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Misdiagnosis of asymptomatic bacteriuria as catheter-associated urinary tract infection (CAUTI) leads to unnecessary tests and other low-value care. We used this topic as the prototype to develop a clinical pathways program to promote evidence-based decision making in a multi-hospital system.
We convened a task force including hospital and critical care physicians, nurses, laboratory staff, and informatics specialists. Our Health Technology Asessment (HTA) center completed a rapid systematic review on guidelines and algorithms for diagnosing CAUTI. Additional rapid reviews were completed as necessary to address specific follow-up questions. A draft pathway based on the guidelines was developed, and then the task force edited it in an iterative process.
We used the Dorsata platform (Dorsata Inc., Washington, DC) to create, distribute and maintain the pathway. Dorsata has both desktop and mobile interfaces that guide clinicians through decision algorithms. Individual pathways include links to references and a portal for direct user feedback. Pathway owners have access to a real-time pathway utilization dashboard.
A standardized order set with the pathway was added to our electronic health record system. We also held educational meetings for residents and provided “huddle sheets” to nurse educators at each hospital. Posters and computer screen savers were also used to raise awareness of the new pathway.
We now have a total of 111 pathways on Dorsata, developed following the same model as the CAUTI evaluation pathway. Some topics, like breast cancer, have as many as sixteen pathways, addressing different clinical questions like first- and second-line therapy. Over 600 individuals have registered for the mobile app, including attending and resident physicians, nurses, and medical students. The pathway site had 1,619 views in December 2016, the most recent month for which complete records are available. The pathways are proving to have an effect on clinical decision making. For example, the annualized number of unnecessary urine cultures avoided as a result of the pathway is 4,474; resulting in estimated direct cost savings of USD67,110.
Using pathways to present HTA information at the point of care is feasible and can improve the value of care.
Risk prediction scores have been devised to identify patients at increased risk for Venous Thromboembolism (VTE) in different patient populations and settings. Guideline recommendations for VTE risk assessment vary greatly. We performed a systematic review to synthesize evidence on clinical risk prediction scores for VTE in hospitalized medical and surgical patients.
We systematically searched Medline, EMBASE, Cochrane, National Institute of Health and Care Excellence (NICE), National Guidelines Clearinghouse (NGC), and Guidelines International Network (GIN) databases up to March 2016. We included studies validating risk prediction scores for adult hospitalized patients. We excluded studies for any of the following reasons: non-English publication, conducted in non-OECD (Organisation for Economic Co-operation and Development) countries, validation cohorts focused solely on critical care patients, or scores developed for specific surgical or medical sub-specialty populations. We plotted receiver operating characteristic (ROC) curves of included studies and performed summary ROC meta-analyses for scores in which >1 external validation studies were combinable. Risk of bias was assessed qualitatively. We assessed the strength of the evidence base using Grading of Recommendations Assessment, Development and Evaluation (GRADE).
We screened 110 primary studies and included 18 of those for analysis. There were seven studies of the Caprini score, three studies of the Padua score, two studies of the IMPROVE score; and one study each of the Arcelus, Geneva, Khorana, RAP, and Kucher scores . Strength of evidence was downgraded for study risk of bias because most studies disproportionately included patients at high risk of VTE. Our summary estimates of the performance of the three combinable scores at clinically-relevant thresholds are: Caprini score at a threshold of three in surgical patients – 96 percent sensitivity, 44 percent specificity; IMPROVE at a threshold of one in medical patients – 96 percent sensitivity, 20 percent specificity; and Padua at a threshold of 4–87 percent sensitivity and 58 percent specificity.
There is moderate strength evidence for use of the Caprini score to predict VTE in surgical patients and for the Padua and IMPROVE scores in medical patients. Lower thresholds may be warranted to achieve sufficient sensitivity to identify low risk populations who may not require routine VTE prophylaxis. Studies making direct comparisons of risk prediction scores in similar patient populations are lacking and are necessary to ascertain which score is most effective.
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