Choudhry Niteesh K, Anderson Geoffrey M, Laupacis Andreas, Ross-Degnan Dennis, Normand Sharon-Lise T, Soumerai Stephen B
Harvard Medical School and Brigham and Women's Hospital, Boston 02120, USA.
BMJ. 2006 Jan 21;332(7534):141-5. doi: 10.1136/bmj.38698.709572.55. Epub 2006 Jan 10.
To quantify the influence of physicians' experiences of adverse events in patients with atrial fibrillation who were taking warfarin.
Population based, matched pair before and after analysis.
Database study in Ontario, Canada.
The physicians of patients with atrial fibrillation admitted to hospital for adverse events (major haemorrhage while taking warfarin and thromboembolic strokes while not taking warfarin). Pairs of other patients with atrial fibrillation treated by the same physicians were selected.
Odds of receiving warfarin by matched pairs of a given physician's patients (one treated after and one treated before the event) were compared, with adjustment for stroke and bleeding risk factors that might also influence warfarin use. The odds of prescriptions for angiotensin converting enzyme (ACE) inhibitor before and after the event was assessed as a neutral control.
For the 530 physicians who had a patient with an adverse bleeding event (exposure) and who treated other patients with atrial fibrillation during the 90 days before and the 90 days after the exposure, the odds of prescribing warfarin was 21% lower for patients after the exposure (adjusted odds ratio 0.79, 95% confidence interval 0.62 to 1.00). Greater reductions in warfarin prescribing were found in analyses with patients for whom more time had elapsed between the physician's exposure and the patient's treatment. There were no significant changes in warfarin prescribing after a physician had a patient who had a stroke while not on warfarin or in the prescribing of ACE inhibitors by physicians who had patients with either bleeding events or strokes.
A physician's experience with bleeding events associated with warfarin can influence prescribing warfarin. Adverse events that are possibly associated with underuse of warfarin may not affect subsequent prescribing.
量化医师在房颤患者服用华法林过程中不良事件经历的影响。
基于人群的配对前后分析。
加拿大安大略省的数据库研究。
因不良事件（服用华法林时发生大出血以及未服用华法林时发生血栓栓塞性中风）入院的房颤患者的医师。选择由同一位医师治疗的其他房颤患者配对。
比较给定医师的配对患者（一名在事件发生后接受治疗，一名在事件发生前接受治疗）接受华法林治疗的几率，并对可能影响华法林使用的中风和出血风险因素进行调整。评估事件前后血管紧张素转换酶（ACE）抑制剂处方的几率作为中性对照。
对于530名有患者发生不良出血事件（暴露）且在暴露前90天和暴露后90天治疗其他房颤患者的医师，暴露后患者服用华法林的几率降低了21%（调整后的优势比为0.79，95%置信区间为0.62至1.00）。在医师暴露与患者治疗之间间隔时间更长的患者分析中，华法林处方的减少幅度更大。医师有患者在未服用华法林时发生中风后，华法林处方没有显著变化，有患者发生出血事件或中风的医师在ACE抑制剂处方方面也没有显著变化。
医师对华法林相关出血事件的经历会影响华法林的处方。可能与华法林使用不足相关的不良事件可能不会影响后续处方。
