抗凝门诊分级管理的药学模式的实践与探索

目的：通过对抗凝门诊的分级管理制度进行分析评价,为国内抗凝治疗管理提供借鉴。方法：根据我院抗凝门诊分级管理标准对患者进行分级。对抗凝风险较高的一级患者实施专业化的抗凝管理;二级患者采用常规的抗凝管理手段;稳定的三级患者通过自我管理和定期的复诊保持抗凝水平。选取2019年8月至2020年1月在南京大学医学院附属鼓楼医院抗凝门诊就诊的患者,分析患者抗凝管理质量及等级变化情况。结果：2019年8月至2020年1月抗凝门诊就诊患者共计1587人次,一级、二级、三级患者分别为401、547、639人次。随访次数不少于三次的患者共251人,等级变化趋势图分为波动型,平稳型,趋优型和趋劣型四类,分别为34、76、122、19人。抗凝门诊患者国际标准化比值（INR）达标率达72.8%,轻微出血发生率为6.55%,未发生大出血和血栓栓塞事件。结论：我院抗凝门诊实施分级管理模式后,提升了抗凝门诊管理质量,提高了药师工作效率。未来,分级管理可以与临床药师工作的考核评价、门诊资源调配、患者费用相结合,进一步提升抗凝管理水平。     

抗凝专业临床药师工作模式及临床实践

目的:探索临床药师实施抗凝工作的切入点。方法:借鉴国内外先进管理模式,结合北京大学第一医院具体情况,在如下方面开展了相关工作:1院内抗凝患者的教育管理;2药物基因组学方法指导下进行的药物剂量建议;3医护药师联合的随访门诊;为药师参与的抗凝一体化门诊的建立提供工作模式参考。结果:已经初步取得临床的认可,目前完成抗凝相关患者教育和药物基因组学指导下的药物剂量建议会诊120余例。为进一步建立抗凝的全程化药学服务提供了参考资料。结论:抗凝专业临床药师的介入可以为全面抗凝临床药学服务提供新的模式。     

美国抗凝治疗及药师角色

目的：介绍美囤抗凝治疗管理模式一抗凝门诊的状况以及抗凝门诊中药师的角色,为我国的抗凝治疗提供参考。方法：通过文献检索了解抗凝门诊的效果、工作模式,及药师在其中扮演的角色与药师处方权。结果和结论：药师管理的抗凝门诊是有效的,这一模式值得我国借鉴。     

服用华法林患者抗凝治疗现状调查及质量评价

摘要：目的:对我院服用华法林抗凝治疗患者开展回顾性分析,评价其抗凝治疗质量,为探索提高华法林抗凝质量的连续性药学服务工作模式提供参考。方法:收集2015年1月～2018年12月在我院服用华法林并定期监测国际标准化比值(INR)的患者,根据纳入与排除标准筛选入组患者,调查其抗凝现状,采用线性内插法计算INR在治疗范围内的时间百分比(TTR),对结果进行统计分析。结果:华法林用量呈逐年增长趋势,服用华法林进行抗凝治疗的患者数亦逐年增加。患者就诊科室中,心血管内科所占比例最大,为59.76%;患者数最多的抗凝适应证为心房颤动,其次包括心脏瓣膜置换、静脉栓塞、肺栓塞等。患者TTR的总体平均值为(66.27±16.35)%;2015年TTR>70%的患者占比为42.03%,2016年为43.36%,2017年为47.01%,2018年为56.55%。结论:我院患者服用华法林治疗质量可以接受,INR达标率逐年增高,积极开展连续性药学服务具有重要意义。     

