BMC Med Inform Decis Mak - Effectiveness of a novel and scalable clinical decision support intervention to improve venous thromboembolism prophylaxis: a quasi-experimental study.

Tópicos

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Resumo

CKGROUND: Venous thromboembolism (VTE) causes morbidity and mortality in hospitalized patients, and regulators and payors are encouraging the use of systems to prevent them. Here, we examine the effect of a computerized clinical decision support (CDS) intervention implemented across a multi-hospital academic health system on VTE prophylaxis and events.METHODS: The study included 223,062 inpatients admitted between April 2007 and May 2010, and used administrative and clinical data. The intervention was integrated into a commercial electronic health record (EHR) in an admission orderset used for all admissions. Three time periods were examined: baseline (period 1), and the time after implementation of the first CDS intervention (period 2) and a second iteration (period 3). Providers were prompted to accept or decline prophylaxis based on patient risk. Time series analyses examined the impact of the intervention on VTE prophylaxis during time periods two and three compared to baseline, and a simple pre-post design examined impact on VTE events and bleeds secondary to anticoagulation. VTE prophylaxis and events were also examined in a prespecified surgical subset of our population meeting the public reporting criteria defined by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI).RESULTS: Unadjusted analyses suggested that "recommended", "any", and "pharmacologic" prophylaxis increased from baseline to the last study period (27.1% to 51.9%, 56.7% to 78.1%, and 42.0% to 54.4% respectively; p<0.01 for all comparisons). Results were significant across all hospitals and the health system overall. Interrupted time series analyses suggested that our intervention increased the use of "recommended" and "any" prophylaxis by 7.9% and 9.6% respectively from baseline to time period 2 (p<0.01 for both comparisons); and 6.6% and 9.6% respectively from baseline to the combined time periods 2 and 3 (p<0.01 for both comparisons). There were no significant changes in "pharmacologic" prophylaxis in the adjusted model. The overall percent of patients with VTE increased from baseline to the last study period (2.0% to 2.2%; p=0.03), but an analysis excluding patients with VTE "present on admission" (POA) demonstrated no difference in events (1.3% to 1.3%; p=0.80). Overall bleeds did not significantly change. An analysis examining VTE prophylaxis and events in a surgical subset of patients defined by the AHRQ PSI demonstrated increased "recommended", "any", and "pharmacologic" prophylaxis from baseline to the last study period (32.3% to 60.0%, 62.8% to 85.7%, and 47.9% to 63.3% respectively; p<0.01 for all comparisons) as well as reduced VTE events (2.2% to 1.7%; p<0.01).CONCLUSIONS: The CDS intervention was associated with an increase in "recommended" and "any" VTE prophylaxis across the multi-hospital academic health system. The intervention was also associated with increased VTE rates in the overall study population, but a subanalysis using only admissions with appropriate POA documentation suggested no change in VTE rates, and a prespecified analysis of a surgical subset of our sample as defined by the AHRQ PSI for public reporting purposes suggested reduced VTE. This intervention was created in a commonly used commercial EHR and is scalable across institutions with similar systems.

Resumo Limpo

ckground venous thromboembol vte caus morbid mortal hospit patient regul payor encourag use system prevent examin effect computer clinic decis support cds intervent implement across multihospit academ health system vte prophylaxi eventsmethod studi includ inpati admit april may use administr clinic data intervent integr commerci electron health record ehr admiss orderset use admiss three time period examin baselin period time implement first cds intervent period second iter period provid prompt accept declin prophylaxi base patient risk time seri analys examin impact intervent vte prophylaxi time period two three compar baselin simpl prepost design examin impact vte event bleed secondari anticoagul vte prophylaxi event also examin prespecifi surgic subset popul meet public report criteria defin agenc healthcar research qualiti ahrq patient safeti indic psiresult unadjust analys suggest recommend pharmacolog prophylaxi increas baselin last studi period respect p comparison result signific across hospit health system overal interrupt time seri analys suggest intervent increas use recommend prophylaxi respect baselin time period p comparison respect baselin combin time period p comparison signific chang pharmacolog prophylaxi adjust model overal percent patient vte increas baselin last studi period p analysi exclud patient vte present admiss poa demonstr differ event p overal bleed signific chang analysi examin vte prophylaxi event surgic subset patient defin ahrq psi demonstr increas recommend pharmacolog prophylaxi baselin last studi period respect p comparison well reduc vte event pconclus cds intervent associ increas recommend vte prophylaxi across multihospit academ health system intervent also associ increas vte rate overal studi popul subanalysi use admiss appropri poa document suggest chang vte rate prespecifi analysi surgic subset sampl defin ahrq psi public report purpos suggest reduc vte intervent creat common use commerci ehr scalabl across institut similar system

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