药师干预对华法林抗凝治疗质量的影响
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摘要
目的评价临床药师开展的药学服务对华法林抗凝治疗质量的影响及产生的效果。方法 2016. 9～2017. 9期间临床药师纳入我院血管外科及心内科因血栓栓塞性疾病的预防或治疗而需要口服华法林抗凝治疗的患者,按设定的药学服务流程进行管理及随访,同时调取我院信息系统中2013. 7～2015. 7期间服用华法林的患者作为基线对照组,记录两组患者的INR(国际标准化比值)变化情况、华法林稳态剂量、达稳态时间等,并计算患者的TTR(达标时间百分比),对两组的指标变化情况进行统计分析。结果与对照组相比,临床药师干预的患者TTR明显升高[(63. 65±32. 00)%vs.(50. 80±22. 32)%,P=0. 003],高质量抗凝治疗的患者比例明显提高(47. 89%vs. 20. 09%,P <0. 001),达稳态时间明显缩短[(22. 81±14. 91) vs.(46. 14±80. 79),P=0. 003],INR监测次数明显增多[(11. 7±4. 8) vs.(6. 0±3. 5),P <0. 001];药师用药教育后患者的抗凝认知评分较用药教育前大幅升高[(16. 78±0. 92) vs.(6. 93±3. 77),P <0. 001]。结论临床药师参与抗凝药物治疗管理可显著改善患者华法林抗凝治疗的质量。
OBJECTIVE To evaluate the effects of clinical pharmacy services in patients with warfarin and highlight the important role of clinical pharmacists. METHODS Patients in need of warfarin were enrolled as intervention group during 2016. 9-2017. 9 to receive standard anticoagulation management and follow-up provided by clinical pharmacists,and clinical data of patients who meet the inclusion criteria during 2013. 7-2015. 7 as control group was analyzed retrospectively. International normalized ratio( INR) values,maintenance doses,time to achieve therapeutic range,and etc. were recorded and TTRs( time in therapeutic range) were calculated to compare the outcomes of each group. RESULTS TTRs in intervention group were significantly higher than those in control group[( 63. 65 ± 32. 00) % vs.( 50. 80 ± 22. 32) %,P = 0. 003],and so was the percentage of patients with the best quality of warfarin therapy( 47. 89% vs. 20. 09%,P < 0. 001). Time to achieve therapeutic range was shorter[( 22. 81 ± 14. 91) vs.( 46. 14 ± 80. 79),P = 0. 003] and the frequency of INR test was higher [( 11. 7 ± 4. 8) vs.( 6. 0 ± 3. 5),P < 0. 001] in intervention group compared with those in control group. Patients' cognitive scores of warfarin therapy were substantially increased after pharmacist' s education[( 16. 78 ± 0. 92) vs.( 6. 93 ± 3. 77),P < 0. 001]. CONCLUSION Anticoagulation therapy management provided by clinical pharmacists could significantly improve the quality of warfarin therapy.
OBJECTIVE To evaluate the effects of clinical pharmacy services in patients with warfarin and highlight the important role of clinical pharmacists. METHODS Patients in need of warfarin were enrolled as intervention group during 2016. 9-2017. 9 to receive standard anticoagulation management and follow-up provided by clinical pharmacists,and clinical data of patients who meet the inclusion criteria during 2013. 7-2015. 7 as control group was analyzed retrospectively. International normalized ratio( INR) values,maintenance doses,time to achieve therapeutic range,and etc. were recorded and TTRs( time in therapeutic range) were calculated to compare the outcomes of each group. RESULTS TTRs in intervention group were significantly higher than those in control group[( 63. 65 ± 32. 00) % vs.( 50. 80 ± 22. 32) %,P = 0. 003],and so was the percentage of patients with the best quality of warfarin therapy( 47. 89% vs. 20. 09%,P < 0. 001). Time to achieve therapeutic range was shorter[( 22. 81 ± 14. 91) vs.( 46. 14 ± 80. 79),P = 0. 003] and the frequency of INR test was higher [( 11. 7 ± 4. 8) vs.( 6. 0 ± 3. 5),P < 0. 001] in intervention group compared with those in control group. Patients' cognitive scores of warfarin therapy were substantially increased after pharmacist' s education[( 16. 78 ± 0. 92) vs.( 6. 93 ± 3. 77),P < 0. 001]. CONCLUSION Anticoagulation therapy management provided by clinical pharmacists could significantly improve the quality of warfarin therapy.