抗凝治疗全程药学管理在血栓栓塞性疾病防治中的应用

目的 探讨临床药师开展抗凝治疗全程药学管理对抗凝治疗的安全性、合理性、有效性和依从性的影响。方法 选取2019年12月～2020年12月期间临床药师开展抗凝治疗全程药学管理的病例，通过入院时、住院中、出院时、出院后门诊随访四个维度开展药学服务，并统计分析各项措施实施后的效果。结果 临床药师共开展抗凝药学监护398例，药物重整189例，其中抗凝药物剂量重整28例(14.81%)。抗凝治疗药物使用合理率由56.67%显著提高到93.33%。华法林抗凝治疗TTR达标率由干预前17.3%提高到55.77%。全程药学管理的患者对抗凝治疗的依从性(96.7%)显著高于管理前(80.61%)。结论 临床药师开展抗凝治疗全程药学管理有助于提高患者的治疗安全性、合理性、有效性、依从性，药师在工作中不断创新，也是全程药学服务工作顺利实施的必要条件。     

心房颤动的华法林抗凝治疗存在的临床问题

目的：探讨房颤患者华法林抗凝治疗存在的临床问题。方法：分析2006～2008年新疆塔城地区人民医院内科67例心房颤动患者华法林抗凝治疗的随诊临床资料。结果：10例不能定期门诊随诊监测INR,4例发生出血而停药,2例发生血栓及栓塞,3例出现皮疹及皮肤瘙痒而停药,INR未达标率24．1％。结论：房颤患者华法林抗凝治疗存在依从性差,达标率低,受当地医疗条件限制,部分医师和患者对房颤的危险及华法林抗凝治疗的重要性认识不足等临床问题。     

华法林抗凝门诊管理模式

该文通过检索近年来国内、外相关文献,对临床药师参与华法林抗凝个体化治疗研究方面的论文进行分析、归纳、总结为建立华法林抗凝门诊、推动抗凝治疗的个体化药学服务提供参考。建立抗凝门诊,临床药师协同医师为患者制定个体化用药方案,掌握华法林个体化用药规律,促进华法林抗凝的安全、合理应用。     

我院非瓣膜性房颤患者抗凝治疗现状调查分析

目的:了解非瓣膜性心房颤动患者抗凝治疗现状,为其规范化抗凝治疗提供参考。方法:选取我院2015年7月-2016年6月非瓣膜性心房颤动患者1 056例,按照《2012年欧洲心脏病学会(ESC)心房颤动治疗指南》,对患者进行血栓栓塞危险和出血风险评估,并评价其抗凝治疗规范化情况。结果:血栓栓塞危险评分≥1的例数为1 028例,占总非瓣膜性心房颤动患者的97.3%。763例患者接受抗血栓治疗,而服用华法林抗凝治疗的仅有139例。服用华法林患者出院前凝血酶原时间的国际标准化比值达标率仅30.9%。结论:非瓣膜性心房颤动患者抗凝治疗现状不容乐观,应采取有效的干预措施,提高心房颤动患者抗凝治疗规范化程度。     

生姜合并华法林致INR升高2例报道及文献回顾

目的:探讨生姜对华法林抗凝作用的影响、作用机制和处理方法。方法与结果:病例回顾:1例62岁的患者长期服用华法林并稳定维持剂量,开始每日合并9g生姜1月后查INR值升至4.41,就诊抗凝门诊后停用生姜,后根据INR值逐步调整华法林剂量至原来水平;另1例70岁患者长期服用稳定维持剂量的华法林抗凝治疗,食用醋泡姜1周后INR升至4.59,停用醋泡姜后逐渐调整华法林剂量至原来水平。结论:生姜与华法林相互作用机制尚不明确,本研究与文献回顾显示华法林与生姜相互作用为"很可能"。当长期服用华法林的患者需要生姜补充替代治疗时,推荐抗凝门诊药师根据食用生姜的量和疗程判断可能发生相互作用的严重程度,加强监测INR值,必要时调整华法林剂量,从而为临床实践提供指导。     

抗凝药物治疗管理门诊对华法林抗凝效果影响的实践分析

目的探讨抗凝药物治疗管理门诊对华法林抗凝效果的影响.方法回顾性分析2019年7月至2020年1月于首都医科大学附属北京安贞医院抗凝药物治疗管理门诊拟服用或正在服用华法林的患者64例.记录患者一般情况、就诊目的、国际标准化比值(INR)、INR达稳时间、治疗范围内的时间百分比(TTR)、出血及血栓事件.结果患者平均年龄(...     

