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Abstract

Background: All hospitalized patients should be assessed for venous thromboembolism (VTE) risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacological prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen. Objectives: The objective of the study was to examine the effect of a quality improvement intervention on race-based and sex-based health care disparities across 2 distinct clinical services. Research design: This was a retrospective cohort study of a quality improvement intervention. Subjects: The study included 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients. Measures: In this study, the proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis was evaluated. Results: Racial disparities existed in prescription of best-practice VTE prophylaxis in the preimplementation period between black and white patients on both the trauma (70.1% vs. 56.6%, P=0.025) and medicine (69.5% vs. 61.7%, P=0.015) services. After implementation of the CCDS tool, compliance improved for all patients, and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, P=0.99) and medicine (91.8% vs. 88.0%, P=0.082). Similar findings were noted for sex disparities in the trauma cohort. Conclusions: Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and sex, practice varied widely before our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across 2 distinct clinical services. Health information technology approaches to care standardization are effective to eliminate health care disparities.

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... Authors reported whether sex and/or gender differences may be expected in introduction 2 (9) [40,43] Authors ensured adequate representation of males and females in methods sections 3 (14) [44,45,47] Methods section included variables/information that enabled a gender-based analysis 9 (40) [27,32,34,36,39,40,44,46,47] Authors discussed sex differences or apply a gender perspective in discussion 5 (23) [31,38,40,44,47] Authors discussed the implications of the results from a gender perspective. 6 (27) [31,32,34,42,43,47] since the 90s, our scoping review has shown that few studies have tried to tackle this bias. ...
... Authors reported whether sex and/or gender differences may be expected in introduction 2 (9) [40,43] Authors ensured adequate representation of males and females in methods sections 3 (14) [44,45,47] Methods section included variables/information that enabled a gender-based analysis 9 (40) [27,32,34,36,39,40,44,46,47] Authors discussed sex differences or apply a gender perspective in discussion 5 (23) [31,38,40,44,47] Authors discussed the implications of the results from a gender perspective. 6 (27) [31,32,34,42,43,47] since the 90s, our scoping review has shown that few studies have tried to tackle this bias. ...
... Authors reported whether sex and/or gender differences may be expected in introduction 2 (9) [40,43] Authors ensured adequate representation of males and females in methods sections 3 (14) [44,45,47] Methods section included variables/information that enabled a gender-based analysis 9 (40) [27,32,34,36,39,40,44,46,47] Authors discussed sex differences or apply a gender perspective in discussion 5 (23) [31,38,40,44,47] Authors discussed the implications of the results from a gender perspective. 6 (27) [31,32,34,42,43,47] since the 90s, our scoping review has shown that few studies have tried to tackle this bias. ...
... [18,19] Over a decade, a multidisciplinary VTE Collaborative implemented a variety of interventions to optimize the prescription and delivery of risk-appropriate VTE prophylaxis. [20] They demonstrated that implementation of a computer clinical decision support tool eliminated race and sex-based disparities in VTE prophylaxis prescription, [21,22] and was an unintended consequence, or "halo effect," [23] of applying quality improvement strategies to optimize care for all patients. While these interventions improved prescription of risk-appropriate VTE prophylaxis, [21,24,25] they discovered that prescribed doses were not reliably administered to patients, [26,27] contributing to the development of potentially preventable VTE events. ...
... Quality improvement efforts and initiatives have skyrocketed nationwide for well over a decade. While we used quality improvement to explore and eliminate disparities, [22] we did not find other groups who examined the differential effect of race on their study findings. Moving forward, we suggest that all quality improvement initiatives be rigorously examined to ensure there is no differential effect by race, and other demographics such as age, sex, gender, and ethnicity, as appropriate. ...
... Moving forward, we suggest that all quality improvement initiatives be rigorously examined to ensure there is no differential effect by race, and other demographics such as age, sex, gender, and ethnicity, as appropriate. [22] While some may say that this is a negative study, we still see benefit in objectively studying and publishing these types of data to ensure quality improvement efforts do not inadvertently worsen health disparities. ...
Article
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Background Racial disparities are common in healthcare. Venous thromboembolism (VTE) is a leading cause of preventable harm, and disparities observed in prevention practices. We examined the impact of a patient-centered VTE education bundle on the non-administration of preventive prophylaxis by race. Methods A post-hoc, subset analysis (stratified by race) of a larger nonrandomized trial. Pre-post comparisons analysis were conducted on 16 inpatient units; study periods were October 2014 through March 2015 (baseline) and April through December 2015 (post-intervention). Patients on 4 intervention units received the patient-centered, nurse educator-led intervention if the electronic health record alerted a non-administered dose of VTE prophylaxis. Patients on 12 control units received no intervention. We compared the conditional odds of non-administered doses of VTE prophylaxis when patient refusal was a reason for non-administration, stratified by race. Results Of 272 patient interventions, 123 (45.2%) were white, 126 (46.3%) were black, and 23 (8.5%) were other races. A significant reduction was observed in the odds of non-administration of prophylaxis on intervention units compared to control units among patients who were black (OR 0.61; 95% CI, 0.46–0.81, p<0.001), white (OR 0.57; 95% CI, 0.44–0.75, p<0.001), and other races (OR 0.50; 95% CI, 0.29–0.88, p = 0.015). Conclusion Our finding suggests that the patient education materials, developed collaboratively with a diverse group of patients, improved patient’s understanding and the importance of VTE prevention through prophylaxis. Quality improvement interventions should examine any differential effects by patient characteristics to ensure disparities are addressed and all patients experience the same benefits.
... The evidentiary table (Table 1) outlines the characteristics of the included studies and their outcomes. Of the 32 included studies, 3 were randomized controlled trials, 8,50,52 3 retrospective cohort studies, 7,18,36 18 pre-post studies, 12,13,15,16,19,20,33,35,37,[39][40][41][42][43][44][45][46][47][48][49] and 5 time series studies. 17,23,32,34,38 Six were conducted before 2010 7,32,39,41,48,49 and 12 within the past 3 years. ...
... 17,23,32,34,38 Six were conducted before 2010 7,32,39,41,48,49 and 12 within the past 3 years. 12,15,16,18,[33][34][35][36]38,46,47,50 The majority (n ¼ 29) were conducted in the United States, with the remaining conducted in Taiwan (n ¼ 1), 13 Korea (n ¼ 1), 48 and Israel (n ¼ 1). 41 Most (n ¼ 26) were conducted in the hospital setting at single-institution, academic medical centers. ...
... Two were conducted at a Veterans Affairs hospital 35,43 and 4 in a multipractice primary care setting. 15,41,44,49 Fourteen studies targeted inpatient medicine, 7,8,12,13,16,18,23,32,34,37,40,[45][46][47][48] 4 emergency medicine, 20,38,39,43 5 primary care, 13,41,44,49,51 3 anesthesia, 17,36,52 and 2 pediatrics 23,33 with the remainder targeting diverse specialties. Common clinical topics included venous thromboembolism (VTE) prophylaxis (n ¼ 4), 37,40,45,47 drug-drug or drug-allergy interactions (n ¼ 4), 7,8,49,53 reducing low-yield imaging (n ¼ 3), 44,50,51 and use of pulmonary CT angiography (CTA) for pulmonary embolism (n ¼ 2). ...
Article
Objective: Clinical decision support (CDS) hard-stop alerts-those in which the user is either prevented from taking an action altogether or allowed to proceed only with the external override of a third party-are increasingly common but can be problematic. To understand their appropriate application, we asked 3 key questions: (1) To what extent are hard-stop alerts effective in improving patient health and healthcare delivery outcomes? (2) What are the adverse events and unintended consequences of hard-stop alerts? (3) How do hard-stop alerts compare to soft-stop alerts? Methods and materials: Studies evaluating computerized hard-stop alerts in healthcare settings were identified from biomedical and computer science databases, gray literature sites, reference lists, and reviews. Articles were extracted for process outcomes, health outcomes, unintended consequences, user experience, and technical details. Results: Of 32 studies, 15 evaluated health outcomes, 16 process outcomes only, 10 user experience, and 4 compared hard and soft stops. Seventy-nine percent showed improvement in health outcomes and 88% in process outcomes. Studies reporting good user experience cited heavy user involvement and iterative design. Eleven studies reported on unintended consequences including avoidance of hard-stopped workflow, increased alert frequency, and delay to care. Hard stops were superior to soft stops in 3 of 4 studies. Conclusions: Hard stops can be effective and powerful tools in the CDS armamentarium, but they must be implemented judiciously with continuous user feedback informing rapid, iterative design. Investigators must report on associated health outcomes and unintended consequences when implementing IT solutions to clinical problems.
... [24][25][26] Haut et al also showed that implementation of a computer-based VTE protocol can help reduce disparities. 25,27 The persistence in these disparities across race, even in the era of electronic medical records and computerized physician tools, suggests that additional proactive efforts are needed. Nevertheless, the potential to bypass these prompts introduces the possibility of provider bias. ...
... than white patients (56.6%) (P = .025). 27 Guidelines for preventing hospital-associated venous thromboembolism across all medical specialties have included increased computerized order support systems to ensure appropriate administration. 35,36 However, in trauma patients, the decision regarding when to start VTE prophylaxis is often more nuanced given the concern for hemorrhage. ...
Article
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Background Race is associated with differences in quality of care process measures and incidence of venous thromboembolism (VTE) in trauma patients. We aimed to investigate if racial disparities exist in the administration of VTE prophylaxis in trauma patients. Methods We queried the Trauma Quality Improvement Project database from 2017 to 2019. Patients ages ≥16 years old with ISS ≥15 were included. Patients with no signs of life on arrival, any AIS ≥6, hospital length of stay <1 day, anticoagulant use before admission, or without recorded race were excluded. Patients were grouped by race: white, black, Asian, American Indian, and Native Hawaiian or Pacific Islander. The association between VTE prophylaxis administration and race was determined using a Poisson regression model with robust standard errors to adjust for confounders. Results A total of 285,341 patients were included. Black patients had the highest rates of VTE prophylaxis exposure (73.8%), shortest time to administration (1.6 days), and highest use of low molecular weight heparin (56%). Black patients also had the highest incidence of deep vein thrombosis (2.8%) and pulmonary embolism (1.4%). Black patients were 4% more likely to receive VTE prophylaxis than white patients [adj. IRR (95% CI): 1.04 (1.03-1.05), P < .001]. American Indians were 8% less likely to receive VTE prophylaxis [adj. IRR (95% CI): .92 (.88-.97), P < .001] than white patients. No differences between white and Asian or Native Hawaiian or Pacific Islander patients existed. Discussion While black patients had the highest incidence of DVT and PE, they had higher administration rates and earlier initiation of VTE prophylaxis. Further work can elucidate modifiable causes of these differences.
... Indeed, surgeons have estimated similar comorbidities to be more severe in Black patients than in White patients, and Black patients have been offered aggressive treatment less often than White patients with equivalent indications. 15,20,31,32,33,34,35,36 Because of the association between race and socioeconomic status, a surgeon might assess angina in a well-dressed, upper-middle-class White man differently than in a Black man experiencing housing insecurity with a medically equivalent condition. Similarly, chronic obstructive pulmonary disease of equal severity may look very different in a White woman who was driven to the consultation than in a Black woman who took public transportation and then walked several blocks to reach the surgeon's office. ...
... 51,52 In other settings, standardizing clinical decisions and postoperative pathways has been shown to reduce racial disparities among surgical patients. 33,53,54,55 Second, the system would not be affected by concern for reported outcome metrics that might otherwise bias surgical judgment. Finally, the system could track not only the patients accepted for surgery but also those declined for surgery, thus providing a mechanism for recognizing biased trends. ...
