Arnsten J H, Gelfand J M, Singer D E
General Internal Medicine Unit, Massachusetts General Hospital, Boston USA.
Am J Med. 1997 Jul;103(1):11-7. doi: 10.1016/s0002-9343(97)90048-6.
The number of patients for whom long-term anticoagulation is indicated has increased dramatically over the past decade. Good patient compliance is necessary to safely realize the benefits of anticoagulation, yet barriers to compliance with anticoagulation therapy have not been studied.
We conducted a case-control study in the Anticoagulation Therapy Unit (ATU) at Massachusetts General Hospital. Forty-three patients who had been discharged from the ATU for noncompliance (cases) and 89 randomly selected compliant ATU controls were interviewed. Noncompliant cases had self-discontinued warfarin or were taking warfarin with inadequate monitoring of international normalized ratio (INR) levels. Telephone interviews assessed sociodemographic features, indication for anticoagulation, patient satisfaction, and health beliefs.
Noncompliant cases were more likely to be younger (mean 53.7 years versus 68.7 years, P < 0.0001), male (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.5, 8.2) and nonwhite (OR 6.4, 95% CI 1.9, 21.9), and less likely to have had a stroke or transient ischemic attack (OR 0.2, 95% CI 0.1, 0.7). In open-ended questioning, cases were more likely to report that they did not know why warfarin had been prescribed (OR 4.4, 95% CI 1.4, 14.2). Noncompliant cases were more likely not to have a regular physician (OR 11.1, 95% CI 3.6, 50.0); among patients with a regular physician, noncompliant cases were more likely to feel dissatisfied. Examination of health beliefs revealed that noncompliant cases felt more burdened by taking warfarin, and perceived fewer health benefits.
Patients who are noncompliant with warfarin share distinctive clinical characteristics. Notably, younger, male patients who have not experienced a thromboembolic event are more likely to forego INR testing or to stop anticoagulation therapy completely. Improved patient education, physician involvement, and ease of monitoring may improve compliance, particularly among younger male patients.
在过去十年中，需要长期抗凝治疗的患者数量急剧增加。患者良好的依从性对于安全实现抗凝治疗的益处至关重要，但抗凝治疗的依从性障碍尚未得到研究。
我们在马萨诸塞州总医院的抗凝治疗科进行了一项病例对照研究。对43名因不依从而从抗凝治疗科出院的患者（病例组）和89名随机选择的依从性好的抗凝治疗科对照患者进行了访谈。不依从的病例自行停用了华法林，或在服用华法林时对国际标准化比值（INR）水平监测不足。通过电话访谈评估社会人口学特征、抗凝治疗指征、患者满意度和健康观念。
不依从的病例更可能较年轻（平均年龄53.7岁对68.7岁，P<0.0001）、为男性（比值比[OR]3.5，95%置信区间[CI]1.5，8.2）和非白人（OR 6.4，95%CI 1.9，21.9），且发生中风或短暂性脑缺血发作的可能性较小（OR 0.2，95%CI 0.1，0.7）。在开放式提问中，病例组更可能报告他们不知道为何开具华法林（OR 4.4，95%CI 1.4，14.2）。不依从的病例更可能没有固定的医生（OR 11.1，95%CI 3.6，50.0）；在有固定医生的患者中，不依从的病例更可能感到不满意。对健康观念的调查显示，不依从的病例觉得服用华法林负担更重，且认为健康益处更少。
不依从华法林治疗的患者具有独特的临床特征。值得注意的是，未经历过血栓栓塞事件的年轻男性患者更可能放弃INR检测或完全停止抗凝治疗。改善患者教育、医生参与度和监测便利性可能会提高依从性，尤其是在年轻男性患者中。
