Cohen Jessica, Sinvani Liron, Wang Jason J, Kozikowski Andrzej, Patel Vidhi, Qiu Guang, Pekmezaris Renee, Spyropoulos Alex C
Division of Hospital Medicine, Department of Medicine, Northwell Health, Manhasset, New York, United States.
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, New York, United States.
TH Open. 2018 Jul 18;2(3):e242-e249. doi: 10.1055/s-0038-1667138. eCollection 2018 Jul.
Warfarin's adverse drug events are dangerous, common, and costly. While outpatient warfarin management tools exist, there is a dearth of guidance for inpatients. We sought to describe a health system's chronic warfarin quality metrics in older inpatients, defined by international normalized ratio (INR) control, explore associations between INR overshoots and clinical outcomes, and identify factors associated with overshoots. Data on patients 65 years and older who were prescribed chronic warfarin and admitted during January 1, 2014, to June 30, 2016, were extracted through retrospective chart review. We defined overshoots as INRs 5 or greater after 48 hours of hospitalization. Logistic regression modeling was used to determine risks for overshoots and multivariate analysis for overshoots' association with length of stay (LOS), bleeding, and mortality. Of the 12,107 older inpatients on chronic warfarin, most were 75 years or older (75.7%), female (51.2%), and white (70.0%). While 1,333 (11.0%) of patients had overshoots during the admission, 449 (33.7%) of these reached overshoots after 48 hours. When stratified by overshoots versus no overshoots, LOS more than doubled (15.6 vs. 6.8 days) and the bleed rate was significantly higher (27.4 vs. 8.3%) in the overshoot group. While overall mortality was small (0.4%), the overshoot group's mortality was significantly higher (3.12 vs. 0.28%). Black race and weight were overshoots; history of heart failure and antibiotic/amiodarone exposure were overshoots. This is the largest study examining warfarin quality metrics for hospitalized adults, specifically older inpatients. Our model may serve as the basis for identifying high-risk warfarin patients to target interventions to reduce adverse drug events.
华法林的药物不良事件危险、常见且代价高昂。虽然存在门诊华法林管理工具，但针对住院患者的指导却很匮乏。
我们试图描述一个卫生系统中，以国际标准化比值（INR）控制来定义的老年住院患者慢性华法林治疗的质量指标，探讨INR超标的情况与临床结局之间的关联，并确定与超标相关的因素。
通过回顾性病历审查，提取了2014年1月1日至2016年6月30日期间，65岁及以上且正在接受慢性华法林治疗并住院的患者的数据。我们将超标定义为住院48小时后INR达到5或更高。采用逻辑回归模型来确定超标风险，并通过多变量分析来研究超标与住院时间（LOS）、出血和死亡率之间的关联。
在12107名接受慢性华法林治疗的老年住院患者中，大多数为75岁及以上（75.7%）、女性（51.2%）且为白人（70.0%）。虽然1333名（11.0%）患者在住院期间出现了超标情况，但其中449名（33.7%）是在48小时后达到超标。按超标与未超标分层后，超标组的住院时间增加了一倍多（15.6天对6.8天），出血率显著更高（27.4%对8.3%）。虽然总体死亡率较低（0.4%），但超标组的死亡率显著更高（3.12%对0.28%）。黑人种族和体重与超标相关；心力衰竭病史以及抗生素/胺碘酮暴露与超标相关。
这是针对住院成年人，特别是老年住院患者的华法林质量指标进行研究的规模最大的一项研究。我们的模型可作为识别高危华法林患者的基础，以便针对性地采取干预措施来减少药物不良事件。