Quality of anticoagulation care in patients discharged from a pharmacist-managed anticoagulation clinic after stabilization of warfarin therapy

STUDY OBJECTIVE: To determine if transitioning patients from a pharmacist- managed anticoagulation clinic after stabilization of warfarin therapy to physician-managed care alters the quality of anticoagulation care. DESIGN: Retrospective medical record review. SETTING: Pharmacist-managed, urban academic medical center-based outpatient anticoagulation clinic. PATIENTS: Forty patients who were stabilized on warfarin therapy. MEASUREMENTS AND MAIN RESULTS: Quality of anticoagulation care was measured by percentage of international normalized ratios (INRs) in target range, anticoagulation-related health care visits, and responses to satisfaction surveys. A significant decrease in anticoagulation control was observed on transition to physician-managed care. Before transition, 76% of all INRs were in target range versus 48% after transition (p<0.0001, chi(2) test). When performing paired analysis, a median 75% of each patient's INRs were therapeutic before transition compared with 36.5% after (p<0.0001, Wilcoxon signed rank test). Thirty-two percent of first INR values measured after transition from the clinic were in target range, and the median time to first follow-up INR was 41 days. The number of INR values above 4.5 and below 1.5 increased significantly after transition from the anticoagulation clinic (p<0.0001 and p=0.01, respectively, chi(2) test). Before transition from the anticoagulation clinic, two anticoagulation-related emergency department visits were reported in one patient. After transition, 13 cases of additional medical care were reported among seven patients; seven of the 13 cases required an office visit with the physician, and six resulted in emergency room evaluation. None of these cases resulted in hospitalization. Patient satisfaction with clinical care provided by the anticoagulation clinic was significantly higher before transition. CONCLUSION: Transition of patients from a pharmacist-managed anticoagulation clinic back to physician-managed anticoagulation care after stabilization of warfarin therapy was associated with a significant decrease in INR control, increased medical care related to anticoagulation, and decreased patient satisfaction.     

Barriers to patient self-testing of prothrombin time: national survey of anticoagulation practitioners

Oral anticoagulation with warfarin requires routine monitoring of prothrombin time, expressed as the international normalized ratio (INR). Patient self-testing for INR is common in Europe but not in the United States. In order to determine the frequency of INR self-testing among patients whose anticoagulant therapy is managed in U.S. anticoagulation clinics, to describe the processes that support this self-testing, and to identify the barriers as experienced by anticoagulation clinic providers, a three-part survey was mailed to 538 anticoagulation specialists in the United States. The response rate was 43.7%. Policies and procedures of almost 60% of anticoagulation clinics prohibited INR self-testing for enrolled patients. In addition, less than 1% of patients being managed by U.S. anticoagulation clinics use self-testing to obtain INR results. Primary barriers were the cost of self-testing instruments (78.7% of respondents), cost of reagent cartridges (60.4%), and fear that self-testing might lead to unintended self-management (35.7%). Over 75% of respondents believed that some reimbursement for the cost of self-testing devices and supplies would increase the likelihood that anticoagulation clinics would recommend INR self-testing.     

Pharmacy students provide care comparable to pharmacists in an outpatient anticoagulation setting

Objective

To evaluate whether student participation in ambulatory clinics influenced the percentage of therapeutic international normalized ratio (INR) results among patients on chronic warfarin therapy.

Methods

Medical records in outpatient anticoagulation clinics managed by pharmacists under physician protocol were reviewed retrospectively in 2 university-affiliated clinics in Amarillo and Lubbock, TX. Pharmacy student activities included patient interviews, vital sign measurements, fingersticks, counseling, and documentation. Patient visits were conducted by a precepted pharmacy student or a pharmacist without a student, and the INR was measured at the subsequent patient visit.