Article
Many regard iatrogenic injuries as consequences of diagnosis or intervention actions. But inaction-not offering indicated major surgery-can also result in iatrogenic injury. This article explores some surgeons' overestimations of operative risk based on patients' race and socioeconomic status as unduly influential in their decisions about whether to perform major cancer or cardiac surgery on some patients with appropriate clinical indications. This article also considers artificial intelligence and machine learning-based clinical decision support systems that might offer more accurate, individualized risk assessment that could make patient selection processes more equitable, thereby mitigating racial and ethnic inequity in cancer and cardiac disease.
... Implementation of the ERP significantly reduced pLOS for both black and white patients in the VA hospital system without increasing complications, suggesting that interventions that improve the consistency of care by standardizing protocols may reduce variations in observed outcomes based on race. Lau and colleagues demonstrated this concept in addressing racial disparities in venous thromboembolism prophylaxis on a trauma service in which black and white patients received standard care 56.6% and 70.1% of the time, respectively [29]. Following standardization of venous thromboembolism prophylaxis choices, racial disparities were eliminated [29]. ...
... Lau and colleagues demonstrated this concept in addressing racial disparities in venous thromboembolism prophylaxis on a trauma service in which black and white patients received standard care 56.6% and 70.1% of the time, respectively [29]. Following standardization of venous thromboembolism prophylaxis choices, racial disparities were eliminated [29]. Like ERP, this pathway followed evidence-based algorithms to guide physicians in clinical management demonstrating that when care was applied to all patients in the same manner, the results were the same for all patients [14]. ...
Article
Full-text available
Background Enhanced Recovery Pathways (ERP) have been shown to reduce racial disparities following surgery. The objective of this study is to determine whether ERP implementation mitigates racial disparities at a Veterans Affairs Hospital. Methods A retrospective cohort study was conducted using data obtained from the Veterans Affairs Surgical Quality Improvement Program. All patients undergoing elective colorectal surgery following ERP implementation were included. Current procedural terminology (CPT) codes were used to identify patients who underwent similar procedures prior to ERP implementation. Results Our study included 417 patients (314 pre-ERP vs. 103 ERP), 97.1% of which were male, with an average age of 62.32 (interquartile range (IQR): 25–90). ERP patients overall had a significantly shorter post-operative length of stay (pLOS) vs. pre-ERP patients (median 4 days (IQR: 3–6.5) vs. 6 days (IQR: 4–9) days (p < 0.001)). Within the pre-ERP group, median pLOS for both races was 6 days (IQR: 4–6; p < 0.976) and both groups experienced a decrease in median pLOS (4 vs. 6 days; p < 0.009 and p < 0.001) following ERP implementation. Conclusions Racial disparities did not exist in patients undergoing elective surgery at a single VA Medical Center. Implementation of an ERP significantly reduced pLOS for black and white patients.
... By creating automatic systems that collect data including race/ethnicity, income, zip code, and insurance status, it provides opportunities for quality improvement methods to address healthcare gaps. The use of clinical decision support tools has been successfully used to identified clinician level disparities and form a basis for action on objective criteria [29,30]. For example, an observational study found racial disparities in VTE prophylaxis among hospitalized trauma patients and after implementing a clinical decision-based support tool, rates of VTE improved and gaps were eliminated [29]. ...
... The use of clinical decision support tools has been successfully used to identified clinician level disparities and form a basis for action on objective criteria [29,30]. For example, an observational study found racial disparities in VTE prophylaxis among hospitalized trauma patients and after implementing a clinical decision-based support tool, rates of VTE improved and gaps were eliminated [29]. ...
Article
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Purpose of Review Examine the state of health disparities among trauma patients and review the current evidence on disparity interventions. Recent Findings Successful interventions to address disparity among trauma patients include increasing trauma care accessibility in high demand locations, expansion of healthcare insurance, disrupting local and systemic practice through quality improvement frameworks, and identifying social drivers of health. Summary Geography, race, ethnicity, income, and health insurance coverage continue to account for disparate health outcomes among trauma victims. These outcomes include healthcare accessibility, in-hospital mortality, and access to rehabilitative care among others. Current interventions to address these disparities are focused on improving healthcare accessibility, including specialized trauma centers, interrupting local practice, and understanding the role social determinants of health play into outcomes. Future research is needed to identify unmeasured determinants of health while continuing to address disparity at a healthcare level.
... Although men in the general population have a higher risk of VTE recurrence than women, this risk differs by race, with Black and Latina women having a higher recurrence risk of VTE than white women in the USA 234 . For primary prevention of VTE, a US hospital-based project showed that care standardization through implementation of a mandatory computerized clinical decision support tool eliminated disparities in the use of VTE anticoagulation prophylaxis 235 . Also in the USA, Black individuals with VTE were fivefold more likely to experience complications of care after hospitalization for a VTE, including readmission, bleeding and death, than white individuals 236,237 . ...
Article
Venous thromboembolism, that consists of the interrelated conditions deep-vein thrombosis and pulmonary embolism, is an under-appreciated vascular disease. In Western regions, approximately 1 in 12 individuals will be diagnosed with venous thromboembolism in their lifetime. Rates of venous thromboembolism are lower in Asia, but data from other regions are sparse. Numerous risk factors for venous thromboembolism have been identified, which can be classified as acute or subacute triggers (provoking factors that increase the risk of venous thromboembolism) and basal or acquired risk factors (which can be modifiable or static). Approximately 20% of individuals who have a venous thromboembolism event die within 1 year (although often from the provoking condition), and complications are common among survivors. Fortunately, opportunities exist for primordial prevention (prevention of the development of underlying risk factors), primary prevention (management of risk factors among individuals at high risk of the condition) and secondary prevention (prevention of recurrent events) of venous thromboembolism. In this Review, we describe the epidemiology of venous thromboembolism, including the incidence, risk factors, outcomes and opportunities for prevention. Meaningful health disparities exist in both the incidence and outcomes of venous thromboembolism. We also discuss these disparities as well as opportunities to reduce them.
... In addition, we implemented the interventions as part of an overarching strategy at our institution, which already has a computerized clinical decision support tool that stratifies patients by major risk categories and has improved prescription of risk-appropriate VTE prophylaxis. 7,8,28,43 Our targeted alert approach is supported by previous research that recommends reducing unneeded electronic alert interventions to mitigate alert fatigue. 44,45 This dissemination study relied on nurses' endorsement and welcoming of the intervention into routine clinical practice. ...
Article
Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster‐randomized controlled trial, all adult non–intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real‐time, electronic alert–triggered, patient‐centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre‐ versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57–0.71]). Nonadministration decreased significantly ( P <0.001) in both arms: patient‐centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48–0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62–0.84]). Patient refusal decreased significantly in both arms: patient‐centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37–0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59–0.86]). No differential effect occurred on medical versus surgical units. The patient‐centered education bundle was significantly more effective in reducing all nonadministered ( P =0.03) and refused doses ( P =0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0–1.61]; P =0.03 for interaction). Conclusions Information technology strategies like the alert‐triggered, targeted patient‐centered education bundle, and nurse‐focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03367364.
... The use of health information technologies for integration into the EHR and clinical workflow facilitates sustainment (54, 55) (leveraging contextual resources). EHR-based algorithms are important for improving equitable implementation (27) because quantification reduces reliance on social stereotyping (56). For example, the use of computer adaptive testing for precise, brief irritability screening and generation of a predictive algorithm to guide decision-making would enhance provider motivation and reduce cognitive burden (57). ...
Article
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Translation of developmental science discoveries is impeded by numerous barriers at different stages of the research-to-practice pipeline. Actualization of the vast potential of the developmental sciences to improve children's health and development in the real world is imperative but has not yet been fully realized. In this commentary, we argue that an integrated developmental-implementation sciences framework will result in a translational mindset essential for accelerating real world impact. We delineate key principles and methods of implementation science of salience to the developmental science audience, lay out a potential synthesis between implementation and developmental sciences, provide an illustration of the Mental Health, Earlier Partnership (MHE-P), and set actionable steps for realization. Blending these approaches along with wide-spread adoption of the translational mindset has transformative potential for population-level impact of developmental science discovery.
... There is reassuring research championing the use of education and clinical decision support tools. After conducting a literature review, studies demonstrated that utilizing a computerized alert was linked to a statistically significant decrease in inappropriate medication prescribing, especially with added education and training (Smith et al., 2014;Faine et al., 2015;Lau et al., 2014;Gupta, 2014;Niehoff et al., 2016). Evidence suggests that tailoring the electronic alert to a specific audience and allowing users to provide feedback improves overall compliance and effectiveness (Niehoff et al., 2016). ...
Article
Older adults frequently experience delirium after surgery, contributing to a decline in quality of life, increasing morbidity and mortality rates, and adding significant costs to the healthcare system. The Beers Criteria was developed by the American Geriatrics Society and lists medications correlated with a decline in cognition among older adults. These medications are commonly administered in the perioperative period by anesthesia practitioners. At a large university hospital, an educational video was distributed, followed by the launch of an electronic health record alert advising over 300 anesthesia practitioners to reduce dosing or omit Beers Criteria medications in patients aged 70 or older. The total administration and total mean dosage of Beers Criteria medications administered were measured across four study periods: pre-educational video/pre-alert, post-education/pre-alert, and at two post-education/post-alert time points in select surgeries. This quality improvement project demonstrated significant reduction in Beers Criteria medications administered to patients 70 years or older to reduce rates of cognitive decline.
... Constructs not already assessed could likely be added with relatively little additional burden to mental health clinicians and clients. An additional advantage of making the DRS part of routine practice is that mandatory checklists have been shown to increase the occurrence of risk-appropriate treatment while simultaneously decreasing healthcare disparities [73]. Notably, there are documented disparities in the application of mental health and suicide risk assessments [74] that could potentially be eliminated with a DRS-based clinical decision support model. ...
Article
Full-text available
Background Worldwide, nearly 800,000 individuals die by suicide each year; however, longitudinal prediction of suicide attempts remains a major challenge within the field of psychiatry. The objective of the present research was to develop and evaluate an evidence-based suicide attempt risk checklist [i.e., the Durham Risk Score (DRS)] to aid clinicians in the identification of individuals at risk for attempting suicide in the future. Methods and findings Three prospective cohort studies, including a population-based study from the United States [i.e., the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study] as well as 2 smaller US veteran cohorts [i.e., the Assessing and Reducing Post-Deployment Violence Risk (REHAB) and the Veterans After-Discharge Longitudinal Registry (VALOR) studies], were used to develop and validate the DRS. From a total sample size of 35,654 participants, 17,630 participants were selected to develop the checklist, whereas the remaining participants ( N = 18,024) were used to validate it. The main outcome measure was future suicide attempts (i.e., actual suicide attempts that occurred after the baseline assessment during the 1- to 3-year follow-up period). Measure development began with a review of the extant literature to identify potential variables that had substantial empirical support as longitudinal predictors of suicide attempts and deaths. Next, receiver operating characteristic (ROC) curve analysis was utilized to identify variables from the literature review that uniquely contributed to the longitudinal prediction of suicide attempts in the development cohorts. We observed that the DRS was a robust prospective predictor of future suicide attempts in both the combined development (area under the curve [AUC] = 0.91) and validation (AUC = 0.92) cohorts. A concentration of risk analysis found that across all 35,654 participants, 82% of prospective suicide attempts occurred among individuals in the top 15% of DRS scores, whereas 27% occurred in the top 1%. The DRS also performed well among important subgroups, including women (AUC = 0.91), men (AUC = 0.93), Black (AUC = 0.92), White (AUC = 0.93), Hispanic (AUC = 0.89), veterans (AUC = 0.91), lower-income individuals (AUC = 0.90), younger adults (AUC = 0.88), and lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) individuals (AUC = 0.88). The primary limitation of the present study was its its reliance on secondary data analyses to develop and validate the risk score. Conclusions In this study, we observed that the DRS was a strong predictor of future suicide attempts in both the combined development (AUC = 0.91) and validation (AUC = 0.92) cohorts. It also demonstrated good utility in many important subgroups, including women, men, Black, White, Hispanic, veterans, lower-income individuals, younger adults, and LGBTQ individuals. We further observed that 82% of prospective suicide attempts occurred among individuals in the top 15% of DRS scores, whereas 27% occurred in the top 1%. Taken together, these findings suggest that the DRS represents a significant advancement in suicide risk prediction over traditional clinical assessment approaches. While more work is needed to independently validate the DRS in prospective studies and to identify the optimal methods to assess the constructs used to calculate the score, our findings suggest that the DRS is a promising new tool that has the potential to significantly enhance clinicians’ ability to identify individuals at risk for attempting suicide in the future.
