用于 COVID-19 住院患者的血栓预防的通用临床决策支持工具：IMPROVE-DD 集群随机试验的事后分析。
Universal clinical decision support tool for thromboprophylaxis in hospitalized COVID-19 patients: post hoc analysis of the IMPROVE-DD cluster randomized trial.
机构信息
Northwell, New Hyde Park, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA; Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA.
Northwell, New Hyde Park, New York, USA; Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA.
出版信息
J Thromb Haemost. 2024 Nov;22(11):3172-3182. doi: 10.1016/j.jtha.2024.07.025. Epub 2024 Aug 14.
BACKGROUND
Inpatient and extended postdischarge thromboprophylaxis of COVID-19 patients remains suboptimal despite antithrombotic guidelines.
OBJECTIVES
To determine whether a novel electronic health record-agnostic clinical decision support (CDS) tool incorporating the International Medical Prevention Registry on Venous Thromboembolism plus D-dimer (IMPROVE-DD) venous thromboembolism (VTE) scores increases appropriate inpatient and extended postdischarge thromboprophylaxis and improves outcomes in COVID-19 inpatients.
METHODS
This post hoc analysis of the IMPROVE-DD cluster randomized trial evaluated thromboprophylaxis CDS among COVID-19 inpatients at 4 New York hospitals between December 21, 2020, and January 21, 2022. Hospitals were randomized 1:1 to CDS (intervention, n = 2) vs no CDS (usual care, n = 2). The primary outcome was rate of appropriate thromboprophylaxis. Secondary outcomes included rates of major thromboembolism, all-cause and VTE-related readmissions and death, major bleeding (MB), and all-cause mortality 30 days after discharge.
RESULTS
Two thousand four hundred fifty-two COVID-19 inpatients were analyzed (CDS, 1355; no CDS, 1097). Mean age was 73.7 ± 9.37 years; 50.1% of participants were male. CDS adoption was 96.8% (intervention group). CDS was associated with increased appropriate at-discharge extended thromboprophylaxis (42.6% vs 28.8%; odds ratio [OR], 1.83; 95% CI, 1.39-2.41; P < .001). CDS was associated with reduced VTE (OR, 0.54; 95% CI, 0.39-0.75; P < .001), arterial thromboembolism (OR, 0.10; 95% CI, 0.01-0.81; P = .01), total thromboembolism (OR, 0.50; 95% CI, 0.36-0.69; P < .001), and 30-day all-cause readmission/death (OR, 0.78; 95% CI, 0.62-0.99; P = .04). There were no differences in MB, VTE-related readmissions/death, or all-cause mortality.
CONCLUSION
Electronic health record-agnostic CDS incorporating IMPROVE-DD VTE scores had high adoption, was associated with increased appropriate at-discharge extended thromboprophylaxis, and reduced thromboembolism and all-cause readmission/death without increasing MB in COVID-19 inpatients.
背景
尽管有抗血栓治疗指南，但 COVID-19 患者的住院和延长出院后血栓预防仍然不理想。
目的
确定一种新的电子病历无关的临床决策支持 (CDS) 工具，该工具纳入了国际静脉血栓栓塞和 D-二聚体预防登记 (IMPROVE-DD) 静脉血栓栓塞 (VTE) 评分，是否能增加 COVID-19 住院患者的适当住院和延长出院后血栓预防，并改善患者结局。
方法
本项对 IMPROVE-DD 群组随机试验的事后分析评估了 4 家纽约医院 COVID-19 住院患者的血栓预防 CDS（2020 年 12 月 21 日至 2022 年 1 月 21 日）。医院 1:1 随机分配至 CDS（干预组，n=2）与无 CDS（常规护理组，n=2）。主要结局为适当的血栓预防率。次要结局包括主要血栓栓塞、全因和 VTE 相关再入院和死亡、大出血 (MB) 以及出院后 30 天的全因死亡率。
结果
共分析了 2452 例 COVID-19 住院患者（CDS 组 1355 例，无 CDS 组 1097 例）。平均年龄为 73.7±9.37 岁，50.1%的参与者为男性。CDS 的采用率为 96.8%（干预组）。与无 CDS 相比，CDS 与出院后延长的适当血栓预防增加相关（42.6% vs. 28.8%；优势比 [OR]，1.83；95%置信区间 [CI]，1.39-2.41；P<0.001）。CDS 与 VTE（OR，0.54；95%CI，0.39-0.75；P<0.001）、动脉血栓栓塞（OR，0.10；95%CI，0.01-0.81；P=0.01）、总血栓栓塞（OR，0.50；95%CI，0.36-0.69；P<0.001）以及 30 天全因再入院/死亡（OR，0.78；95%CI，0.62-0.99；P=0.04）的减少相关。在 MB、VTE 相关再入院/死亡或全因死亡率方面，两组间无差异。
结论
纳入 IMPROVE-DD VTE 评分的电子病历无关 CDS 的采用率高，与 COVID-19 住院患者出院后延长的适当血栓预防增加以及血栓栓塞和全因再入院/死亡减少相关，而不会增加 MB。
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