Results

Records of 1,958 anticoagulation patient visits were reviewed; 865 patients were treated by pharmacists, and 1093 were treated by precepted students. The follow-up INR was therapeutic for 48.5% of third-year (P3) students'' patients, 45.6% of fourth-year (P4) students'' patients, 51.2% of residents'' patients, and 44.7% of pharmacists''s patients (p = 0.23). Eight variables were associated with the follow-up INR (baseline INR, warfarin noncompliance, held warfarin doses, a warfarin dosage adjustment, diet change, alcohol use, tobacco use, and any medication changes).

Conclusion

Student participation in the patient-care process did not compromise patient care and no significant difference in patient outcomes was found between patients in an anticoagulation clinic cared for by precepted students and those cared for by pharmacists.     

Management of Chinese patients on warfarin therapy in two models of anticoagulation service - a prospective randomized trial

AIM: To compare the treatment outcomes of a clinical pharmacist-managed anticoagulation service with physician-managed service in Chinese patients. METHODS: A prospective, randomized clinical trial was conducted at the anticoagulation clinic of a teaching hospital in Hong Kong. Patients aged > or = 18 years who would required warfarin therapy for at least 3 months were recruited. Patients were randomized to the pharmacist-managed or physician-managed group. Primary clinical outcome was assessed by the percentage of patient time spent within the target international normalized ratio (INR) range. The incidence of major thromboembolic events (TEs) and major bleeding was assessed as secondary clinical outcomes. The cost per patient per month (cPPPM) was calculated and patient satisfaction was assessed by patient satisfaction questionnaire (PSQ)-18. RESULTS: One hundred and forty-one patients were recruited at the anticoagulation clinic and 137 patients completed the study. Patients in the pharmacist-managed group (n = 68) were in the target INR 64% of patient time vs. 59% in the physician-managed group (n = 69) (P < 0.001). There was no significant difference in incidence of major TEs or bleeding. The cPPPM in the pharmacist-managed group (76 +/- 95 US dollar) (43 +/- 53 British pound) was lower than in the physician-managed group (98 +/- 158 US dollar) (55 +/- 89 British pound) (P < 0.001). The PSQ-18 score of the pharmacist-managed group (3.8 +/- 0.2) was higher than that of the physician-managed group (3.6 +/- 0.3) (P < 0.001). CONCLUSION: The pharmacist-managed anticoagulation service was more effective and less costly than the physician-managed service in achieving target anticoagulation control for Chinese patients on warfarin therapy.     

非瓣膜性房颤患者抗凝治疗影响因素分析

目的 调查我院住院非瓣膜性房颤患者抗凝治疗情况,分析可能影响抗凝治疗的因素,探讨临床药师在抗凝管理中发挥的作用。 方法 收集我院住院非瓣膜性房颤患者238例,对抗凝药物选择、剂量、国际标准化比值（INR）、凝血功能监测频率、合并用药、基础疾病、出血并发症、用药教育等进行回顾性分析。 结果 我院CHA2DS2-VASc评分在2分及以上的非瓣膜性房颤患者规范抗凝覆盖率48.8%,年龄和合并冠心病会影响临床抗凝药物选择,临床药师为患者提供用药教育对患者抗凝治疗接受度影响具有显著统计学意义（p＜0.01）。出院前PT/INR在目标值范围内的患者仅占38.15%（29/76）,TTRs平均值为49.57%±3.68%。年龄、性别、华法林初始剂量、出血风险、合并用药等不影响INR达标情况,合并疾病中仅消化道疾病对INR达标间存在统计学意义（P=0.027）,住院期间患者凝血功能监测频率也影响患者INR达标率（p=0.038）。结论 目前我院非瓣膜性房颤患者的规范抗凝覆盖率仍较低,临床药师可充分利用自身专业知识,开展患者抗凝药物用药教育,积极参与到抗凝管理中,提高抗凝期间凝血功能监测频率,提高抗凝达标率,促进卒中防治效果。     