引文
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[6]GARWOOD C L,DUMO P,BARINGHAUS S N,et al.Quality of anticoagulation care in patients discharged from a pharmacistmanaged anticoagulation clinic after stabilization of warfarin therapy[J].Pharmacotherapy,2008,28(1):20-26.
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[8]ROSENDAAL F R,CANNEGIETER S C,VAN DER MEER F J,et al.A method to determine the optimal intensity of oral anticoagulant therapy[J].Thromb Haemost,1993,69(3):236-239.
[9]GE W H.Handbook of Warfarin Anticoagulation Therapy for Clinical Pharmacist(华法林抗凝治疗临床药师指导手册)[M].Beijing:People's Medical Publishing House,2009:9-64.
[10]CAMM A J,LIP G Y,DE CATERINA R,et al.2012 focused update of the ESC Guidelines for the management of atrial fibrillation:an update of the 2010 ESC Guidelines for the management of atrial fibrillation.Developed with the special contribution of the European Heart Rhythm Association[J].Eur Heart J,2012,33(21):2719-2747.
[11]CONNOLLY S J,EZEKOWITZ M D,YUSUF S,et al.Dabigatran versus warfarin in patients with atrial fibrillation[J].N Engl J Med,2009,361(12):1139-1151.
[12]PATEL M R,MAHAFFEY K W,GARG J,et al.Rivaroxaban versus warfarin in nonvalvular atrial fibrillation[J].N Engl J Med,2011,365(10):883-891.
[13]GRANGER C B,ALEXANDER J H,MCMURRAY J J,et al.Apixaban versus warfarin in patients with atrial fibrillation[J].NEngl J Med,2011,365(11):981-992.
[14]CONNOLLY S J,POGUE J,EIKELBOOM J,et al.Benefit of oral anticoagulant over antiplatelet therapy in atrial fibrillation depends on the quality of international normalized ratio control achieved by centers and countries as measured by time in therapeutic range[J].Circulation,2008,118(20):2029-2037.
[15]BAKER J W,PIERCE K L,RYALS C A.INR goal attainment and oral anticoagulation knowledge of patients enrolled in an anticoagulation clinic in a veterans affairs medical center[J].J Manag Care Pharm,2011,17(2):133-142.
[16]JOSHUA J K,KAKKAR N.Lacunae in patient knowledge about oral anticoagulant treatment:results of a questionnaire survey[J].Indian J Hematol Blood Transfus,2015,31(2):275-280.
[17]CHEN L,YE S W,JIANG Y H,et al.The management mode of warfarin anticoagulation clinic[J].Her Med(医药导报),2015,34(2):281-283.
[18]HU D,SUN Y.Epidemiology,risk factors for stroke,andmanagement of atrial fibrillation in China[J].J Am Coll Cardiol,2008,52:865-868.
[19]ZHOU Z Q,HU D Y,CHEN J,et al.An epidemiological survey of atrial fibrillation in China[J].Chin J Intern Med(中华内科杂志),2004,43(7):491-494.
[20]XI X Y,YAO D N,HUANG Y K,et al.National survey on clinical pharmacy services of tertiary hospitals in China:Part 1.Introduction of survey and basic conditions of clinical pharmacy service provision[J].Chin Pharm J(中国药学杂志),2017,52(19):1746-1752.
[21]CUI L,XI X Y,YAO D N,et al.National survey on clinical pharmacy services of tertiary hospitals in China:Part 3.Status quo of clinical pharmacy service provision[J].Chin Pharm J(中国药学杂志),2018,53(10):837-842.
[2]Chinese Society of Cardiology,Committee of Cardiocerebrovascular Diseases of Gerontological Society of China.China consensus of warfarin anticoagulation therapy[J].Chin J Intern Med(中华内科杂志),2013,52(1):76-82.
[3]ANSELL J,HIRSH J,DALEN J,et al.Managing oral anticoagulanttherapy[J].Chest,2001,119(suppl):22S-38S.