... 13,14 A clinical decision support (CDS) tool can help surmount these barriers and therefore would be beneficial in reducing the known disparities in AC use and outcomes and improve AC initiation and persistence. [15][16][17] In our previous work, we explored the role of provider e-mail messaging, in-basket messaging, and educational outreach and its effects on rates of AC prescription. We found that it was possible to reach providers and saw an improvement in patient comfort with AC prescription, but no significant increase in AC prescription. ...
Article
Full-text available
Background Six million Americans suffer from atrial fibrillation (AF), a heart rhythm abnormality that significantly increases the risk of stroke. AF is responsible for 15% of ischemic strokes, which lead to permanent disability in 60% of cases and death in up to 20%. Anticoagulation (AC) is the mainstay for stroke prevention in patients with AF. Despite guidelines recommending AC for patients, up to half of eligible patients are not on AC. Clinical decision support tools in the electronic health record (EHR) can help bridge the disparity in AC prescription for patients with AF. Objective To enhance and assess the effectiveness of our previous rule-based alert on AC initiation and persistence in a diverse patient population from UMass-Memorial Medical Center and University of Florida at Jacksonville. Methods Using the EHR, we will track AC initiation and persistence. We will interview both patients and providers to determine a measure of satisfaction with AC management. We will track digital crumbs to better understand the alert’s mechanism of effect and further add enhancements. These enhancements will be used to refine the alert and aid in developing an implementation toolkit to facilitate use of the alert at other health systems. Conclusion If the number of AC starts, the likelihood of persisting on AC, and the frequency alert use are found to be higher among intervention vs control providers, we believe such findings will confirm our hypothesis on the effectiveness of our alert.
... Research in adult populations demonstrated that a pathway with computerized clinical decision support was effective at reducing disparities. 32 Health information technology approaches should be explored to standardize pediatric care in the ED setting, along with other QI approaches utilizing a health equity lens. ...
Article
Background Acute gastroenteritis (AGE) is a common pediatric diagnosis in emergency medicine, accounting for 1.7 million visits annually. Little is known about racial/ethnic differences in care in the setting of standardized care models. Methods We used quality improvement data for children 6 months to 18 years presenting to a large, urban pediatric emergency department (ED) treated via a clinical pathway for AGE/dehydration between 2011 and 2018. Race/ethnicity was evaluated as a single variable (non‐Hispanic [NH]‐White, NH‐Black, Hispanic, and NH‐other) related to ondansetron and intravenous fluid (IVF) administration, ED length of stay (LOS), hospital admission, and ED revisits using multivariable regression. Results Of 30,849 ED visits for AGE/dehydration, 18.0% were NH‐White, 57.2% NH‐Black, 12.5% Hispanic, and 12.3% NH‐other. Multivariable mixed‐effects generalized linear regression controlling for age, sex, triage acuity, payor, and language revealed that, compared to NH‐White patients, NH‐other patients were more likely to receive ondansetron (aOR [95% CI] 1.30 [1.17, 1.43]). NH‐Black, Hispanic, and NH‐other patients were significantly less likely to receive IVF (0.59 [0.53, 0.65]; 0.74 [0.64, 0.84]; 0.74 [0.65, 0.85]) or be admitted to the hospital (0.54 [0.45, 0.64]; 0.62 [0.49, 0.78]; 0.76 [0.61, 0.94]), respectively. NH‐Black and Hispanic patients had shorter LOS (median 245 minutes for NH‐White, 176 NH‐Black, 199 Hispanic, and 203 NH‐other patients) without significant differences in ED revisits. Conclusions Despite the presence of a clinical pathway to guide care, NH‐Black, Hispanic, and NH‐other children presenting to the ED with AGE/dehydration were less likely to receive IVF or hospital admission and had shorter LOS compared to NH‐White counterparts. There was no difference in patient revisits which suggests discretionary overtreatment of NH‐White patients, even with clinical guidelines in place. Further research is needed to understand the drivers of differences in care to develop interventions promoting equity in pediatric emergency care.
... 56 In another study, Black patients were less often given VTE pharmacoprophylaxis in hospital. 57 Thus, socioeconomic and race/ethnic disparities, including structural racism, warrant due consideration in strategies of primary prevention of unprovoked VTE. ...
Article
Venous thromboembolism (VTE) is an important vascular disease and public health problem. Prevention of VTE has focused mainly on using thromboprophylaxis to avoid provoked VTE or recurrent VTE, with little attention paid to the possibility of preventing the one third to one half of VTEs that are unprovoked. We review growing research suggesting that unhealthy lifestyle risk factors may cause a considerable proportion of unprovoked VTE. Using epidemiologic data to calculate population attributable risks, we estimate that in the United States obesity may contribute to 30% of VTEs, physical inactivity to 4%, current smoking to 3%, and Western dietary pattern to 11%. We also review possibilities for VTE primary prevention either through a high‐risk individual approach or a population‐wide approach. Interventions for outpatients at high VTE risk but without VTE provoking factors have not been fully tested; yet, improving patient awareness of risk and symptoms, lifestyle counseling, and possibly statins or direct oral anticoagulants may prove useful in primary prevention of unprovoked VTE. A population approach to prevention would bolster awareness of VTE and aim to shift lifestyle risk factors downward in the whole population using education, environmental changes, and policy. Assuming the epidemiological associations are accurate, causal, and independent of each other, a reduction of obesity, physical inactivity, current smoking, and Western diet by 25% in the general population might reduce the incidence of unprovoked VTE by 12%. We urge further research and consideration that primary prevention of unprovoked VTE may be a worthwhile public health aim.
... Implementation of a CDSS significantly improved provision of compliant VTE prophylaxis and eliminated disparities in provision. 170 The Johns Hopkins model was subsequently implemented at the University of Virginia as a mandatory CDSS embedded into the online order entry system for patients undergoing general surgery. Implementation of the CDSS was associated with a significant decrease in 30-day VTE (1.25% versus 0.64%; P=0.033) and allowed the institution to improve its ranking for VTE from the ninth to first decile among 760 hospitals participating in the National Surgical Quality Improvement Program. ...
Article
Venous thromboembolism (VTE) is a major preventable disease that affects hospitalized inpatients. Risk stratification and prophylactic measures have good evidence supporting their use, but multiple reasons exist that prevent full adoption, compliance, and efficacy that may underlie the persistence of VTE over the past several decades. This policy statement provides a focused review of VTE, risk scoring systems, prophylaxis, and tracking methods. From this summary, 5 major areas of policy guidance are presented that the American Heart Association believes will lead to better implementation, tracking, and prevention of VTE events. They include performing VTE risk assessment and reporting the level of VTE risk in all hospitalized patients, integrating preventable VTE as a benchmark for hospital comparison and pay-for-performance programs, supporting appropriations to improve public awareness of VTE, tracking VTE nationwide with the use of standardized definitions, and developing a centralized data steward for data tracking on VTE risk assessment, prophylaxis, and rates.
... The appropriate provisioning of CDS was characterized by the "five rights": making the right information available to the right person, in the right format, through the right channel, at the right time [16]. The automatic provisioning of CDS can have a positive impact on important healthcare issues, such as patient safety [17], racial and gender disparities [18], and process adherence [19]. In addition, prior studies show that factors such as automatic provisioning of CDS tools [6,20] can impact the adoption and success of CDS. ...
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Medical calculators play an important role as a component of specific clinical decision support systems that synthesize measurable evidence and can introduce new medical guidelines and standards. Understanding the features of calculators is important for calculator adoption and clinical acceptance. This paper presents a novel classification system for medical calculators. Metadata on 766 medical calculators implemented online were collected, analyzed, and categorized by their input types, method of presenting results, and advisory nature of those results. Reference rate, publication year, and availability of references were collected. We found the majority of calculators are likely not automatable. 16% of medical calculators present advisory results to clinicians. 83% of medical calculators provide references. We show a 9-year lag from publication to implementation of calculators. New medical calculators should be developed with EHR integration and the advisory nature of results in mind so that calculators may become integral to clinical workflow.
... These models should then be incorporated into existing workflows rather than remaining isolated components of the care process. For example, integrated clinical decision support tools already exist for quality improvement efforts, such as venous thromboembolism prophylaxis 38 and inpatient insulin dosing for diabetic patients. 39 A similar paradigm is feasible for risk assessment and counseling tools. ...
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Background: Accurate risk assessment before surgery is complex and hampered by behavioral factors. Underutilized risk-based decision-support tools may counteract these barriers. The purpose of this study was to identify perceptions of and barriers to the use of surgical risk-assessment tools and assess the importance of data framing as a barrier to adoption in surgical trainees. Methods: We distributed a survey and risk assessment activity to surgical trainees at four training institutions. The primary outcomes of this study were descriptive risk assessment practices currently performed by residents, identifiable influences and obstacles to adoption, and the variability of preference sets when comparing modified System Usability Scores of a current risk calculator to a purpose-built calculator revision. Risk calculator comparison responses were compared with simple and multivariable regression to identify predictors for preferentiality. Results: We collected responses from 124 surgical residents (39% response rate). Participants endorsed familiarity with direct verbal communication (100%), sketch diagrams (87%), and brochures (59%). The most contemporary risk communication frameworks, such as best-worst case scenario framing (38%), case-specific risk calculators (43%), and all-procedure calculators (52%) were the least familiar. Usage favored traditional models of communication with only 26% of residents regularly using a strategy other than direct verbal discussion or anatomic sketch diagrams. Barriers limiting routine use included lack of electronic and clinical workflow integration. The mean modified System Usability Scores domain scores were widely dispersed for all domains, and no domain demonstrated one calculator's superiority over another. Conclusion: Risk assessment tools are underutilized by trainees. Of importance, preference sets of clinicians appear to be unpredictable and may benefit more from a customizable, bespoke approach.
Article
Congenital Heart Disease (CHD) is a significant source of pediatric morbidity and mortality. As in other fields of medicine, studies have demonstrated racial and ethnic disparities in congenital heart disease outcomes. The cause of these outcome disparities is multifactorial, involving biological, behavioral, environmental, sociocultural, and systemic medical factors. Potential contributors include differences in preoperative illness severity secondary to coexisting medical conditions, differences in the rate of prenatal and early postnatal detection of CHD, and delayed access to care, as well as discrepancies in socioeconomic and insurance status, and systemic disparities in hospital care. Understanding the factors that contribute to these disparities is an essential step towards developing strategies to address them. As stewards of the perioperative surgical home, anesthesiologists have an important role in developing institutional policies that mitigate racial disparities. Here, we provide a thorough narrative review of recent research concerning perioperative factors contributing to surgical outcomes disparities for children of all ages with CHD, examine potentially modifiable contributing factors, discuss avenues for future research, and suggest strategies to address disparities both locally and nationally.
