Abstract:
BACKGROUND:In 819% of patients with atrial fibrillation (AF) with anticoagulant therapy (ACT), hemorrhagic complications occur, including due to excess doses of AC. At the same time, ACT is necessary for patients with AF, since anticoagulants effectively reduces the risk of ischemic stroke. To make a decision on the appointment of ACT, it is necessary to correlate the risks of ischemic stroke and bleeding, this requires knowledge of current clinical using ACT recommendations and instructions. Among patients admitted to hospital, 30% receive ACT, so increasing adherence to clinical recommendations for prescribing AC to patients with AF by doctors of various profiles is an urgent task. AIM:To analyze the adherence of physicians to recommendations for prescribing ACT before and after the introduction of decision support system (DSS) in patients with AF in a multi-specialty hospital. MATERIALS AND METHODS:A single-center non-randomized study with historical control to assess adherence to recommendations based on the analysis of medical prescriptions and the structure of drug errors in patients with AF in a multi-specialty hospital in Moscow before and after the introduction of DSS. Compliance with the recommendations of physicians was evaluated in the sections indications /contraindications to AC and dosage regimen of AC. The presence of deviations from the clinical recommendations /instructions for medical use of AC was regarded as management of the patient with non-compliance with recommendations. Physicians adherence level to recommendations was calculated as the ratio of cases of compliance with recommendations to the total number of cases. RESULTS:In the control and experimental groups, there was a significant increase in the proportion of POAC at discharge in comparison with admission to hospital: from 54.5 to 76.8% (p=0.0005) and from 63 to 85.7% (p=0.0002), respectively. However, only in the experimental group it was possible to significantly reduce the number of patients without a prescribed ACT (if there are indications) from 7.6 to 1% (p=0.04) in comparison with admission. During the study, it was possible to significantly increase physicians adherence level to the recommendations for the AC dosage regimen in patients with AF from 59% (44 discrepancies for 107 prescriptions) to 84.6% (16 discrepancies for 104 prescriptions); p0.005. Before the introduction of the DSS, the analysis of drug prescriptions revealed 56 drug errors (0.5 errors per patient), after the introduction of the DSS, the number of drug errors significantly decreased to 21 (0.2 errors per patient); p0.05. After the introduction of DSS, the number of sub-therapeutic doses of AC was reduced from 31 (27.7%) to 8 (7.6%); p0.05. CONCLUSION:The level of adherence to the recommendations for prescribing ACT to patients with AF in the hospital is high. The use of DSS increases the level of adherence to the recommendations on the AC dosage regimen in patients with AF, as well as eliminates errors in calculating the risk of ischemic stroke and systemic thromboembolic complications, and contributes to reducing the frequency of prescribing sub-therapeutic doses of AC. :Обоснование. У 819% пациентов с фибрилляцией предсердий (ФП) на фоне антикоагулянтной терапии (АКТ) возникают геморрагические осложнения, в том числе из-за превышения доз антикоагулянтов (АК). При этом назначение АК необходимо больным с ФП, так как АК эффективно снижают риск ишемического инсульта. Для принятия решения о назначении АКТ требуется соотнести риски ишемического инсульта и кровотечения, для этого необходимо знание актуальных клинических рекомендаций и инструкций по применению АК. Среди пациентов, госпитализированных в стационар, 30% получают АКТ, поэтому повышение приверженности клиническим рекомендациям по назначению АК пациентам с ФП врачами различных профилей является актуальной задачей. Цель. Провести анализ приверженности врачей рекомендациям по назначению АКТ до и после внедрения системы поддержки принятия решения (СППР) у пациентов с ФП в многопрофильном стационаре. Материалы и методы. Одноцентровое нерандомизированное исследование с историческим контролем по оценке приверженности рекомендациям на основе анализа врачебных назначений АКТ и структуры лекарственных ошибок у пациентов с ФП в многопрофильном стационаре Москвы до и после внедрения СППР. Соблюдение врачами рекомендаций оценивали по разделам показания/противопоказания к назначению АК и режим дозирования АК. Наличие отклонений от клинических рекомендаций/инструкций по медицинскому применению АК расценивали как ведение пациента с несоблюдением рекомендаций. Уровень приверженности врачей рекомендациям рассчитывали как отношение случаев ведения пациентов с соблюдением рекомендаций к общему количеству случаев. Результаты. В контрольной и экспериментальной группах отмечено достоверное увеличение доли прямых пероральных АК при выписке в сравнении с поступлением в стационар: с 54,5 до 76,8% (p=0,0005) и с 63 до 85,7% (p=0,0002) соответственно. При этом только в экспериментальной группе удалось достоверно снизить число пациентов без назначенной АКТ (при наличии показаний) с 7,6 до 1% (p=0,04) в сравнении с поступлением. За время исследования удалось достоверно увеличить уровень приверженности врачей рекомендациям по режиму дозирования АК у пациентов с ФП с 59% (44 расхождения на 107 назначений) до 84,6% (16 расхождений на 104 назначения); p0,005. До внедрения СППР при анализе лекарственных назначений удалось выявить 56 лекарственных ошибок (0,5 ошибки на пациента), после внедрения СППР количество лекарственных ошибок достоверно снизилось до 21 (0,2 ошибки на пациента); p0,05. После внедрения СППР сократилось число назначений субтерапевтических доз АК с 31 (27,7%) до 8 (7,6%); p0,05. Заключение. Уровень приверженности рекомендациям по назначению АКТ пациентам с ФП у врачей стационара высокий. Использование СППР повышает уровень приверженности клиническим рекомендациям по режиму дозирования АК у пациентов с ФП, а также исключает ошибки расчета риска ишемического инсульта и системных тромбоэмболических осложнений и способствует снижению частоты назначения субтерапевтических доз АК.
journal_name
Ter Arkhjournal_title
Terapevticheskii arkhivauthors
Chernov AA,Kleymenova EB,Sychev DA,Yashina LP,Nigmatkulova MD,Otdelenov VA,Payushchik SAdoi
10.26442/00403660.2020.08.000765subject
Has Abstractpub_date
2020-09-03 00:00:00pages
37-42issue
8eissn
0040-3660issn
2309-5342journal_volume
92pub_type
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