Physicians have long known the risk of venous thromboembolism in surgical candidates. Post-operative patients on bed rest have increased risk of a blood clot formation traveling to a distant organ, resulting in death. In fact, fatal pulmonary embolism may occur in as much as 1 percent of patients undergoing general surgery and 3 percent of orthopedic surgery patients. Often it can be avoided with the prescription of appropriate prophylaxis following surgery.
This month, the Journal of the American Medical Association (JAMA) reports the positive results of a study on the prescription of medication to prevent venous thromboembolism in post-surgical orthopedic patients. This study was conducted in the orthopedic surgery department of Lariboisiere Hospital, a public teaching hospital in the Paris metropolitan area.
This study evaluates physicians’ prescription of anticoagulation medication following the introduction of a clinical decision support system (CDSS) to their post-surgical process. The doctors involved in the study look to improve the quality of health care by suggesting more appropriate courses of treatment to prevent venous thromboembolism in their orthopedic patients.
CDSSs were established in response to a report issued by the Institute of Medicine (IOM) in 1990. The IOM recommended the use of practice guidelines in clinical care in order to regulate doctors’ procedures, reduce the cost of medical care, and improve health care practices. These guidelines turned out to be underutilized in clinical settings, so focus has now turned to CDSSs. A CDSS is defined as any mechanism that assists a physician in the decision-making process during the patient care process.
The CDSS used in this case is an online database designed to support doctors’ decision-making. The database is compiled from information obtained from the patient at the admission desk of the hospital, as well as the patient’s relevant clinical and treatment information entered by the doctor directly following surgery. Based on the information given by the patient and doctor, the CDSS will immediately notify the doctor if the treatment recommendations are unsound. In addition, the CDSS will recommend a more appropriate prescription and explain the reasons. The physician then has the opportunity to change or keep the current order.
During the periods when the CDSS was used, a total of 13.2 percent of prescriptions were deemed inappropriate by the system. Among these, 61.1 percent were modified by the physician according to the recommendation of the CDSS. The other 38.9 percent remained unchanged.
This study shows that physicians’ behavior changed with the introduction of this critiquing system. Their awareness of the most appropriate treatments to combat venous thromboembolism improved with the introduction of the CDSS. The physicians involved recognize the limitations inherent in the study. The CDSS that they used in the orthopedic department of their particular hospital may not be the appropriate solution at other sites. However, the results reported in the JAMA encourage further investigation into the effectiveness of CDSSs to prevent the onset of venous thromboembolism in other hospital settings.
For more information visit:
http://jama.ama-assn.org
http://oncology.medscape.com
Durieux, Pierre. “A Clinical Decision Support System for Prevention of Venous Thromboembolism.” The Journal of the American Medical Association, June 7,2000;283.