Article
Introduction Venous thromboembolism (VTE) is a frequent cause of preventable harm among hospitalized patients. Many prescribed prophylaxis doses are not administered despite supporting evidence. We previously demonstrated a patient-centered education bundle improved VTE prophylaxis administration broadly; however, patient-specific factors driving nonadministration are unclear. We examine the effects of the education bundle on missed doses of VTE prophylaxis by sex. Methods We performed a post-hoc analysis of a nonrandomized controlled trial to evaluate the differences in missed doses by sex. Pre-intervention and intervention periods for patients admitted to 16 surgical and medical floors between 10/2014-03/2015 (pre-intervention) and 04/2015-12/2015 (intervention) were compared. We examined the conditional odds of (1) overall missed doses, (2) missed doses due to patient refusal, and (3) missed doses for other reasons. Results Overall, 16,865 patients were included (pre-intervention 6853, intervention 10,012), with 2350 male and 2460 female patients (intervention), and 6373 male and 5682 female patients (control). Any missed dose significantly reduced on the intervention floors among male (odds ratio OR 0.55; 95% confidence interval CI, 0.44-0.70, P < 0.001) and female (OR 0.59; 95% CI, 0.47-0.73, P < 0.001) patients. Similar significant reductions ensued for missed doses due to patient refusal (P < 0.001). Overall, there were no sex-specific differences (P-interaction >0.05). Conclusions Our intervention increased VTE prophylaxis administration for both female and male patients, driven by decreased patient refusal. Patient education should be applicable to a wide range of patient demographics representative of the target group. To improve future interventions, quality improvement efforts should be evaluated based on patient demographics and drivers of differences in care.
Article
Background: Clinical decision support (CDS) systems are increasingly used to facilitate surgical care delivery. Despite formal recommendations to do so, equity evaluations are not routinely performed on CDS systems and underrepresented populations are at risk of harm and further health disparities. We explored surgical literature to determine frequency and rigor of CDS equity assessments and offer recommendations to improve CDS equity by appending existing frameworks. Methods: We performed a scoping review up to 8/25/21 using PubMed and Google Scholar for the following search terms: clinical decision support, implementation, RE-AIM, Proctor, Proctor's framework, equity, trauma, surgery, surgical. We identified 1,415 citations and 229 abstracts met criteria for review. A total of 84 underwent full review after 145 were excluded if they did not assess outcomes of an electronic CDS tool or have a surgical use case. Results: Only 6% (5/84) of surgical CDS systems reported equity analyses, suggesting that current methods for optimizing equity in surgical CDS are inadequate. We propose revising the RE-AIM framework to include an Equity element (RE2-AIM) specifying that CDS foundational analyses and algorithms are performed or trained on balanced datasets with sociodemographic characteristics that accurately represent the CDS target population and are assessed by sensitivity analyses focused on vulnerable subpopulations. Conclusion: Current surgical CDS literature reports little with respect to equity. Revising the RE-AIM framework to include an Equity element (RE2-AIM) promotes the development and implementation of CDS systems that, at minimum, do not worsen healthcare disparities and possibly improve their generalizability.
Article
Machine learning models may be integrated into clinical decision support (CDS) systems to identify children at risk of specific diagnoses or clinical deterioration to provide evidence-based recommendations. This use of artificial intelligence models in clinical decision support (AI-CDS) may have several advantages over traditional "rule-based" CDS models in pediatric care through increased model accuracy, with fewer false alerts and missed patients. AI-CDS tools must be appropriately developed, provide insight into the rationale behind decisions, be seamlessly integrated into care pathways, be intuitive to use, answer clinically relevant questions, respect the content expertise of the healthcare provider, and be scientifically sound. While numerous machine learning models have been reported in pediatric care, their integration into AI-CDS remains incompletely realized to date. Important challenges in the application of AI models in pediatric care include the relatively lower rates of clinically significant outcomes compared to adults, and the lack of sufficiently large datasets available necessary for the development of machine learning models. In this review article, we summarize key concepts related to AI-CDS, its current application to pediatric care, and its potential benefits and risks. IMPACT: The performance of clinical decision support may be enhanced by the utilization of machine learning-based algorithms to improve the predictive performance of underlying models. Artificial intelligence-based clinical decision support (AI-CDS) uses models that are experientially improved through training and are particularly well suited toward high-dimensional data. The application of AI-CDS toward pediatric care remains limited currently but represents an important area of future research.
Article
Importance: Differences in time to diagnostic and therapeutic measures can contribute to disparities in outcomes. However, whether there is an association of timeliness by sex for trauma patients is unknown. Objective: To investigate whether sex-based differences in time to definitive interventions exist for trauma patients in the US and whether these differences are associated with outcomes. Design, setting, and participants: This was a retrospective cohort study conducted from July 2020 to July 2021, using the 2013 to 2016 Trauma Quality Improvement Program (TQIP) databases from level I to III trauma centers in the US. Patients 18 years or older with an Injury Severity Score (ISS) greater than 15 and who carried diagnoses of traumatic brain injury, intra-abdominal injury, pelvic fracture, femur fracture, and spinal injury as a result of their trauma were included in the study. Data were analyzed from July 2020 to July 2021. Main outcomes and measures: Primary outcomes assessed timeliness to interventions, using Wilcoxon signed rank and χ2 tests. Secondary outcomes included location of discharge after injury, using propensity score-matched generalized estimating equations modeling. Results: Of the 28 332 patients included, 20 002 (70.6%) were male patients (mean [SD] age, 43.3 [18.2] years) and 8330 (29.4%) were female patients (mean [SD] age, 48.5 [21.1] years), with significantly different distributions of ISS scores (ISS score 16-24: male patient, 10 622 [53.1%]; female patient, 4684 [56.2%]; ISS score 41-74: male patient, 2052 [10.3%]; female patient, 852 [10.2%]). Male patients more frequently had abdominal (4257 [21.3%] vs 1268 [15.2%]) and spinal cord (3989 [20.0%] vs 1274 [15.3%]) injuries, whereas female patients experienced greater proportions of femur (3670 [44.0%] vs 8422 [42.1%]) and pelvic (3970 [47.6%] vs 6963 [34.8%]) fractures. Female patients experienced significantly longer emergency department length of stay (median [IQR], 184 [92-314] minutes vs 172 [86-289] minutes; P < .001), longer time in pretriage (median [IQR], 52 [36-80] minutes vs 49 [34-77] minutes; P < .001), and increased likelihood of discharge to nursing or long-term care facilities instead of home after matching by age, ISS, mechanism, and injury type (male patient:female patient, odds ratio, 0.72; 95% CI, 0.67-0.78). Conclusions and relevance: Results of this cohort study suggest that female trauma patients experienced slightly longer delays in trauma care and had a higher likelihood of discharge to long-term care facilities than their male counterparts.
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Implementation of health information technology does not occur in a vacuum or devoid of people. Implementation is substantially affected by the user and organizational culture. This chapter focuses on creating a comprehensive and effective strategy for implementation that promotes the adoption and effective use of a clinical information system. Specifically addressed are organizational culture and behavior assessments based on social-psychology theories that affect the entire implementation process and adoption. Key success factors in implementation include communication, champions’ role, understanding user requirements/needs and workflow, and incorporating user feedback.KeywordsImplementationOrganizational cultureChange managementPeople-process side of changeAdoptionWorkflowCommunication
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Background: There are disparities in surgical outcomes for patients of low socioeconomic status globally, including in countries with universal healthcare systems. There is limited data on the impact of low socioeconomic status on surgical outcomes in Australia. This study examines surgical outcomes by both self-reported unemployment and neighbourhood level socioeconomic status in Australia. Methods: A retrospective administrative data review was conducted at a tertiary care centre over a 10-year period (2008-2018) including all adult surgical patients. Multivariable logistic regression adjusting for year, age, sex and Charlson Comorbidity Index was performed. Results: 106 197 patients underwent a surgical procedure in the decade examined. The overall adverse event rates were mortality (1.13%), total postoperative complications (10.9%), failure to rescue (0.75%) and return to theatre (4.31%). Following multivariable testing, unemployed and low socioeconomic patients had a higher risk of postoperative mortality (OR 2.06 (1.50-2.82), OR 1.37 (1.15-1.64)), all complications (OR 1.43 (1.31-1.56), OR 1.21 (1.14-1.28)), failure to rescue (OR 2.03 (1.39-2.95), OR 1.38 (1.11-1.72)) and return to theatre (OR 1.42 (1.27-1.59), OR 1.24 (1.14-1.36)) (P < 0.005 for all). Conclusions: Despite universal healthcare, there are disparities in surgical adverse events for patients of low socioeconomic status in Australia. Disparities in surgical outcomes can stem from three facets: a patient's access to healthcare (the severity of disease at the time of presentation), variation in perioperative care delivery, and social determinants of health. Further work is required to pinpoint why these disparities are present and to evaluate the impact of strategies that aim to reduce disparities.
Article
Quality improvement (QI) can be a critical means by which to achieve equity in health and health care. QI efforts, however, often fail to be designed and implemented through the lens of health equity. In this article, we will discuss the current state of the intersection between QI and health equity, then lay out specific steps researchers and practitioners can take to ensure that their QI work reduces, rather than increases or maintains, existing disparities. These steps include first, understanding existing disparities and, second, utilizing community engagement to ensure that QI enhances health equity. Before embarking on QI work, QI practitioners should first examine their metric of interest by patient characteristics, starting with race and ethnicity, language, and markers of access to care and socioeconomic status. Developing an understanding of existing disparities relevant to the QI project will ensure that the QI interventions can be designed to be most effective in the disadvantaged populations, thus increasing the likelihood that the intervention reduces existing disparities. In designing QI interventions, practitioners must also plan engagement with stakeholder populations ahead of time, to carefully understand their needs and priorities and how best to address them through QI efforts.
Article
Background: Adverse events in healthcare are primarily due to system failures rather than individuals. Risk reduction strategies should therefore focus on strengthening systems, bringing about improvements in governance, and targeting individual practices or products. The purpose of this study was to conduct a scoping review to develop a global framework of management strategies for sustaining a safety-oriented culture in healthcare organizations, focusing on patient safety and the adoption of good safety-related practices. Methods: We conducted a search on safety-related strategies in 2 steps. The first involved a search in the PubMed database to identify effective, broadly framed, cross-sector domains relevant to clinical risk management strategies in healthcare systems. In the second step, we then examined the strategies adopted by running a scoping review for each domain. Results: Our search identified 8 strategy domains relevant to patient safety: transformational leadership, patient engagement, human resources management quality, innovation technology, skills certification, education in patient safety, teamwork, and effective communication. Conclusions: This scoping review explores management strategies key to healthcare systems' efforts to create safety-oriented organizations. Improvement efforts should focus particularly on the domains identified: combined together, they would nurture an overall safety-oriented culture and have an impact on preventable adverse events.
Article
Background Patients with liver disease have traditionally been regarded as auto-anticoagulated against developing blood clots due to haemorrhage being regarded as the most significant haemostatic complication. More recently, there has been increasing recognition that hypercoagulability is a prominent aspect of cirrhosis, with an increasing number of patients developing thromboembolisms. When prescribing prophylactic low molecular weight heparin for prevention, clinicians are often concerned about the risk of bleeding, including gastrointestinal bleeding, specifically in those with decompensated liver disease and cirrhosis, due to the altered coagulopathy associated with these patients. Aim The aim of this review was to assess if the use of prophylaxis in patients with liver disease is effective in the prevention of venous thromboembolism (VTE) and whether its use is related to an increase in bleeding episodes. Methods A review of the literature was conducted to identify the incidence of VTE and bleeding in liver patients when given prophylactic VTE treatment. Results The majority of evidence was inconclusive; however, the main emerging theme was that administering prophylaxis to patients with decompensated liver disease results in an increased risk of bleeding, while having little effect on reducing the risk of VTE development. Conclusion The bleeding risk associated with VTE prophylaxis treatment and liver disease remains uncertain. Thus the ideal methods of medical prophylactic VTE prevention and monitoring in this patient population have not yet been determined. It is suggested that additional consideration should be given to serum albumin, platelet count and international normalised ratio, as well as renal function, in conjunction with risk assessment tools, when deciding whether to prescribe VTE prophylaxis or not.
