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Evaluation of a fast-and-frugal clinical decision algorithm ('pathways') on clinical outcomes in hospitalised patients with COVID-19 treated with anticoagulants.
Djulbegovic, Benjamin; Hozo, Iztok; Lizarraga, David; Thomas, Joseph; Barbee, Michael; Shah, Nupur; Rubeor, Tyler; Dale, Jordan; Reiser, Jochen; Guyatt, Gordon.
Afiliación
  • Djulbegovic B; Department of Computational & Quantitative Medicine, City of Hope, Beckman Research Institute, Duarte, California, USA.
  • Hozo I; Division of Health Analytics, Beckman Research Institute, Duarte, California, USA.
  • Lizarraga D; Evidence-Based Medicine & Comparative Effectiveness Research, Beckman Research Institute, Duarte, California, USA.
  • Thomas J; Department of Mathematics, Indiana University, Gary, Indiana, USA.
  • Barbee M; Department of Computational & Quantitative Medicine, City of Hope, Beckman Research Institute, Duarte, California, USA.
  • Shah N; Division of Health Analytics, Beckman Research Institute, Duarte, California, USA.
  • Rubeor T; Evidence-Based Medicine & Comparative Effectiveness Research, Beckman Research Institute, Duarte, California, USA.
  • Dale J; Rush University Medical Center (RUMC), Chicago, Illinois, USA.
  • Reiser J; Division of Hospital Medicine, Department of Hospital Medicine, Rush University Medical Center, Chicago, Illinois, USA.
  • Guyatt G; Rush University Medical Center (RUMC), Chicago, Illinois, USA.
J Eval Clin Pract ; 29(1): 3-12, 2023 02.
Article en En | MEDLINE | ID: mdl-36229950
RATIONALE, AIMS AND OBJECTIVES: Critics have charged that evidence-based medicine (EBM) overemphasises algorithmic rules over unstructured clinical experience and intuition, but the role of structured decision support systems in improving health outcomes remains uncertain. We aim to assess if delivery of anticoagulant prophylaxis in hospitalised patients with COVID-19 according to an algorithm based on evidence-based clinical practice guideline (CPG) improved clinical outcomes compared with administration of anticoagulant treatment given at individual practitioners' discretion. METHODS: An observational design consisting of the analysis of all acutely ill, consecutive patients (n = 1783) with confirmed COVID-19 diagnosis admitted between 10 March 2020 to 11 January 2022 to an US academic center. American Society of Haematology CPG for anticoagulant prophylaxis in hospitalised patients with COVID-19 was converted into a clinical pathway and translated into fast-and-frugal decision (FFT) tree ('algorithm'). We compared delivery of anticoagulant prophylaxis in hospitalised patients with COVID-19 according to the FFT algorithm with administration of anticoagulant treatment given at individual practitioners' discretion. RESULTS: In an adjusted analysis, using combination of Lasso (least absolute shrinkage and selection operator) and propensity score based weighting [augmented inverse-probability weighting] statistical techniques controlling for cluster data, the algorithm did not reduce death, venous thromboembolism, or major bleeding, but helped avoid longer hospital stay [number of patients needed to be treated (NNT) = 40 (95% CI: 23-143), indicating that for every 40 patients (23-143) managed on FFT algorithm, one avoided staying in hospital longer than 10 days] and averted admission to intensive-care unit (ICU) [NNT = 19 (95% CI: 13-40)]. All model's selected covariates were well balanced. The results remained robust to sensitivity analyses used to test the stability of the findings. CONCLUSIONS: When delivered using a structured FFT algorithm, CPG shortened the hospital stay and help avoided admission to ICU, but it did not affect other relevant outcomes.
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Texto completo: 1 Banco de datos: MEDLINE Asunto principal: COVID-19 Tipo de estudio: Guideline / Prognostic_studies Límite: Humans Idioma: En Revista: J Eval Clin Pract Asunto de la revista: PESQUISA EM SERVICOS DE SAUDE Año: 2023 Tipo del documento: Article País de afiliación: Estados Unidos

Texto completo: 1 Banco de datos: MEDLINE Asunto principal: COVID-19 Tipo de estudio: Guideline / Prognostic_studies Límite: Humans Idioma: En Revista: J Eval Clin Pract Asunto de la revista: PESQUISA EM SERVICOS DE SAUDE Año: 2023 Tipo del documento: Article País de afiliación: Estados Unidos