Matchar David B
Center for Clinical Health Policy Research, Duke University, Durham, NC, USA.
Card Electrophysiol Rev. 2003 Dec;7(4):379-81. doi: 10.1023/B:CEPR.0000023144.60821.d1.
An Anticoagulation Clinic Service (ACS) has been proposed as one strategy for improving warfarin treatment for patients with atrial fibrillation. In the Managing Anticoagulation Services Trial (MAST), ACSs meeting specifications for high quality care were established in six managed care organizations (MCOs) which had the patients and resources to support this initiative. The trial followed 1165 patients age >or=65 years who had atrial fibrillation as the primary reason for anticoagulation and were enrolled in a participating MCO. The 593 patients in the intervention group saw physicians in a practice cluster which had randomly been assigned to have access to an ACS. These physicians used the ACS on average for about 48% of eligible patients. The 572 patients in the control group received care from physicians in a practice cluster which could not refer patients to the ACS established for the trial but was otherwise unrestricted. The two clusters were compared on the proportion of time warfarin-treated patients were in the target range (2-3) prothrombin time-international normalized ratio (INR) during a 9-month baseline and a 9-month follow-up period. Among patients ( n = 264) for whom data were available for both periods, the changes in percentages of time in the target range were similar in the intervention cluster (baseline: 47.7%; follow-up 55.6%) and in the control cluster (baseline: 49.1%; follow-up: 52.3%; intervention effect: 5%; 95% confidence interval: -5% to 14%; P = 0.32). In both practice clusters, patients had subtherapeutic INR values (1.5 to 1.99) about one fourth of the time. Providing an ACS in a managed care setting did not appear to improve anticoagulation care over the usual care provided at the sites in this trial but could be a reasonable consideration in a practice setting where time in target range is less than 50%. A higher rate of utilization and a more aggressive stance toward subtherapeutic INR values could potentially enhance the effectiveness of an ACS.
抗凝门诊服务（ACS）已被提议作为改善心房颤动患者华法林治疗的一种策略。在管理抗凝服务试验（MAST）中，在六个有患者和资源支持该项目的管理式医疗组织（MCO）中建立了符合高质量护理规范的ACS。该试验跟踪了1165名年龄≥65岁、以心房颤动作为抗凝主要原因且加入了参与试验的MCO的患者。干预组的593名患者在一个被随机分配可使用ACS的医疗团队中看医生。这些医生平均约48%的符合条件患者使用了ACS。对照组的572名患者由一个医疗团队的医生提供护理，该团队不能将患者转介至为该试验设立的ACS，但在其他方面没有限制。在9个月的基线期和9个月的随访期内，比较了两个医疗团队中华法林治疗患者凝血酶原时间 - 国际标准化比值（INR）处于目标范围（2 - 3）的时间比例。在两个时期都有可用数据的患者（n = 264）中，干预组（基线期：47.7%；随访期：55.6%）和对照组（基线期：49.1%；随访期：52.3%；干预效果：5%；95%置信区间：-5%至14%；P = 0.32）目标范围内时间百分比的变化相似。在两个医疗团队中，患者约四分之一的时间INR值低于治疗水平（1.5至1.99）。在管理式医疗环境中提供ACS似乎并未比本试验中各地点提供的常规护理改善抗凝治疗，但在目标范围内时间少于50%的医疗环境中可能是一个合理的考虑因素。更高的利用率和对低于治疗水平的INR值采取更积极的态度可能会增强ACS的有效性。