Article
Objective To examine the trends in CT utilization in the emergency department (ED) for different racial and ethnic groups, factors that may affect utilization, and the effects of increased insurance coverage since passage of the Affordable Care Act in 2010.Materials and methodsData from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2009–2018 were used for the analysis. The NHAMCS is a cross-sectional survey which has random and systematical samples of more than 200,000 visits to over 250 hospital EDs in the USA. Patient demographic characteristics, source of payment/insurance, clinical presentation, and disposition from the ED were recorded. Descriptive statistics and multivariate logistic regression were performed.ResultsBetween 2009 and 2018, the rate of uninsured patients in the ED decreased from 18.1% to as low as 9.9%, but this was not associated with a decrease in the disparity in CT utilization between non-Hispanic Black and non-Hispanic White patients. CT use rate increased 38% over the study period. Factors strongly associated with CT utilization include age, source of payment, triage category, disposition from the ED, and residence. After controlling for these factors, non-Hispanic White patients were 21% more likely to undergo CT than non-Hispanic Black patients, though no disparity was seen for Hispanic or Asian/other groups.Conclusion Despite increased insurance coverage over the sample period, racial disparities between non-Hispanic Black and non-Hispanic White patients persist in CT utilization, though no disparity was seen for Hispanic or Asian/other patients. The source of this disparity remains unclear and is likely multifactorial.
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Race is a social construct; it is a phenotype that has been ascribed meaning through history and human interaction. In order to confront racism and its effect in the medical system, we must speak about it openly. In this chapter, we will use the lens of implicit bias and structural racism to frame how medical management is directly affected by racism and racial bias. We will also provide tools and strategies on how to combat these forms of oppression in our practice.
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The distribution of vascular disease worldwide has evolved dramatically over time, driven primarily by demographic changes and changing rates of atherosclerotic risk factors. In the United States in particular, the proportion of racial/ethnic groups represented in the overall population is increasing. As such, caring for vascular patients now, more than ever, requires focused efforts to understand the impact of race and ethnicity on the epidemiology of vascular disease, delivery of vascular care, and patient outcomes. Recent advancements highlight several important disparity themes that persist across vascular pathologies, including abdominal aortic aneurysm disease, cerebrovascular disease, and peripheral arterial disease. Black and Hispanic patients generally present with more severe manifestations of vascular disease, are less likely to undergo intervention, and experience higher morbidity and mortality compared with White patients. Understanding the reasons for these disparities is critical to developing strategies by which to improve care among an increasingly diverse patient population.
Article
Background Few studies assess use of parathyroidectomy among older adults with symptomatic primary hyperparathyroidism. Our objective was to determine national usage and disparities in parathyroidectomy for symptomatic primary hyperparathyroidism among insured older adults. Methods We identified older adult patients with symptomatic primary hyperparathyroidism using Medicare claims (2006–2017). Primary study variables were race/ethnicity, rurality, and zip-code socioeconomic status. We calculated cumulative incidence of parathyroidectomy and used multivariable Cox proportional hazards regression models to assess the adjusted association of our study variables with parathyroidectomy. Results We included 94,803 patients. The median age at primary hyperparathyroidism diagnosis was 76 years (interquartile range 71–82). The majority of patients were female (72%), non-Hispanic White (82%), from metropolitan areas (82%), and had a Charlson Comorbidity score ≥3 (62%). Nine percent of patients (n = 8,251) underwent parathyroidectomy during follow-up. After adjustment, non-Hispanic Black patients, compared to non-Hispanic White (hazard ratio 0.80; 95% confidence interval 0.74, 0.87), and living in a low socioeconomic status neighborhood (low socioeconomic status vs highest socioeconomic status hazard ratio 0.89; 95% confidence interval 0.83, 0.95) were both associated with lower incidences of parathyroidectomy. Patients from non-metropolitan areas were more likely to undergo parathyroidectomy. Conclusion Parathyroidectomy is underused for symptomatic primary hyperparathyroidism in older adults. Quality improvement efforts, rooted in equitable care, should be undertaken to increase access to parathyroidectomy for this disease.
Article
Objective To evaluate the effectiveness of feedback using an emailed scorecard and a web-based dashboard on risk-appropriate VTE prophylaxis prescribing practices among general surgery interns and residents. Design Prospective cohort study. Setting The Johns Hopkins Hospital, an urban academic medical center. Participants All 45 trainees (19 post-graduate year [PGY] 1 interns and 26 PGY-2 to PGY-5 residents) in our general surgery program. Intervention Feedback implementation encompassed three sequential periods: (1) scorecard (July 1, 2014 through June 30, 2015); (2) no feedback/wash-in (July 1 through October 31, 2015); and (3) web-based dashboard (November 1, 2015 through June 30, 2016). No feedback served as the baseline period for the intern cohort. The scorecard was a static document showing an individual's compliance with risk-appropriate VTE prophylaxis prescription compared to compliance of their de-identified peers. The web-based dashboard included other information (e.g., patient details for suboptimal prophylaxis orders) besides individual compliance compared to their de-identified peers. Trainees could access the dashboard anytime to view current and historic performance. We sent monthly emails to all trainees for both feedback mechanisms. Main outcome was proportion of patients prescribed risk-appropriate VTE prophylaxis, and mean percentages reported. Results During this study, 4088 VTE prophylaxis orders were placed. Among residents, mean prescription of risk-appropriate prophylaxis was higher in the wash-in (98.4% vs 95.6%, p < 0.001) and dashboard (98.4 vs 95.6%, p < 0.001) periods compared to the scorecard period. There was no difference in mean compliance between the wash-in and dashboard periods (98.4% vs 98.4%, p = 0.99). Among interns, mean prescription of risk-appropriate VTE prophylaxis improved between the wash-in and dashboard periods (91.5% vs 96.4%, p < 0.001). Conclusions and Relevance Using audit and individualized performance feedback to general surgery trainees through a web-based dashboard improved prescribing of appropriate VTE prophylaxis to a near-perfect performance.
Article
Background Racial disparities in opioid prescribing are widely documented, though few studies assess racial differences in the postoperative setting specifically. We hypothesized standard opioid prescribing schedules reduce total opioids prescribed postoperatively and mitigate racial variation in postoperative opioid prescribing. Methods This is a retrospective review of adult general surgery cases at a large, public academic institution. Standard opioid prescribing schedules were implemented across general surgery services for common procedures in late 2018 at various timepoints. Interrupted time series analysis was used to compare mean biweekly discharge morphine milligram equivalents prescribed in the preintervention (Jan–Jun 2018) versus postintervention (Jan–Jun 2019) periods for Black and White patients. Linear regression was used to compare mean difference in discharge morphine milligram equivalents among White and Black patients in each study period, while controlling for demographics, chronic opioid use, and procedure/service. Results A total of 2,961 cases were analyzed: 1,441 preintervention and 1,520 postintervention. Procedural frequencies, proportion of Black patients (17% Black), and chronic opioid exposure (7% chronic users) were similar across time periods. Interrupted time series analysis showed significantly lower mean level of morphine milligram equivalents prescribed postintervention compared with the predicted nonintervention trend for both Black and White patients. Adjusted analysis showed on average in 2018 Black patients received significantly higher morphine milligram equivalents than White patients (+19 morphine milligram equivalents, 95% confidence interval 0.5–36.5). There was no significant difference in 2019 (–8 morphine milligram equivalents, 95% confidence interval –20.5 to 4.6). Conclusion Standard opioid prescribing schedules were associated with the elimination of racial differences in postoperative opioid prescribing after common general surgery procedures, while also reducing total opioids prescribed. We hypothesize standard opioid prescribing schedules may mitigate the effect of implicit bias in prescribing.
Article
Objective: To examine the relationship between enoxaparin dose adequacy, quantified with anti-Factor Xa (aFXa) levels, and 90-day symptomatic venous thromboembolism (VTE) and post-operative bleeding. Summary background data: Surgical patients often develop "breakthrough" VTE events-those which occur despite receiving chemical anticoagulation. We hypothesize that surgical patients with low aFXa levels will be more likely to develop 90-day VTE, and those with high aFXa will be more likely to bleed. Methods: Pooled analysis of eight clinical trials (N = 985) from a single institution over a four year period. Patients had peak steady state aFXa levels in response to a known initial enoxaparin dose, and were followed for 90 days. Survival analysis log-rank test examined associations between aFXa level category and 90-day symptomatic VTE & bleeding. Results: Among 985 patients, 2.3% (n = 23) had symptomatic 90-day VTE, 4.2% (n = 41) had 90-day clinically relevant bleeding, and 2.1% (n = 21) had major bleeding. Patients with initial low aFXa were significantly more likely to have 90-day VTE than patients with adequate or high aFXa (4.2% vs. 1.3%, p = 0.007). In a stratified analysis, this relationship was significant for patients who received twice daily (6.2% vs. 1.5%, p = 0.003), but not once daily (3.0% vs. 0.7%, p = 0.10) enoxaparin. No association was seen between high aFXa and 90-day clinically relevant bleeding (4.8% vs. 2.9%, p = 0.34) or major bleeding (3.6% vs. 1.6%, p = 0.18). Conclusions: This manuscript establishes inadequate enoxaparin dosing as a plausible mechanism for breakthrough VTE in surgical patients, and identifies anticoagulant dose adequacy as a novel target for process improvement measures.
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Health information technology (health IT) potentially is a promising vital lever to address racial and ethnic, socioeconomic, and geographic disparities in maternal morbidity and mortality (MMM). This is especially relevant given that approximately 60% of maternal deaths are considered preventable. 1-36 Interventions that leverage health IT tools to target the underlying drivers of disparities at the patient, clinician, and health care system levels potentially could reduce disparities in quality of care throughout the continuum (antepartum, intrapartum, and postpartum) of maternity care. This article presents an overview of the research (and gaps) on the potential of health IT tools to document SDoH and community-level geocoded data in EHR-based CDS systems, minimize implicit bias, and improve adherence to clinical guidelines and coordinated care to inform multilevel (patient, clinician, system) interventions throughout the continuum of maternity care for health disparity populations impacted by MMM. Telemedicine models for improving access in rural areas and new technologies for risk assessment and disease management (e.g., regarding preeclampsia) also are discussed.
Article
Studies have documented that few patients with obesity receive evidence‐based care. One provider characteristic that may impact clinical obesity care, but that has been under studied to date, is political party affiliation. This study sought to evaluate how primary care physicians (PCPs) report managing patients with obesity and assess whether there are differences between Democratic and Republican PCPs. This was a secondary analysis of a cross‐sectional survey of 225 PCPs registered to vote as Democrats or Republicans in 29 US States. After reading a patient vignette, the PCPs reported the following outcomes: likelihood of documenting obesity in the medical record; likelihood of discussing obesity with the patient; and likelihood of engaging in eight different obesity management options. Almost all PCPs reported they would document obesity in the medical record (Republican = 97.6%, Democrat = 94.3%) and discuss it further (Republican = 95.2%, Democrat = 92.2%). Among eight obesity management options, PCPs were least likely to say they would prescribe medication (3.9%) or refer the patient to counselling (24.0%), regardless of political affiliation. Republicans were more likely to report that they would inquire about the time course of obesity (73.4% v. 56.2%, P = 0.012) and discuss health risks of obesity (91.0% vs 78.3%, P = .018). Republican and Democratic PCPs report some differences in managing patients with obesity, suggesting that political beliefs may play a role in some clinical care.
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Although brief alcohol intervention can reduce alcohol use for both men and women, health care providers (HCPs) are less likely to discuss alcohol use or deliver brief intervention to women compared to men. This secondary analysis examined whether previously reported outcomes from a cluster randomized trial of a clinical decision support system (CDSS)-prompting delivery of a brief alcohol intervention (an educational alcohol resource) for patients drinking above cancer guidelines-were moderated by patients' sex. Patients (n = 5702) enrolled in a smoking cessation program at primary care sites across Ontario, Canada, were randomized to either the intervention (CDSS) or control arm (no CDSS). Logistic generalized estimating equations models were fit for the primary and secondary outcome (HCP offer of resource and patient acceptance of resource, respectively). Previously reported results showed no difference between treatment arms in HCP offers of an educational alcohol resource to eligible patients, but there was increased acceptance of the alcohol resource among patients in the intervention arm. The results of this study showed that these CDSS intervention effects were not moderated by sex, and this can help inform the development of a scalable strategy to overcome gender disparities in alcohol intervention seen in other studies.
