title: Development and pilot feasibility study of a health information technology tool to calculate mortality risk for patients with asymptomatic carotid stenosis: the Carotid Risk Assessment Tool (CARAT).
abstract: BACKGROUND
  Patients with no history of stroke but with stenosis of the carotid arteries can reduce the risk of future stroke with surgery or stenting. At present, a physicians' ability to recommend optimal treatments based on an individual's risk profile requires estimating the likelihood that a patient will have a poor peri-operative outcomes and the likelihood that the patient will survive long enough to gain benefit from the procedure. We describe the development of the CArotid Risk Assessment Tool (CARAT) into a 2-year mortality risk calculator within the electronic medical record, integrating the tool into the clinical workflow, training the clinical team to use the tool, and assessing the feasibility and acceptability of the tool in one clinic setting.
  
  
  METHODS
  We modified an existing clinical flowsheet with the local electronic medical record for the CARAT risk model. To understand how CARAT would fit into the existing clinical workflow, we observed the clinic and talked with the clinical staff to develop a process map for the existing clinical workflow. CARAT was completed by the clinic nurse for patients identified on the clinic schedule as having carotid narrowing. We analyzed post-implementation assessment in two ways: quantifying the proportion of eligible patients with whom CARAT was utilized, and surveying surgeons to understand the impact of CARAT on decision-making and clinical workflow.
  
  
  RESULTS
  With minimum investment of institutional resources, we were able to produce a workable tool and pilot the tool in our clinic within a 6 month time period. Over 4 months, 287 patients were seen in the clinic with carotid narrowing, and clinic staff completed CARAT for 195 (68%). Per-surgeon completion rates ranged from 29 to 81%. Most patients (191 of 195, 98%) patients had a low 2-year calculated mortality risk. Most surgeons believed the risk assessment aligned with their expectations of patient predicted risk.
  
  
  CONCLUSIONS
  We successfully integrated CARAT into the existing electronic medical record and have preliminary evidence that CARAT can be a valuable tool for evaluating mortality risk for patients with diseased carotid arteries. Accuracy of the risk calculations must be evaluated in larger, multi-center studies.
authors.affiliation: The Dartmouth Institute of Health Policy and Clinical Practice, Lebanon, NH, USA.
authors.forename: Adrienne E
authors.initials: AE
authors.lastname: Faerber
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Horvath
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
authors.forename: Carey
authors.initials: C
authors.lastname: Stillman
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
authors.forename: Melissa L
authors.initials: ML
authors.lastname: O'Connell
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
authors.forename: Amy L
authors.initials: AL
authors.lastname: Hamilton
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
authors.forename: Karina A
authors.initials: KA
authors.lastname: Newhall
authors.affiliation: The Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Donald S
authors.initials: DS
authors.lastname: Likosky
authors.affiliation: The Dartmouth Institute of Health Policy and Clinical Practice, Lebanon, NH, USA. Philip.P.Goodney@hitchcock.org.|Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA. Philip.P.Goodney@hitchcock.org.
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery; D000066491:Clinical Decision-Making; D057286:Electronic Health Records; D005240:Feasibility Studies; D006801:Humans; D008491:Medical Informatics Applications; D010865:Pilot Projects; D011379:Prognosis; D018570:Risk Assessment