Vadher B D, Patterson D L, Leaning M S
Department of Cardiology, Whittington Hospital Highgate Hill, London, UK.
Clin Lab Haematol. 1995 Dec;17(4):339-45.
Computer clinical decision-support systems require validation before clinical use. This study compared recommendations on warfarin dosage adjustment and timing of the next appointment made by an algorithm with those made by experienced and inexperienced clinicians. Data abstracted from the records of 125 patients seen regularly in the anticoagulant clinic were used. The algorithm recommended dose changes and next appointment for cases with INRs between 1.8 to 4.2 (therapeutic range 2.0-3.0) and between 2.3 to 5.3 (therapeutic range 3.0-4.5). Beyond these values the algorithm referred the cases to "see doctor'. Compared to experienced clinicians, the algorithm was better at "recognising' difficult patients than inexperienced clinicians (kappa = 0.43 and 0.32 respectively). There was no statistically significant difference between all decision makers in dosage recommendations for the non-difficult cases, but there was much more variation amongst the inexperienced clinicians. The interval recommendations were statistically different between and within the different decision-makers. The inexperienced clinicians tended to give relatively longer intervals for a given dose change. In conclusion, the algorithm performs better than inexperienced clinicians and as well as experienced clinicians for the non-difficult cases.
计算机临床决策支持系统在临床应用前需要进行验证。本研究比较了一种算法给出的华法林剂量调整建议和下次预约时间与经验丰富和经验不足的临床医生给出的建议。使用了从抗凝门诊定期就诊的125例患者的记录中提取的数据。该算法针对国际标准化比值（INR）在1.8至4.2（治疗范围2.0 - 3.0）以及2.3至5.3（治疗范围3.0 - 4.5）之间的病例推荐剂量变化和下次预约时间。超出这些值时，算法会将病例转诊至“看医生”。与经验丰富的临床医生相比，该算法在“识别”困难患者方面比经验不足的临床医生表现更好（kappa值分别为0.43和0.32）。对于非困难病例，所有决策者在剂量推荐方面没有统计学上的显著差异，但经验不足的临床医生之间的差异更大。不同决策者之间以及同一决策者内部的间隔建议在统计学上存在差异。对于给定的剂量变化，经验不足的临床医生倾向于给出相对更长的间隔时间。总之，对于非困难病例，该算法的表现优于经验不足的临床医生，且与经验丰富的临床医生相当。