Article
Introduction: Racial/ethnic disparities in surgical outcomes exist. Enhanced recovery programs (ERPs) have reduced some racial/ethnic disparities, but it remains unclear if disparities in experiences are also reduced. The purpose of this study was to use qualitative methods to better understand the surgical experience for African-American and Caucasian patients in the setting of an ERP. Methods: Using purposeful sampling at a minority-serving institution, we recruited African-American and Caucasian patients who had undergone colorectal surgery under an ERP to six focus groups. Participants identified barriers and facilitators to a positive, or negative, surgical experience. Audio recordings were transcribed and analyzed using an indicative thematic approach with NVivo 10 software (QSR International). Results: Forty-three patients (15 African-Americans and 28 Caucasians) participated in six focus groups. Six themes were identified by patients to be important in surgery: 1) knowledge about colorectal surgery, 2) obtaining information, 3) quality of information, 4) setting expectations about surgery, 5) following preoperative and postoperative instructions, and 6) confidence in surgery outcomes. For both racial/ethnic groups, patients felt that more information could have been provided, information should be given at their level of understanding, and trust in the physician made them feel confident in a positive outcome. African-American patients described experiences of having incorrect or no expectations on surgical outcomes, being provided inconsistent information, and feeling misled. African-Americans also described following instructions from family members and valued the importance of diet and exercise in recovery. Conclusions: African-American and Caucasian surgical patients have varied surgical experiences even under an ERP. All patients, however, valued the ability to obtain, process, and understand health information during the surgical process. These elements define "health literacy" and suggest the importance of providing health literacy-sensitive care in surgery.
Article
Introduction: Diversion of excess prescription opioids contributes to the opioid epidemic. We sought to describe and study the impact of a comprehensive departmental initiative to decrease opioid prescribing in surgery. Methods: A multispecialty multidisciplinary initiative was designed to change the culture of postoperative opioid prescribing, including: consensus-built opioid guidelines for 42 procedures from 11 specialties, provider-focused posters displayed in all surgical units, patient opioid/pain brochures setting expectations, and educational seminars to residents, advanced practice providers, residents and nurses. Pre- (April 2016-March 2017) versu post-initiative (April 2017-May 2018) analyses of opioid prescribing at discharge [median oral morphine equivalent (OME)] were performed at the specialty, prescriber, patient, and procedure levels. Refill prescriptions within 3 months were also studied. Results: A total of 23,298 patients were included (11,983 pre-; 11,315 post-initiative). Post-initiative, the median OME significantly decreased for 10 specialties (all P values < 0.001), the percentage of patients discharged without opioids increased from 35.7% to 52.5% (P < 0.001), and there was no change in opioids refills (0.07% vs 0.08%, P = 0.9). Similar significant decreases in OME were observed when the analyses were performed at the provider and individual procedure levels. Patient-level analyses showed that the preinitiative race/sex disparities in opioid-prescribing disappeared post-initiative. Conclusion: We describe a comprehensive multi-specialty intervention that successfully reduced prescribed opioids without increase in refills and decreased sex/race prescription disparities.
Article
Background Gastroparesis is an end-organ sequela of diabetes. We evaluated the roles of race and socioeconomic status in hospitalization rates and utilization of surgical treatments in these patients. Methods Data was extracted from the National Inpatient Sample (NIS) between the years 2012 and 2014, and any discharge diagnosis of gastroparesis (536.3) was included. Gastrostomy, jejunostomy, and total parenteral nutrition were considered nutritional support procedures, and procedures aimed at improving motility were considered definitive disease-specific procedures: pyloroplasty, endoscopic pyloric dilation, gastric pacemaker placement, and gastrectomy. Results There were 747,500 hospitalizations reporting a discharge diagnosis of gastroparesis. On multivariable analysis, black race (OR 1.93, 95% CI 1.89–1.98; p < 0.001) and Medicaid insurance (OR 1.46, 95% CI 1.42–1.50; p < 0.001) were the strongest socioeconomic risk factors for hospitalization due to gastroparesis. Patients in urban teaching institutions were most likely to undergo a surgical intervention for gastroparesis (5.53% of patients versus 3.94% of patients treated in urban non-teaching hospitals and 2.38% of patients in rural hospitals; p < 0.001). Uninsured patients were less than half as likely to receive treatment compared to those with private insurance (OR 0.41, 95% CI 0.34–0.48; p < 0.001), and black patients had an OR 0.75 (95% CI 0.69–0.81; p < 0.001) for receiving treatment. Urban teaching hospitals had a twofold higher likelihood of intervention (OR 2.12, 95% CI 1.84–2.44; p < 0.001). Conclusions Marked racial and economic disparities exist in surgical distribution of care for gastroparesis, potentially driven by differences in utilization of care.
Article
Background: NonHispanic black patients bear a disproportionate burden of the obesity epidemic and its related medical co-morbidities. While bariatric surgery is the most effective treatment for morbid obesity, black patients access bariatric surgery at lower rates than nonHispanic white patients. Objectives: To examine racial differences before bariatric surgery and in short-term perioperative outcomes and complications, and the extent to which race is independently associated with perioperative morbidity and mortality. Setting: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program national database. Methods: Data were extracted from the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use File. Multivariate analysis was used to identify differences in mortality, length of stay, readmission, and reintervention by race in patients undergoing laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy (SG). Results: A total of 108,198 patients were included in the analysis. There were significant differences in perioperative disease burden. Black patients had a higher body mass index at the time they underwent surgery (laparoscopic Roux-en-Y gastric bypass: 48.0 versus 45.7 kg/m2; SG: 46.8 versus 44.9 kg/m2; P < .001). Black patients had significantly longer length of stay and higher rates of readmission in both the laparoscopic Roux-en-Y gastric bypass and SG groups. In the SG group, black patients had significantly higher 30-day mortality (.2% versus .1%, odds ratio = 3.613, 95% confidence interval 1.990-6.558, P < .001) and higher rates of reoperation or reintervention. Conclusions: We found significant racial disparities in bariatric surgery outcomes, including higher mortality in black patients undergoing SG. The specific causes of these disparities remain unclear and must be the subject of future research.
Article
Trauma data bank and other research reveal sex disparities in trauma care. Risk-taking behaviors leading to traumatic injury have been associated with sex, menstrual cycle timing, and cortisol levels. Trauma patient treatment stratified by sex reveals differences in access to services at trauma centers as well as specific treatments, such as venous thromboembolism prophylaxis and massive transfusion component ratios. Trauma patient outcomes, such as in-hospital mortality, multiple organ failure, pneumonia, and sepsis are associated with sex disparities in the general trauma patient. Outcome after general trauma and specifically traumatic brain injury show mixed results with respect to sex disparity.
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Importance Racial disparities in survival after trauma are well described for patients younger than 65 years. Similar information among older patients is lacking because existing trauma databases do not include important patient comorbidity information.Objective To determine whether racial disparities in trauma survival persist in patients 65 years or older.Design, Setting, and Participants Trauma patients were identified from the Nationwide Inpatient Sample (January 1, 2003, through December 30, 2010) using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Injury severity was ascertained by applying the Trauma Mortality Prediction Model, and patient comorbidities were quantified using the Charlson Comorbidity Index.Main Outcomes and Measures In-hospital mortality after trauma for blacks vs whites for younger (16-64 years of age) and older (≥65 years of age) patients was compared using 3 different statistical methods: univariable logistic regression, multivariable logistic regression with and without clustering for hospital effects, and coarsened exact matching. Model covariates included age, sex, insurance status, type and intent of injury, injury severity, head injury severity, and Charlson Comorbidity Index.Results A total of 1 073 195 patients were included (502 167 patients 16-64 years of age and 571 028 patients ≥65 years of age). Most older patients were white (547 325 [95.8%]), female (406 158 [71.1%]), and insured (567 361 [99.4%]) and had Charlson Comorbidity Index scores of 1 or higher (323 741 [56.7%]). The unadjusted odds ratios (ORs) for death in blacks vs whites were 1.35 (95% CI, 1.28-1.42) for patients 16 to 64 years of age and 1.00 (95% CI, 0.93-1.08) for patients 65 years or older. After risk adjustment, racial disparities in survival persisted in the younger black group (OR, 1.21; 95% CI, 1.13-1.30) but were reversed in the older group (OR, 0.83; 95% CI, 0.76-0.90). This finding was consistent across all 3 statistical methods.Conclusions and Relevance Different racial disparities in survival after trauma exist between white and black patients depending on their age group. Although younger white patients have better outcomes after trauma than younger black patients, older black patients have better outcomes than older white patients. Exploration of this paradoxical finding may lead to a better understanding of the mechanisms that cause disparities in trauma outcomes.
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Background Venous thromboembolism (VTE) is a common cause of preventable harm for hospitalised patients. Over the past decade, numerous intervention types have been implemented in attempts to improve the prescription of VTE prophylaxis in hospitals, with varying degrees of success. We reviewed key articles to assess the efficacy of different types of interventions to improve prescription of VTE prophylaxis for hospitalised patients. Methods We conducted a search of MEDLINE for key studies published between 2001 and 2012 of interventions employing education, paper based tools, computerised tools, real time audit and feedback, or combinations of intervention types to improve prescription of VTE prophylaxis for patients in hospital settings. Process outcomes of interest were prescription of any VTE prophylaxis and best practice VTE prophylaxis. Clinical outcomes of interest were any VTE and potentially preventable VTE, defined as VTE occurring in patients not prescribed appropriate prophylaxis. Results 16 articles were included in this review. Two studies employed education only, four implemented paper based tools, four used computerised tools, two evaluated audit and feedback strategies, and four studies used combinations of intervention types. Individual modalities result in improved prescription of VTE prophylaxis; however, the greatest and most sustained improvements were those that combined education with computerised tools. Conclusions Many intervention types have proven effective to different degrees in improving VTE prevention. Provider education is likely a required additional component and should be combined with other intervention types. Active mandatory tools are likely more effective than passive ones. Information technology tools that are well integrated into provider workflow, such as alerts and computerised clinical decision support, can improve best practice prophylaxis use and prevent patient harm resulting from VTE.
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Context Computer-based clinical decision support systems (CDSSs) have been promoted for their potential to improve quality of health care. However, given the limited range of clinical settings in which they have been tested, such systems must be evaluated rigorously before widespread introduction into clinical practice.Objective To determine whether presentation of venous thromboembolism prophylaxis guidelines using a CDSS increases the proportion of appropriate clinical practice decisions made.Design Time-series study conducted between December 1997 and July 1999.Setting Orthopedic surgery department of a teaching hospital in Paris, France.Participants A total of 1971 patients who underwent orthopedic surgery.Intervention A CDSS designed to provide immediate information pertaining to venous thromboembolism prevention among surgical patients was integrated into daily medical practice during three 10-week intervention periods, alternated with four 10-week control periods, with a 4-week washout between each period.Main Outcome Measure Proportion of appropriate prescriptions ordered for anticoagulation, according to preestablished clinical guidelines, during intervention vs control periods.Results Physicians complied with guidelines in 82.8% (95% confidence interval [CI], 77.6%-87.1%) of cases during control periods and in 94.9% (95% CI, 92.5%-96.6%) of cases during intervention periods. During each intervention period, the appropriateness of prescription increased significantly (P<.001). Each time the CDSS was removed, physician practice reverted to that observed before initiation of the intervention. The relative risk of inappropriate practice decisions during control periods vs intervention periods was 3.8 (95% CI, 2.7-5.4).Conclusions In our study, implementation of clinical guidelines for venous thromboembolism prophylaxis through a CDSS used routinely in an orthopedic surgery department and integrated into the hospital information system changed physician behavior and improved compliance with guidelines. Figures in this Article Computer-based clinical decision support systems (CDSSs) are defined as "any software designed to directly aid in clinical decision making in which characteristics of individual patients are matched to a computerized knowledge base for the purpose of generating patient-specific assessments or recommendations that are then presented to clinicians for consideration."1 Clinical decision support systems have been promoted for their potential to improve the quality of health care by supporting clinical decision making. In particular, it has been suggested that physicians have difficulties processing complex information2 and will improve their prescription practices in response to electronically delivered recommendations.3 However, given their rapid rate of development and the limited range of clinical settings in which they have been tested to date, it has been stressed that CDSSs should be rigorously evaluated before widespread introduction into clinical practice.1,4 In clinical hospital practice, venous thromboembolism remains a serious problem and pulmonary embolism is a major cause of death.5 Fatal pulmonary embolism may occur in up to 1% of general surgery patients and 3% of orthopedic surgical patients who do not receive prophylaxis.6 The most efficient way to prevent both fatal and nonfatal venous thromboembolism is to use routine prophylaxis for moderate- to high-risk patients. Despite the publication of several clinical guidelines for venous thomboembolism prophylaxis in both Europe and North America6- 9 as well as studies suggesting that prophylaxis remains underused, few studies aimed at improving prophylaxis practices have been performed.10- 11 One probable reason is that optimal decisions about the use of anticoagulants in prevention of venous thromboembolism require access to a large amount of complex information to evaluate the degree of risk of hospitalized patients. We have developed a CDSS to implement clinical guidelines on venous thromboembolism prophylaxis in an orthopedic surgery department. In this study, we evaluated the effect of this system on physician behavior. We aimed to determine whether real-time presentation of venous thromboembolism prophylaxis guidelines through a CDSS increases the proportion of appropriate anticoagulant prescriptions ordered and whether this behavior change was extinguished after discontinuing use of the CDSS.
