Choudhry Niteesh K, Soumerai Stephen B, Normand Sharon-Lise T, Ross-Degnan Dennis, Laupacis Andreas, Anderson Geoffrey M
Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts, USA.
Am J Med. 2006 Jul;119(7):607-15. doi: 10.1016/j.amjmed.2005.09.052.
The study investigated the determinants of warfarin use in patients with atrial fibrillation (AF).
We assembled a retrospective cohort of community-dwelling elderly patients (aged > or = 66 years) with AF using linked administrative databases. We identified the physicians responsible for the ambulatory care of these patients using physician service claims and compared patients who did and did not have an identifiable provider. For those patients with an identifiable provider, we assessed the association between patient, physician, and hospital factors and warfarin use.
Our cohort consisted of 140,185 patients, of whom 116,200 (83%) had an identifiable cardiac provider. Patients without a provider were significantly more likely to have comorbid conditions that increase their risk of warfarin-associated bleeding. After adjustment for clinical factors, patients without a provider were significantly less likely to receive warfarin (odds ratio 0.37, 95% confidence interval: 0.36-0.38). Of patients with providers, 50,551 patients (43.5%) received warfarin within 180 days after hospital discharge. Warfarin use was positively associated with AF-associated stroke risk factors (eg, prior stroke, congestive heart failure) and negatively associated with warfarin-associated bleeding risk factors (eg, history of intracerebral hemorrhage). After controlling for patient and hospital factors, patients cared for by noncardiologist physicians with cardiology consultation were more likely to receive warfarin then patients treated in noncollaborative environments.
Warfarin continues to be substantially underprescribed to patients who are at high risk for AF-associated cardioembolic stroke. Our findings highlight the need for targeted quality improvement interventions and suggest preferred models of AF care involving routine collaboration between cardiologists and other physicians.
本研究调查了心房颤动（AF）患者使用华法林的决定因素。
我们利用关联的行政数据库，组建了一个社区居住的老年AF患者（年龄≥66岁）的回顾性队列。我们通过医生服务索赔确定负责这些患者门诊护理的医生，并比较了有和没有可识别医疗服务提供者的患者。对于那些有可识别医疗服务提供者的患者，我们评估了患者、医生和医院因素与华法林使用之间的关联。
我们的队列包括140,185名患者，其中116,200名（83%）有可识别的心脏科医疗服务提供者。没有医疗服务提供者的患者更有可能患有增加华法林相关出血风险的合并症。在调整临床因素后，没有医疗服务提供者的患者接受华法林治疗的可能性显著降低（比值比0.37，95%置信区间：0.36 - 0.38）。在有医疗服务提供者的患者中，50,551名患者（43.5%）在出院后180天内接受了华法林治疗。华法林的使用与AF相关的中风危险因素（如既往中风、充血性心力衰竭）呈正相关，与华法林相关的出血危险因素（如脑出血病史）呈负相关。在控制了患者和医院因素后，由非心脏病专家医生护理并接受心脏病学咨询的患者比在非协作环境中治疗的患者更有可能接受华法林治疗。
对于AF相关的心源性栓塞性中风高危患者，华法林的处方量仍然严重不足。我们的研究结果强调了有针对性的质量改进干预措施的必要性，并提出了AF护理的首选模式，包括心脏病专家与其他医生之间的常规协作。
