Bahl Vinita, Moote Marc J, Hu Hsou Mei, Campbell Darrell A
Department of Surgery, University of Michigan Health Michigan Medicine, Ann Arbor, Michigan, United States.
Office of Clinical Affairs, University of Michigan Health Michigan Medicine, Ann Arbor, Michigan, United States.
TH Open. 2024 Sep 12;8(3):e317-e328. doi: 10.1055/s-0044-1790519. eCollection 2024 Jul.
Venous thromboembolism (VTE) causes significant preventable morbidity and mortality in hospitalized patients. Assessing VTE risk is essential to initiating appropriate prophylaxis and reducing VTE outcomes. Studies show that computerized clinical decision support (CDS) can improve VTE risk assessment (RA), prophylaxis, and outcomes but few examined the effectiveness of specific design features. From 2008 to 2016, University of Michigan Health implemented CDS for VTE prevention in four stages, which alternated between voluntary and mandatory RA using the 2005 Caprini model and generated inpatient orders for risk-appropriate prophylaxis based on CHEST guidelines. This cross-sectional study evaluated the impact of mandatory versus voluntary RA on VTE prophylaxis and outcomes for adult medical and surgical patients admitted to the health system. Interrupted time series analysis was conducted to evaluate the trend in smart order set-recommended VTE prophylaxis by CDS stage. Logistic regression with CDS stage as the primary independent variable was used in pairwise comparisons of VTE during hospitalization and within 90 days post-discharge for mandatory versus voluntary RA. Adjusted odd ratios (ORs) were calculated for total, in-hospital, and post-discharge VTE. In this study of 223,405 inpatients over 8 years, smart order set-recommended prophylaxis increased from 65 to 79%; it increased significantly when voluntary RA in Stage 1 became mandatory in Stage 2 (10.59%, < 0.001) and decreased significantly when it returned to voluntary in Stage 3 (-11.24%, < 0.001). The rate increased slightly when mandatory RA was reestablished in Stage 4 (0.23%, = 0.935). Adjusted ORs for VTE were lower for mandatory RA versus adjacent stages with voluntary RA. The adjusted OR for Stage 2 versus Stage 1 was 14% lower ( < 0.05) and versus Stage 3 was 11% lower ( < 0.05). The adjusted OR for Stage 4 versus Stage 3 was 4% lower ( = 0.60). These results were driven by changes in in-hospital VTE. By contrast, the incidence of post-discharge VTE increased in each successive stage. Mandatory RA was more effective in improving smart order set-recommended prophylaxis and VTE outcomes, particularly in-hospital VTE. Post-discharge VTE increased despite high adherence to risk-appropriate prophylaxis, indicating that guidelines for extended, post-discharge prophylaxis are needed to further reduce VTE for hospitalized patients.
静脉血栓栓塞症（VTE）在住院患者中导致了大量可预防的发病和死亡情况。评估VTE风险对于启动适当的预防措施和降低VTE后果至关重要。研究表明，计算机化临床决策支持（CDS）可以改善VTE风险评估（RA）、预防措施及后果，但很少有研究考察特定设计特征的有效性。2008年至2016年期间，密歇根大学健康系统分四个阶段实施了用于VTE预防的CDS，使用2005年卡普里尼模型在自愿和强制RA之间交替，并根据CHEST指南生成针对风险适宜预防措施的住院医嘱。这项横断面研究评估了强制与自愿RA对该健康系统收治的成年内科和外科患者VTE预防措施及后果的影响。
进行了中断时间序列分析，以评估按CDS阶段划分的智能医嘱集推荐的VTE预防措施的趋势。在对住院期间及出院后90天内强制与自愿RA的VTE进行成对比较时，使用以CDS阶段作为主要自变量的逻辑回归。计算了总体、住院期间和出院后VTE的调整比值比（OR）。
在这项对8年期间223,405名住院患者的研究中，智能医嘱集推荐的预防措施从65%增加到了79%；当第1阶段的自愿RA在第2阶段变为强制时，预防措施显著增加（10.59%，<0.001），而当在第3阶段恢复为自愿时显著下降（-11.24%，<0.001）。当在第4阶段重新建立强制RA时，该比率略有增加（0.23%，=0.935）。与相邻的自愿RA阶段相比，强制RA的VTE调整OR更低。第2阶段与第1阶段相比，调整OR低14%（<0.05），与第3阶段相比低11%（<0.05）。第4阶段与第3阶段相比，调整OR低4%（=0.60）。这些结果是由住院期间VTE的变化驱动的。相比之下，出院后VTE的发生率在每个连续阶段都有所增加。
强制RA在改善智能医嘱集推荐的预防措施和VTE后果方面更有效，尤其是在住院期间的VTE方面。尽管对风险适宜的预防措施有较高的依从性，但出院后VTE仍有所增加，这表明需要制定延长出院后预防措施的指南，以进一步降低住院患者的VTE发生率。