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Venous thromboembolism (VTE) prophylaxis for surgical patients cannot be overemphasized. The Joint Commission, the American College of Surgeons, the American College of Chest Physicians, the Agency for Healthcare Research and Quality, and others advocate risk-appropriate prophylaxis for all surgical patients. Despite strong evidence supporting its efficacy, VTE prophylaxis is frequently underutilized, with reported rates of 32% to 59%.1,2 Although VTE has been labeled a “never event” by some organizations, it is clear that many hospital-acquired events are not preventable.3,4 A newly suggested definition of preventable harm linking the process of VTE prophylaxis to outcomes3 has been adopted as a Clinical Quality Measure by the Centers for Medicare and Medicaid Services in their “meaningful use” incentive program. We sought to link process and outcome data from disparate sources in order to determine the proportions of surgical patients prescribed risk-appropriate VTE prophylaxis who developed potentially preventable VTE.
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Progress in patient safety improvement has been hindered by a lack of high-quality research on error prevention, poor understanding of how context influences safety strategies, and insufficient information on how best to implement evidence-based safety strategies. The Agency for Healthcare Research and Quality funded a multi-institutional effort to address these challenges, which culminated in the release of the Making Health Care Safer II report. Detailing methodology that the report's authors used to systematically review the evidence on effectiveness, context, and implementation for 41 key safety strategies, this commentary presents 10 strategies considered ready for widespread implementation. These strategies—including checklists to prevent certain health care–associated infections and surgical complications, bundled interventions to reduce falls and pressure ulcers, and interventions to decrease medication errors and improve hand hygiene—are all considered to have strong evidence of effectiveness, minimal potential for adverse consequences, and be reasonably easy to implement. This commentary is part of a special patient safety supplement in the Annals of Internal Medicine.
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Venous thromboembolism (VTE) is an important cause of preventable morbidity and mortality in medically ill patients. Randomized controlled trials indicate that pharmacologic prophylaxis reduces deep venous thrombosis (relative risk [RR] = 0.46; 95% confidence interval [CI], 0.36-0.59) and pulmonary embolism (RR = 0.49; 95% CI, 0.33-0.72) with a nonsignificant trend toward more bleeding (RR = 1.36; 95% CI, 0.80-2.33]. Low-molecular-weight heparin (LMWH) and unfractionated heparin are equally efficacious in preventing deep venous thrombosis (RR = 0.85; 95% CI, 0.69-1.06) and pulmonary embolism (RR = 1.05; 95% CI, 0.47-2.38), but LMWH is associated with significantly less major bleeding (RR = 0.45; 95% CI, 0.23-0.85). LMWH is favored for VTE prophylaxis in critically ill patients. New VTE and bleeding risk stratification tools offer the potential to improve the risk-benefit ratio for VTE prophylaxis in medically ill patients. Intermittent pneumatic compression devices should be used for VTE prophylaxis in patients with contraindications to pharmacologic prophylaxis. Graduated compression stockings should be used with caution. VTE prevention in medically ill patients using extended-duration VTE prophylaxis and new oral anticoagulants warrant further investigation. VTE prophylaxis prescription and administration rates are suboptimal and warrant multidisciplinary performance improvement strategies.
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Objective Venous thromboembolism is associated with substantial morbidity and mortality and is largely preventable. Despite this fact, appropriate prophylaxis is vastly underutilized. To improve compliance with best practice prophylaxis for VTE in hospitalized trauma patients, we implemented a mandatory computerized provider order entry–based clinical decision support tool. The system required completion of checklists of VTE risk factors and contraindications to pharmacologic prophylaxis. With this tool, we were able to determine a patient's risk stratification level and recommend appropriate prophylaxis. To evaluate the effect of our mandatory computerized provider order entry–based clinical decision support tool on compliance with prophylaxis guidelines for venous thromboembolism (VTE) and VTE outcomes among admitted adult trauma patients. Design Retrospective cohort study (from January 2007 through December 2010). Setting University-based, state-designated level 1 adult trauma center. Patients A total of 1599 hospitalized adult trauma patients with a hospital length of stay greater than 1 day. Main Outcome Measures The primary outcome measure was the proportion of patients who were ordered risk-appropriate guideline-suggested VTE prophylaxis. The secondary outcome measure was the proportion of patients with any preventable VTE (defined as VTE in a patient not ordered guideline-appropriate VTE prophylaxis), pulmonary embolism, and/or deep vein thrombosis. Results Compliance with guideline-appropriate prophylaxis increased from 66.2% to 84.4% (P < .001). The rate of preventable harm from VTE decreased from 1.0% to 0.17% (P = .04). Conclusions Implementation of a mandatory computerized provider order entry–based clinical decision support tool significantly improved compliance with VTE prophylaxis guidelines in hospitalized adult trauma patients. This improved compliance was associated with a significant decrease in the rate of preventable harm, which was defined as VTE events in patients not ordered appropriate prophylaxis.
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Venous thromboembolism (VTE) is a common cause of potentially preventable mortality, morbidity, and increased medical costs. Risk-appropriate prophylaxis can prevent most VTE events, but only a small fraction of patients at risk receive this treatment. Prospective quality improvement programme. Johns Hopkins Hospital, Baltimore, Maryland, USA. A multidisciplinary team established a VTE Prevention Collaborative in 2005. The collaborative applied the four step TRIP (translating research into practice) model to develop and implement a mandatory clinical decision support tool for VTE risk stratification and risk-appropriate VTE prophylaxis for all hospitalised adult patients. Initially, paper based VTE order sets were implemented, which were then converted into 16 specialty-specific, mandatory, computerised, clinical decision support modules. VTE risk stratification within 24 hours of hospital admission and provision of risk-appropriate, evidence based VTE prophylaxis. The VTE team was able to increase VTE risk assessment and ordering of risk-appropriate prophylaxis with paper based order sets to a limited extent, but achieved higher compliance with a computerised clinical decision support tool and the data feedback which it enabled. Risk-appropriate VTE prophylaxis increased from 26% to 80% for surgical patients and from 25% to 92% for medical patients in 2011. A computerised clinical decision support tool can increase VTE risk stratification and risk-appropriate VTE prophylaxis among hospitalised adult patients admitted to a large urban academic medical centre. It is important to ensure the tool is part of the clinician's normal workflow, is mandatory (computerised forcing function), and offers the requisite modules needed for every clinical specialty.
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Are we at the point of diminishing returns? Orthopaedic surgery is known to be associated with a high risk of venous thromboembolism, and prophylaxis for orthopaedic patients is vital. In the linked systematic review and meta-analysis (doi:10.1136/bmj.e3675), Gomez-Outes and colleagues present a comparative effectiveness review that examines newer anticoagulant agents (dabigatran, rivaroxaban, and apixaban) in the prevention of venous thromboembolism after hip or knee replacement surgery.1 This review used randomised controlled trials that had directly compared one of the newer agents with enoxaparin to indirectly compare the effects of these drugs on venous thromboembolism outcomes and clinically relevant bleeding. The review therefore gives us an idea of what the results of a head to head trial would be like. This type of network meta-analysis in which multiple treatments are compared using both direct comparisons of interventions within randomised controlled trials and indirect comparisons across trials on the basis of a common comparator is on the methodological cutting edge of systematic reviews, but it can be fraught with peril if not done with scientific rigour.2 It found that rivaroxaban led to significantly lower rates of symptomatic venous thromboembolism than enoxaparin but at the cost of significantly increased bleeding. Both apixaban and dabigatran were as effective as enoxaparin in preventing venous thromboembolism, but apixaban …
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The eighth iteration of the American College of Chest Physicians Antithrombotic Guidelines presented, in a paper version, a narrative evidence summary and rationale for the recommendations, a small number of evidence profiles summarizing bodies of evidence, and some articles with quite extensive summary tables of primary studies. In total, this represented 600 recommendations summarized in 968 pages of text. Many readers responded that the result was too voluminous for their liking or practical use.
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The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines differs substantially from the prior versions both in process and in content. In this introduction, we describe some of the differences and the rationale for the changes.
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Studies involving physicians suggest that unconscious bias may be related to clinical decision making and may predict poor patient-physician interaction. The presence of unconscious race and social class bias and its association with clinical assessments or decision making among medical students is unknown. To estimate unconscious race and social class bias among first-year medical students and investigate its relationship with assessments made during clinical vignettes. A secure Web-based survey was administered to 211 medical students entering classes at Johns Hopkins School of Medicine, Baltimore, Maryland, in August 2009 and August 2010. The survey included the Implicit Association Test (IAT) to assess unconscious preferences, direct questions regarding students' explicit race and social class preferences, and 8 clinical assessment vignettes focused on pain assessment, informed consent, patient reliability, and patient trust. Adjusting for student demographics, multiple logistic regression was used to determine whether responses to the vignettes were associated with unconscious race or social class preferences. Association of scores on an established IAT for race and a novel IAT for social class with vignette responses. Among the 202 students who completed the survey, IAT responses were consistent with an implicit preference toward white persons among 140 students (69%, 95% CI, 61%-75%). Responses were consistent with a preference toward those in the upper class among 174 students (86%, 95% CI, 80%-90%). Assessments generally did not vary by patient race or occupation, and multivariable analyses for all vignettes found no significant relationship between implicit biases and clinical assessments. Regression coefficient for the association between pain assessment and race IAT scores was -0.49 (95% CI, -1.00 to 0.03) and for social class, the coefficient was -0.04 (95% CI, -0.50 to 0.41). Adjusted odds ratios for other vignettes ranged from 0.69 to 3.03 per unit change in IAT score, but none were statistically significant. Analysis stratified by vignette patient race or class status yielded similarly negative results. Tests for interactions between patient race or class status and student IAT D scores in predicting clinical assessments were not statistically significant. The majority of first-year medical students at a single school had IAT scores consistent with implicit preference for white persons and possibly for those in the upper class. However, overall vignette-based clinical assessments were not associated with patient race or occupation, and no association existed between implicit preferences and the assessments.
