Background:There are multiple risk assessment models (RAMs) for venous thromboembolism prophylaxis, but it is unknown whether they increase appropriate prophylaxis.Methods:To determine the impact of a RAM embedded in the electronic health record, we conducted a stepped-wedge hospital-level cluster-randomized trial conducted from October 1, 2017 to February 28, 2019 at 10 Cleveland Clinic hospitals. We included consecutive general medical patients aged 18 years or older. Patients were excluded if they had a contraindication to prophylaxis, including anticoagulation for another condition, acute bleeding, or comfort-only care. A RAM was embedded in the general admission order set and physicians were encouraged to use it. The decisions to use the RAM and act on the results were reserved to the treating physician. The primary outcome was the percentage of patients receiving appropriate prophylaxis (high-risk patients with pharmacological thromboprophylaxis plus low-risk patients without prophylaxis) within 48 hours of hospitalization. Secondary outcomes included total patients receiving prophylaxis, venous thromboembolism among high-risk patients at 14 and 45 days, major bleeding, heparin-induced thrombocytopenia, and length of stay. Mixed-effects models were used to analyze the study outcomes.Results:A total of 26 506 patients (mean age, 61; 52% female; 73% White) were analyzed, including 11 134 before and 15 406 after implementation of the RAM. After implementation, the RAM was used for 24% of patients, and the percentage of patients receiving appropriate prophylaxis increased from 43.1% to 48.8% (adjusted odds ratio, 1.11 [1.00–1.23]), while overall prophylaxis use decreased from 73.5% to 65.2% (adjusted odds ratio, 0.87 [0.78–0.97]). Rates of venous thromboembolism among high-risk patients (adjusted odds ratio, 0.72 [0.38–1.36]), rates of bleeding and heparin-induced thrombocytopenia (adjusted odds ratio, 0.19 [0.02–1.47]), and length of stay were unchanged.Conclusions:Implementation of a RAM for venous thromboembolism increased appropriate prophylaxis use, but the RAM was used for a minority of patients.REGISTRATION:URL: https://www.clinicaltrials.gov/study/NCT03243708?term=nct03243708&rank=1; Unique identifier: NCT03243708.

中文翻译：

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在电子健康记录中嵌入静脉血栓栓塞风险评估模型与常规护理的影响：整群随机试验

背景：有多种用于静脉血栓栓塞预防的风险评估模型 (RAM)，但尚不清楚它们是否会增加适当的预防。方法：为了确定嵌入电子健康记录中 RAM 的影响，我们进行了阶梯楔形医院- 2017年10月1日至2019年2月28日在10家克利夫兰诊所医院进行的水平整群随机试验。我们纳入了 18 岁或以上的连续普通内科患者。如果患者有预防禁忌症，包括因其他病症而抗凝、急性出血或仅舒适护理，则被排除在外。RAM 嵌入在一般入院医嘱集中，并鼓励医生使用它。使用 RAM 和根据结果采取行动的决定由治疗医生保留。主要结局是住院 48 小时内接受适当预防的患者（接受药物血栓预防的高危患者加上未接受预防的低危患者）的百分比。次要结局包括接受预防治疗的患者总数、14 和 45 天高危患者的静脉血栓栓塞、大出血、肝素诱导的血小板减少症和住院时间。采用混合效应模型分析研究结果。结果：共分析了26 506例患者（平均年龄61岁；52%女性；73%白人），其中RAM实施前11 134例，RAM实施后15 406例。实施后，RAM 用于 24% 的患者，接受适当预防的患者百分比从 43.1% 增加到 48.8%（调整后的比值比，1.11 [1.00–1.23]），而总体预防使用从 73.5% 下降到65.2%（调整后的优势比，0.87 [0.78–0.97]）。高危患者的静脉血栓栓塞发生率（调整后的比值比，0.72 [0.38–1.36]）、出血和肝素诱导的血小板减少症的发生率（调整后的比值比，0.19[0.02–1.47]）和住院时间没有变化。结论：实施 RAM 治疗静脉血栓栓塞增加了适当的预防使用，但 RAM 只用于少数患者。注册：URL：https://www.clinicaltrials.gov/study/NCT03243708?term=nct03243708&rank=1；唯一标识符：NCT03243708。