Landefeld C S, Anderson P A
University Hospitals of Cleveland, Ohio.
Ann Intern Med. 1992 May 15;116(10):829-37. doi: 10.7326/0003-4819-116-10-829.
To test the efficacy of consultation designed to prevent anticoagulant-related bleeding.
Randomized, controlled trial.
A large teaching hospital.
A total of 101 patients at increased (greater than 15%) risk for major, in-hospital bleeding while starting long-term anticoagulant therapy who were identified using a validated prediction rule.
Fifty-five patients received usual care under the direction of the attending physician who had initiated anticoagulant therapy. Forty-six patients received guideline-based consultation in addition to usual care. Guideline-based consultation included individualized review of the risks and benefits of anticoagulant therapy and, on the basis of current practice guidelines, recommendations for daily management.
The main outcome was in-hospital bleeding, which was classified using a reliable, explicit index.
Major or minor bleeding occurred in 17 of 55 patients (31%) receiving usual care alone, compared with 6 of 46 patients (13%) receiving consultation in addition to usual care (P = 0.03). The protective efficacy of consultation was 58% (95% CI, 3% to 82%). Consultation was associated with similar reductions in the frequencies of major bleeding (from 13% to 4%) and minor bleeding (from 18% to 9%). Consultative recommendations had an 84% compliance rate and directly affected anticoagulant management: In the consult group, nonsteroidal anti-inflammatory agents were stopped in six patients (13%), and therapeutic ranges were achieved more often for activated partial thromboplastin times (52% compared with 45% in the usual care group, P = 0.08) and for prothrombin times (47% compared with 27% in the usual care group, P less than 0.001). Nearly all housestaff and attending physicians (91%) for patients receiving consultation also reported that consultation improved housestaff learning. The consult group had a somewhat lower rate of thromboembolism in the 90 days after discharge (5% compared with 17%, P = 0.06). Death rates and mean lengths of stay were similar in the two groups.
Guideline-based consultation was associated with reduction in the frequency of anticoagulant-related bleeding in patients at increased risk for major in-hospital bleeding.
检验旨在预防抗凝相关出血的会诊的疗效。
随机对照试验。
一家大型教学医院。
共101例在开始长期抗凝治疗时发生院内大出血风险增加（大于15%）的患者，通过有效的预测规则确定。
55例患者在启动抗凝治疗的主治医师指导下接受常规治疗。46例患者除接受常规治疗外，还接受基于指南的会诊。基于指南的会诊包括对抗凝治疗的风险和益处进行个体化评估，并根据现行实践指南提出日常管理建议。
主要结局是院内出血，使用可靠、明确的指标进行分类。
仅接受常规治疗的55例患者中有17例（31%）发生了大出血或小出血，而除常规治疗外还接受会诊的46例患者中有6例（13%）发生了出血（P = 0.03）。会诊的保护效力为58%（95%CI，3%至82%）。会诊使大出血（从13%降至4%）和小出血（从18%降至9%）的发生率有相似程度的降低。会诊建议的依从率为84%，并直接影响抗凝管理：在会诊组中，6例患者（13%）停用了非甾体抗炎药，活化部分凝血活酶时间（52%，常规治疗组为45%，P = 0.08）和凝血酶原时间（47%，常规治疗组为27%，P<0.001）达到治疗范围的情况更为常见。接受会诊患者的几乎所有住院医师和主治医师（91%）也报告说会诊提高了住院医师的学习效果。会诊组出院后90天内的血栓栓塞发生率略低（5%，常规治疗组为17%，P = 0.06）。两组的死亡率和平均住院时间相似。
对于院内大出血风险增加的患者，基于指南的会诊可降低抗凝相关出血的发生率。