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Many studies have reported that black individuals undergoing dialysis survive longer than those who are white. This observation is paradoxical given racial disparities in access to and quality of care, and is inconsistent with observed lower survival among black patients with chronic kidney disease. We hypothesized that age and the competing risk of transplantation modify survival differences by race. To estimate death among dialysis patients by race, accounting for age as an effect modifier and kidney transplantation as a competing risk. An observational cohort study of 1,330,007 incident end-stage renal disease patients as captured in the United States Renal Data System between January 1, 1995, and September 28, 2009 (median potential follow-up time, 6.7 years; range, 1 day-14.8 years). Multivariate age-stratified Cox proportional hazards and competing risk models were constructed to examine death in patients who receive dialysis. Death in black vs white patients who receive dialysis. Similar to previous studies, black patients undergoing dialysis had a lower death rate compared with white patients (232,361 deaths [57.1% mortality] vs 585,792 deaths [63.5% mortality], respectively; adjusted hazard ratio [aHR], 0.84; 95% confidence interval [CI], 0.83-0.84; P <.001). However, when stratifying by age and treating kidney transplantation as a competing risk, black patients had significantly higher mortality than their white counterparts at ages 18 to 30 years (27.6% mortality vs 14.2%; aHR, 1.93; 95% CI, 1.84-2.03), 31 to 40 years (37.4% mortality vs 26.8%; aHR, 1.46; 95% CI, 1.41-1.50), and 41 to 50 years (44.8% mortality vs 38.0%; aHR, 1.12; 95% CI, 1.10-1.14; P <.001 for interaction terms between race and each aforementioned age category), as opposed to patients aged 51 to 60 years (51.5% vs 50.9%; aHR, 0.93; 95% CI, 0.92-0.94), 61 to 70 years (64.9% vs 67.2%; aHR, 0.87; 95% CI, 0.86-0.88), 71 to 80 years (76.1% vs 79.7%; aHR, 0.85; 95% CI, 0.84-0.86), and older than 80 years (82.4% vs 83.6%; aHR, 0.87; 95% CI, 0.85-0.88). Overall, among dialysis patients in the United States, there was a lower risk of death for black patients compared with their white counterparts. However, the commonly cited survival advantage for black dialysis patients applies only to older adults, and those younger than 50 years have a higher risk of death.
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To assess whether a low level of decision support within a hospital computerized provider order entry system has an observable influence on the medication ordering process on ward-rounds and to assess prescribers' views of the decision support features. 14 specialty teams (46 doctors) were shadowed by the investigator while on their ward-rounds and 16 prescribers from these teams were interviewed. Senior doctors were highly influential in prescribing decisions during ward-rounds but rarely used the computerized provider order entry system. Junior doctors entered the majority of medication orders into the system, nearly always ignored computerized alerts and never raised their occurrence with other doctors on ward-rounds. Interviews with doctors revealed that some decision support features were valued but most were not perceived to be useful. The computerized alerts failed to target the doctors who were making the prescribing decisions on ward-rounds. Senior doctors were the decision makers, yet the junior doctors who used the system received the alerts. As a result, the alert information was generally ignored and not incorporated into the decision-making processes on ward-rounds. The greatest value of decision support in this setting may be in non-ward-round situations where senior doctors are less influential. Identifying how prescribing systems are used during different clinical activities can guide the design of decision support that effectively supports users in different situations. If confirmed, the findings reported here present a specific focus and user group for designers of medication decision support.
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In hospital, deep vein thrombosis (DVT) increases the morbidity and mortality in patients with acute medical illness. DVT prophylaxis is well known to be effective in preventing venous thromoembolism (VTE). However, its use remains suboptimal. The objective of this study was to evaluate the impact of quality improvement project on adherence with VTE prophylaxis guidelines and on the incidence of hospital-acquired VTEs in medical patients. The study was conducted at Saudi Aramco Medical Services Organization from June 2008 to August 2009. Quality improvement strategies included education of physicians, the development of a protocol, and weekly monitoring of compliance with the recommendations for VTE prophylaxis as included in the multidisciplinary rounds. A feedback was provided whenever a deviation from the protocol occurs. During the study period, a total of 560 general internal medicine patients met the criteria for VTE prophylaxis. Of those, 513 (91%) patients actually received the recommended VTE prophylaxis. The weekly compliance rate in the initial stage of the intervention was 63% (14 of 22) and increased to an overall rate of 100% (39 of 39) (P = 0.002). Hospital-acquired DVT rate was 0.8 per 1000 discharges in the preintervention period and 0.5 per 1000 discharges in the postintervention period, P = 0.51. However, there was a significant increase in the time-free period of the VTE and we had 11 months with no single DVT. In this study, the use of multiple interventions increased VTE prophylaxis compliance rate.
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In August 2008, the US Centers for Medicare & Medicaid Services (CMS) added deep venous thrombosis and pulmonary embolism after total knee arthroplasty (TKA) and total hip arthroplasty (THA) to the list of never events.1 If a patient experiences deep venous thrombosis or pulmonary embolism following one of these procedures, a portion of the payment made by CMS to hospitals is to be withheld. On the surface this decision seems to be a win-win for hospitals, clinicians, and patients. Venous thromboembolism (VTE) is a common cause of preventable harm,2 yet many hospitalized patients fail to receive adequate VTE prophylaxis.3 Accordingly, the strategy of using financial incentives to encourage better performance should result in fewer thrombotic events and consequently less morbidity and mortality related to VTE and its treatment.
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To determine the effect of race and insurance status on trauma mortality. Review of patients (aged 18-64 years; Injury Severity Score > or = 9) included in the National Trauma Data Bank (2001-2005). African American and Hispanic patients were each compared with white patients and insured patients were compared with uninsured patients. Multiple logistic regression analyses determined differences in survival rates after adjusting for demographics, injury severity (Injury Severity Score and revised Trauma Score), severity of head and/or extremity injury, and injury mechanism. A total of 429 751 patients met inclusion criteria. African American (n = 72,249) and Hispanic (n = 41,770) patients were less likely to be insured and more likely to sustain penetrating trauma than white patients (n = 262,878). African American and Hispanic patients had higher unadjusted mortality rates (white, 5.7%; African American, 8.2%; Hispanic, 9.1%; P = .05 for African American and Hispanic patients) and an increased adjusted odds ratio (OR) of death compared with white patients (African American OR, 1.17; 95% confidence interval [CI], 1.10-1.23; Hispanic OR, 1.47; 95% CI, 1.39-1.57). Insured patients (47%) had lower crude mortality rates than uninsured patients (4.4% vs 8.6%; P = .05). Insured African American and Hispanic patients had increased mortality rates compared with insured white patients. This effect worsened for uninsured patients across groups (insured African American OR, 1.2; 95% CI, 1.08-1.33; insured Hispanic OR, 1.51; 95% CI, 1.36-1.64; uninsured white OR, 1.55; 95% CI, 1.46-1.64; uninsured African American OR, 1.78; 95% CI, 1.65-1.90; uninsured Hispanic OR, 2.30; 95% CI, 2.13-2.49). The reference group was insured white patients. Race and insurance status each independently predicts outcome disparities after trauma. African American, Hispanic, and uninsured patients have worse outcomes, but insurance status appears to have the stronger association with mortality after trauma.
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Many studies have documented race and gender differences in health care received by patients. However, few studies have related differences in the quality of interpersonal care to patient and physician race and gender. To describe how the race/ethnicity and gender of patients and physicians are associated with physicians' participatory decision-making (PDM) styles. Telephone survey conducted between November 1996 and June 1998 of 1816 adults aged 18 to 65 years (mean age, 41 years) who had recently attended 1 of 32 primary care practices associated with a large mixed-model managed care organization in an urban setting. Sixty-six percent of patients surveyed were female, 43% were white, and 45% were African American. The physician sample (n = 64) was 63% male, with 56% white, and 25% African American. Patients' ratings of their physicians' PDM style on a 100-point scale. African American patients rated their visits as significantly less participatory than whites in models adjusting for patient age, gender, education, marital status, health status, and length of the patient-physician relationship (mean [SE] PDM score, 58.0 [1.2] vs 60.6 [3.3]; P = .03). Ratings of minority and white physicians did not differ with respect to PDM style (adjusted mean [SE] PDM score for African Americans, 59.2 [1.7] vs whites, 61.7 [3.1]; P = .13). Patients in race-concordant relationships with their physicians rated their visits as significantly more participatory than patients in race-discordant relationships (difference [SE], 2.6 [1.1]; P = .02). Patients of female physicians had more participatory visits (adjusted mean [SE] PDM score for female, 62.4 [1.3] vs male, 59.5 [3.1]; P = .03), but gender concordance between physicians and patients was not significantly related to PDM score (unadjusted mean [SE] PDM score, 76.0 [1.0] for concordant vs 74.5 [0.9] for discordant; P = .12). Patient satisfaction was highly associated with PDM score within all race/ethnicity groups. Our data suggest that African American patients rate their visits with physicians as less participatory than whites. However, patients seeing physicians of their own race rate their physicians' decision-making styles as more participatory. Improving cross-cultural communication between primary care physicians and patients and providing patients with access to a diverse group of physicians may lead to more patient involvement in care, higher levels of patient satisfaction, and better health outcomes.
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In its study of racial and ethnic disparities in health care, the Institute of Medicine (IOM) concluded that there were large and significant disparities in the quality and quantity of health care received by minority groups in the United States. This article shows that where a patient lives can itself have a large impact on the level and quality of health care the patient receives. Since black or Hispanic populations tend to live in different areas from non-Hispanic white populations, location matters in the measurement and interpretation of health (and health care) disparities. There is wide variation in racial disparities across geographic lines: some areas have substantial disparities, while others have equal treatment. Furthermore, there is no consistent pattern of disparities: some areas may have a wide disparity in one treatment but no disparity in another. The problem of differences in quality of care across regions, as opposed to racial disparities in care, should remain the target of policy makers, as reducing quality disparities would play a major role in improving the health care received by all Americans and by minority Americans in particular.
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Venous thromboembolism (VTE) is an important cause of preventable morbidity and mortality in medically ill patients. Randomized controlled trials indicate that pharmacologic prophylaxis reduces deep venous thrombosis (relative risk [RR] = 0.46; 95% confidence interval [CI], 0.36-0.59) and pulmonary embolism (RR = 0.49; 95% CI, 0.33-0.72) with a nonsignificant trend toward more bleeding (RR = 1.36; 95% CI, 0.80-2.33]. Low-molecular-weight heparin (LMWH) and unfractionated heparin are equally efficacious in preventing deep venous thrombosis (RR = 0.85; 95% CI, 0.69-1.06) and pulmonary embolism (RR = 1.05; 95% CI, 0.47-2.38), but LMWH is associated with significantly less major bleeding (RR = 0.45; 95% CI, 0.23-0.85). LMWH is favored for VTE prophylaxis in critically ill patients. New VTE and bleeding risk stratification tools offer the potential to improve the risk-benefit ratio for VTE prophylaxis in medically ill patients. Intermittent pneumatic compression devices should be used for VTE prophylaxis in patients with contraindications to pharmacologic prophylaxis. Graduated compression stockings should be used with caution. VTE prevention in medically ill patients using extended-duration VTE prophylaxis and new oral anticoagulants warrant further investigation. VTE prophylaxis prescription and administration rates are suboptimal and warrant multidisciplinary performance improvement strategies.
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The authors hypothesized that use of a computer alert program to alert physicians regarding hospitalized patients at high risk for VTE might reduce the frequency of DVT by increasing the frequency of prophylaxis. A computer program was developed linked to a patient database to identify hospitalized patients at risk for VTE. The patients were randomly assigned to an intervention group in which the treating physician was made aware of the patient’s risk of VTE (n = 1255) or to a control group in which no such alert was issued (n = 1251). Physicians receiving the alert for VTE prophylaxis were required to acknowledge the alert and could then order or withhold prophylaxis according to clinical judgment. Prophylaxis included graduated compression stockings, pneumatic compression boots, unfractionated heparin, warfarin, or low-molecular-weight heparin. Clinically diagnosed, objectively confirmed VTE (DVT or pulmonary embolism) at 90 days was the primary end point.
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Background Race and socioeconomic disparities are pervasive and persist throughout our health care system. Inequities have also been identified in outcomes after trauma despite its immediate nature and the perceived equal access to emergent care.