[4]SPYROPOULOS A C.Managing oral anticoagulation requires expertexperience and clinical evidence[J].J Thromb Thrombolysis,2006,21(1):91-94.
[5]GUPTA V,KOGUT S J,THOMPSON S.Evaluation of differences in percentage of international normalized ratios in range between pharmacist-led and physician-led anticoagulation management services[J].J Pharm Pract,2015,28(3):249-255.
[6]GARWOOD C L,DUMO P,BARINGHAUS S N,et al.Quality of anticoagulation care in patients discharged from a pharmacistmanaged anticoagulation clinic after stabilization of warfarin therapy[J].Pharmacotherapy,2008,28(1):20-26.
[7]LI L L,LI Y,DU L P,et al.Quality evaluation of anticoagulant therapy in patients who taking warfarin in our hospital[J].J China Pharm(中国药房),2016,27(15):2032-2034.
[8]ROSENDAAL F R,CANNEGIETER S C,VAN DER MEER F J,et al.A method to determine the optimal intensity of oral anticoagulant therapy[J].Thromb Haemost,1993,69(3):236-239.
[9]GE W H.Handbook of Warfarin Anticoagulation Therapy for Clinical Pharmacist(华法林抗凝治疗临床药师指导手册)[M].Beijing:People's Medical Publishing House,2009:9-64.
[10]CAMM A J,LIP G Y,DE CATERINA R,et al.2012 focused update of the ESC Guidelines for the management of atrial fibrillation:an update of the 2010 ESC Guidelines for the management of atrial fibrillation.Developed with the special contribution of the European Heart Rhythm Association[J].Eur Heart J,2012,33(21):2719-2747.
[11]CONNOLLY S J,EZEKOWITZ M D,YUSUF S,et al.Dabigatran versus warfarin in patients with atrial fibrillation[J].N Engl J Med,2009,361(12):1139-1151.
[12]PATEL M R,MAHAFFEY K W,GARG J,et al.Rivaroxaban versus warfarin in nonvalvular atrial fibrillation[J].N Engl J Med,2011,365(10):883-891.
[13]GRANGER C B,ALEXANDER J H,MCMURRAY J J,et al.Apixaban versus warfarin in patients with atrial fibrillation[J].NEngl J Med,2011,365(11):981-992.
[14]CONNOLLY S J,POGUE J,EIKELBOOM J,et al.Benefit of oral anticoagulant over antiplatelet therapy in atrial fibrillation depends on the quality of international normalized ratio control achieved by centers and countries as measured by time in therapeutic range[J].Circulation,2008,118(20):2029-2037.
[15]BAKER J W,PIERCE K L,RYALS C A.INR goal attainment and oral anticoagulation knowledge of patients enrolled in an anticoagulation clinic in a veterans affairs medical center[J].J Manag Care Pharm,2011,17(2):133-142.
[16]JOSHUA J K,KAKKAR N.Lacunae in patient knowledge about oral anticoagulant treatment:results of a questionnaire survey[J].Indian J Hematol Blood Transfus,2015,31(2):275-280.
[17]CHEN L,YE S W,JIANG Y H,et al.The management mode of warfarin anticoagulation clinic[J].Her Med(医药导报),2015,34(2):281-283.
[18]HU D,SUN Y.Epidemiology,risk factors for stroke,andmanagement of atrial fibrillation in China[J].J Am Coll Cardiol,2008,52:865-868.
[19]ZHOU Z Q,HU D Y,CHEN J,et al.An epidemiological survey of atrial fibrillation in China[J].Chin J Intern Med(中华内科杂志),2004,43(7):491-494.
[20]XI X Y,YAO D N,HUANG Y K,et al.National survey on clinical pharmacy services of tertiary hospitals in China:Part 1.Introduction of survey and basic conditions of clinical pharmacy service provision[J].Chin Pharm J(中国药学杂志),2017,52(19):1746-1752.
[21]CUI L,XI X Y,YAO D N,et al.National survey on clinical pharmacy services of tertiary hospitals in China:Part 3.Status quo of clinical pharmacy service provision[J].Chin Pharm J(中国药学杂志),2018,53(10):837-842.