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创伤后深静脉血栓形成(DVT)的预测因素:医院实践与患者因素——一项对国家创伤数据库(NTDB)的分析

Predictors of posttraumatic deep vein thrombosis (DVT): hospital practice versus patient factors-an analysis of the National Trauma Data Bank (NTDB).

作者信息

Haut Elliott R, Chang David C, Pierce Charles A, Colantuoni Elizabeth, Efron David T, Haider Adil H, Cornwell Edward E, Pronovost Peter J

机构信息

Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.

出版信息

J Trauma. 2009 Apr;66(4):994-9; discussion 999-1001. doi: 10.1097/TA.0b013e3181991adc.

Abstract

OBJECTIVE

Trauma centers that perform more duplex ultrasounds report more deep vein thromboses (DVT). However, it is uncertain if this is due to variations in hospital practices or patient characteristics and case mix. We hypothesize that admission to trauma centers that use duplex ultrasound more frequently, independently predicts DVT reporting for individual patients, controlling for patient-level risk factors.

METHODS

We analyzed patients from trauma centers reporting at least one vascular ultrasound and one DVT to the National Trauma Data Bank (v6.2). Because National Trauma Data Bank contains no data on hospital duplex surveillance practice, we defined "screening" trauma centers as those performing ultrasound on more than 2% of patients. The primary outcome measure was DVT diagnosis. Multiple logistic regression was performed, using patient-level risk factor covariates as well as hospital duplex rate to compare patients at "screening" versus "non-screening" trauma centers. Sensitivity analysis was performed by varying duplex rate cutoff, outcome measure, and patient population.

RESULTS

Approximately half of 492,496 patients were admitted to "screening" trauma centers. Unadjusted DVT rate was threefold higher in "screening" trauma center patients (1.18% vs. 0.35%, p < 0.001). Age > or = 40 years, extremity injury, head injury, ventilator days > or = 3, venous injury and major surgery were independently associated with DVT diagnosis. "Screening" trauma center admission was independently associated with a higher likelihood of DVT reporting (odds ratio, 2.16; 95% confidence interval, 1.07-4.34). No qualitative differences were identified on sensitivity analyses.

CONCLUSIONS

Trauma center ultrasound practice is an independent predictor of DVT diagnosis for individual patients, controlling for patient-level risk factors. Elevated DVT rates at these centers are due to surveillance bias. In the absence of standardized surveillance, hospital DVT rate is an inappropriate quality of care measure after trauma.

摘要

目的

进行更多双功超声检查的创伤中心报告的深静脉血栓形成(DVT)病例更多。然而,尚不确定这是由于医院实践的差异还是患者特征和病例组合所致。我们假设,入住更频繁使用双功超声的创伤中心,在控制患者层面的风险因素后,能独立预测个体患者的DVT报告情况。

方法

我们分析了向国家创伤数据库(v6.2)报告至少一次血管超声检查和一次DVT的创伤中心的患者。由于国家创伤数据库没有关于医院双功超声监测实践的数据,我们将“筛查”创伤中心定义为对超过2%的患者进行超声检查的中心。主要结局指标是DVT诊断。进行了多因素逻辑回归分析,使用患者层面的风险因素协变量以及医院双功超声检查率,比较“筛查”与“非筛查”创伤中心的患者。通过改变双功超声检查率的临界值、结局指标和患者群体进行敏感性分析。

结果

在492496例患者中,约一半入住“筛查”创伤中心。“筛查”创伤中心患者未调整的DVT发生率高出三倍(1.18%对0.35%,p<0.001)。年龄≥40岁、肢体损伤、头部损伤、机械通气天数≥3天、静脉损伤和大手术与DVT诊断独立相关。入住“筛查”创伤中心与更高的DVT报告可能性独立相关(比值比,2.16;95%置信区间,1.07 - 4.34)。敏感性分析未发现定性差异。

结论

创伤中心的超声检查实践是个体患者DVT诊断的独立预测因素,可控制患者层面的风险因素。这些中心DVT发生率升高是由于监测偏倚。在缺乏标准化监测的情况下,创伤后医院的DVT发生率是不适当的医疗质量衡量指标。

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