非瓣膜性心房颤动患者中不适当的直接口服抗凝剂处方：法国初级保健 CACAO 队列研究的横断面分析。
Inappropriate direct oral anticoagulant prescriptions in patients with non-valvular atrial fibrillation: cross-sectional analysis of the French CACAO cohort study in primary care.
机构信息
Primary Care Department, School of Medicine, University of Paris-Est Créteil, Créteil; INSERM, IMRB, CEpiA Team (Clinical Epidemiology and Ageing), University of Paris-Est Créteil, Créteil.
Primary Care Department, School of Medicine, University of Paris-Est Créteil, Créteil.
出版信息
Br J Gen Pract. 2021 Jan 28;71(703):e134-e139. doi: 10.3399/bjgp20X714005. Print 2021.
BACKGROUND
Direct oral anticoagulants (DOACs) account for an increasing proportion of prescriptions in patients with non-valvular atrial fibrillation (NVAF) in primary care. Inappropriate dosing of DOACs is a common problem, with under-dosing being a particular issue. However, conflicting results have been reported about the factors independently associated with inappropriate dosing.
AIM
To describe inappropriate prescriptions of DOACs among patients in the CACAO French nationwide general practice cohort, and to identify the factors independently associated with inappropriate DOAC doses.
DESIGN AND SETTING
Cross-sectional baseline analysis of the CACAO French national multicentre prospective cohort of adult patients in primary care receiving an oral anticoagulant who were recruited between April and October 2014.
METHOD
A total of 1111 patients from the CACAO cohort who received a DOAC for NVAF were included in this study. Inappropriate prescriptions of DOACs were described (inappropriate dosage, contraindications, non-indications, interactions, and non-compliance with the precautions for use). Multivariate logistic models were used to investigate factors associated with inappropriate DOAC dosing (under-dosing and over-dosing).
RESULTS
Overall, 438 patients (39.4%) received at least one inappropriate DOAC prescription. The most common inappropriate prescription was inappropriate dosage ( = 374, 33.7%), particularly under-dosing ( = 348, 31.3%). Multivariate analysis revealed that factors independently associated with under-dosing were older age, prescription of apixaban or dabigatran, and a CHA2DS2-VASc score ≥2 vs. a score = 1. Factors with over-dosing were kidney failure, a HAS-BLED score ≥3, and older age.
CONCLUSION
The appropriateness of DOAC prescribing for NVAF can be improved, especially in older patients, and in patients with kidney failure, a higher risk of ischaemic stroke, and/or a higher risk of bleeding. GPs have a key role in increasing the proportion of appropriate DOAC prescriptions via informational, educational, and/or management strategies.
背景
直接口服抗凝剂（DOAC）在初级保健中用于非瓣膜性心房颤动（NVAF）患者的处方比例不断增加。DOAC 剂量不当是一个常见问题，其中剂量不足是一个特别的问题。然而，关于与剂量不当独立相关的因素，已有相互矛盾的结果报告。
目的
描述法国 CACAO 全国初级保健多中心前瞻性队列中 NVAF 患者 DOAC 的不适当处方，并确定与 DOAC 剂量不适当独立相关的因素。
设计和设置
这是对 2014 年 4 月至 10 月期间招募的接受口服抗凝剂的成年患者的 CACAO 法国全国多中心前瞻性队列的横断面基线分析。
方法
共纳入 1111 例来自 CACAO 队列的接受 DOAC 治疗 NVAF 的患者，本研究描述了 DOAC 的不适当处方（剂量不当、禁忌证、非适应证、相互作用和不遵守使用注意事项）。使用多变量逻辑模型研究了与 DOAC 剂量不当（剂量不足和剂量过大）相关的因素。
结果
总体而言，438 例（39.4%）患者至少有一次不适当的 DOAC 处方。最常见的不适当处方是剂量不当（=374，33.7%），特别是剂量不足（=348，31.3%）。多变量分析显示，与剂量不足独立相关的因素是年龄较大、阿哌沙班或达比加群的处方以及 CHA2DS2-VASc 评分≥2 与评分=1。剂量过大的相关因素是肾衰竭、HAS-BLED 评分≥3 和年龄较大。
结论
可以改善 NVAF 中 DOAC 处方的适当性，特别是在年龄较大的患者、肾衰竭患者、缺血性卒中风险较高的患者和/或出血风险较高的患者中。全科医生在通过信息、教育和/或管理策略增加适当的 DOAC 处方比例方面发挥着关键作用。
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