推荐用于预防未来的卒中。这种治疗通常用于无症状性狭窄，在没有干预的情况下，未来卒中的风险较低，因此干预的潜在受益远低于有症状的患者。当考虑无症状颈动脉狭窄的血运重建时，患者和供应商必须权衡手术的前期风险与中风的长期风险，并考虑患者的预期寿命。在临床情况下，最好的决定是对低风险患者进行血运重建，这些患者将活得足够长，可以从手术中受益，而对预期寿命较短的高风险患者进行药物治疗。然而，提供者和决策者发现很难确定动脉内膜切除术的短期风险以及中风或死亡的长期风险方面的关键变量来为这些决策提供信息。 可以利用健康IT来支持该医疗保健决策的两个关键方面：（1）通过使用详细的患者和手术变量（例如临床登记中存在的变量）进行短期手术风险分层，以及（2）纵向随访，以评估血运重建在患者剩余生命期间预防卒中的有效性。我们的小组已经证明，第一个组成部分可以使用来自区域登记处的真实的世界数据来建立，第二个组成部分可以通过使用行政索赔数据以广泛、具有成本效益的方式实现。 在本申请中，我们将开发和实施合并的临床登记和索赔健康IT工具，该工具将在门诊环境中支持无症状颈动脉疾病患者的临床决策。这种方法利用了登记研究中的临床详细信息，并从管理索赔中获得了完整的随访。具体而言，我们将：（1）使用合并的登记-索赔数据集识别哪些无症状患者可能接受不必要的颈动脉血运重建，并设计健康IT工具将这些发现传达给提供者，以及（2）确定与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。 该健康IT工具将识别最不可能从颈动脉血运重建术中受益的患者，并允许患者和提供者做出 在门诊环境中，关于医疗管理与血运重建的更明智的选择。这一工具还将通过血管外科学会血管质量倡议作为更广泛实施的模式，并将告知决策者通过减少不必要的护理来减少医疗保健支出的机会。

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.