Patient-Centered approach to reducing harm from VTE

描述（由申请人提供）：静脉血栓栓塞（VTE）是医院发病率和死亡率的一个严重来源。肝素化学预防已被证明可以减少静脉血栓栓塞的发生，但它会增加出血的风险，而且接受它会感到不舒服。因此，静脉血栓栓塞预防应保留给静脉血栓栓塞中度至高风险和低出血风险的患者。然而，识别静脉血栓栓塞低风险患者可能很困难，因为大多数患者至少有一种静脉血栓栓塞的风险因素，而且在美国医院没有经过验证的风险预测工具。相反，许多医院选择了一种“一刀切”的方法，几乎普及了预防措施，使许多患者面临不必要的出血风险。然而，要提供真正以病人为中心的护理，美国医生面临着几个挑战。首先，没有公认的风险计算器，他们可以用来评估个人

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.