识别预测老年房颤患者使用非维生素 K 拮抗剂口服抗凝剂的处方因素。
Identifying Factors That Predict the Prescription of Non-vitamin K Antagonist Oral Anticoagulants in Older Individuals With Atrial Fibrillation.
机构信息
Cardiology Department, Health Sciences North, Sudbury, Ontario, Canada; Health Sciences North Research Institute, Sudbury, Ontario, Canada; Northern Ontario School of Medicine, Laurentian University, Sudbury, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
出版信息
J Am Med Dir Assoc. 2019 Aug;20(8):984-987. doi: 10.1016/j.jamda.2019.01.131. Epub 2019 Mar 8.
OBJECTIVES
Factors that influence decision of non-vitamin K antagonist oral anticoagulants (NOACs) use among older atrial fibrillation (AF) patients in long-term care (LTC) facilities have not been well studied. The aim of this study was to assess whether increased frailty influenced physicians to prescribe NOACs over warfarin.
DESIGN
We retrospectively reviewed the electronic medical record (EMR) and pharmacy data of 25 LTC facilities in Ontario, Canada, in May 2015. The diagnosis of AF was ascertained from EMR and confirmed by complete chart review of a random sample of the cohort. A score of ≥2 on the Changes in Health, End-stage disease, Signs, and Symptoms (CHESS) scale was used as a surrogate marker of frailty.
MEASURES
Multivariable logistic regression model was used to assess whether a higher frailty score is associated with the use of NOACs in comparison to warfarin, independent of potential patient-level confounders.
SETTING AND PARTICIPANTS
In total, 3378 active residents were assessed in 25 LTC facilities. All the residents were ≥65 years old. We identified 433 residents with AF; 273 (63%) AF residents were on anticoagulation therapy and included in the analysis.
RESULTS
Residents were more often treated with NOACs (n = 159; 58%) in comparison to warfarin (n = 114; 42%). A CHESS score of ≥2 increased the odds of prescribing NOACs by 2.46 times [95% confidence interval (CI) 1.11, 5.49; P = .03] when adjusted for important patient-level factors. Patients with hypertension had a trend of increased NOAC prescriptions but did not reach statistical significance [odds ratio 2.1 (95% CI 0.91, 4.81), P = .08]. None of the patient-level factors were associated with NOAC prescriptions.
CONCLUSIONS AND IMPLICATIONS
In this real world cohort of AF patients in LTC who are prescribed an oral anticoagulation therapy, a higher CHESS score (≥2) is associated with increased use of NOACs in comparison to warfarin.
目的
影响长期护理（LTC）机构中老年心房颤动（AF）患者使用非维生素 K 拮抗剂口服抗凝剂（NOACs）的因素尚未得到很好的研究。本研究旨在评估衰弱程度增加是否会影响医生开 NOACs 而不是华法林。
设计
我们回顾性地审查了加拿大安大略省 25 个 LTC 设施的电子病历（EMR）和药房数据，时间为 2015 年 5 月。AF 的诊断来自 EMR，并通过对队列的随机样本进行完整图表审查加以确认。健康变化、终末期疾病、体征和症状（CHESS）量表的评分≥2 被用作衰弱的替代标志物。
措施
多变量逻辑回归模型用于评估与华法林相比，较高的衰弱评分是否与使用 NOACs 相关，而与潜在的患者水平混杂因素无关。
设置和参与者
共有 25 家 LTC 机构评估了 3378 名活跃居民。所有居民年龄均≥65 岁。我们确定了 433 名患有 AF 的居民；273 名（63%）接受 AF 治疗的 AF 居民正在接受抗凝治疗，并包括在分析中。
结果
与华法林相比（n=114；42%），居民更常使用 NOACs（n=159；58%）。当调整重要的患者水平因素时，CHESS 评分≥2 使开具 NOACs 的可能性增加了 2.46 倍[95%置信区间（CI）1.11，5.49；P=0.03]。患有高血压的患者开具 NOAC 处方的趋势增加，但未达到统计学意义[比值比 2.1（95% CI 0.91，4.81），P=0.08]。患者水平因素均与 NOAC 处方无关。
结论和意义
在这项针对 LTC 中接受口服抗凝治疗的 AF 患者的真实世界队列研究中，较高的 CHESS 评分（≥2）与与华法林相比，NOACs 的使用增加相关。
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