新型冠状病毒肺炎疫情下抗凝药学服务的策略及应用研究

目的：新型冠状病毒肺炎疫情期间采用线上程序远程的抗凝药学模式服务服用华法林的患者，以保证华法林抗凝治疗的有效性和安全性。方法：采用回顾性调查及问卷调查的方式，分析疫情期间2020年1.20-2.19实施远程抗凝药学服务以来，患者治疗窗内时间（time in therapeutic range，TTR）、不良事件、患者咨询、患者依从性、患者INR监测率、患者满意度等数据，并与去年同期线下门诊进行对比。结果：在实施远程抗凝管理的药学服务后，远程线上服务人次占比（90.63%）同比去年（13.57%）上涨明显（P<0.001），患者TTR （79.57%）同比去年（58.90%）明显提高（P=0.004），不良事件发生率降低，华法林按时服药率（96.77%）明显升高（P=0.003），国际标准化比值（International Normalized Ratio，INR）监测率（93.55%）显著提高（P=0.002），患者满意度极高，明显减少患者在院停留时间及经济成本。结论：在新冠肺炎疫情期间，该抗凝药学模式的实施解决了抗凝患者密集的药学服务需求和其减少患者暴露避免潜在交叉感染风险之间的矛盾，构建起临床药师抗击疫情的新型抗凝药学服务模式。     

品管圈活动在降低我院门诊药房发药差错率中的应用

目的:降低医院门诊药房发药差错率,促进药学服务质量提升。方法:以"降低门诊药房发药差错率"为主题,在我院门诊药房按照品管圈活动的10个步骤实施各项活动,并评价该活动的有形成果和无形成果。结果:通过开展品管圈活动,拟定了几方面的对策,如配方人员仔细核对打印标签,药品调配后摆放整齐;对同一成分不同规格、包装非常类似的2种药品,用其他品种的药品隔开,并贴上醒目图标等。有形成果方面,与改善前比较门诊药房发药差错率下降62.9%(29.25件vs.10.85件),目标达标率120.66%;无形成果方面,员工品管手法、解决问题的能力及责任心等方面的评分明显提高。结论:开展品管圈活动可以提升门诊药房药学服务质量,促进临床用药更加安全、有效。     

Outcomes of warfarin therapy managed by pharmacists via hospital anticoagulation clinic versus online anticoagulation clinic

Background In response to the recognized difficulty in the management of patients on anticoagulation therapy, anticoagulation management services were developed in both hospital anticoagulation clinics (HACs) and an online anticoagulation clinic (OAC) by a pharmacist. Objective To compare monitoring outcomes and complications of warfarin therapy managed by pharmacists via hospital or on-line. Setting The anticoagulation clinic of Fujian Medical University Union Hospital, China. Method A retrospective, observational cohort study was used to compare patients managed via hospital  to those managed o-line between December 2015 and 2016. The primary outcome was the percentage of time in the therapeutic range (TTR). The secondary outcomes were the incidence rates of hemorrhagic events, thrombotic events and extreme international normalized ratio (INR) values. Results A total of 152 patients were evaluated; 70 patients managed in a HAC were compared to 82 patients managed via an OAC. There were no significant differences in the TTR (78.9 vs. 74.0%, P?=?0.393) and adverse events [major bleeding events (0 vs. 1.2%, P?=?1.000), minor bleeding events (10.0 vs. 9.8%, P?=?0.960), thromboembolic events (0 vs. 0%, P?=?1.000), warfarin-related emergency visits (2.9 vs. 3.7%, P?=?1.000)], warfarin-related hospital admissions (0 vs. 1.2%, P?=?1.000), and the incidence of subtherapeutic (3.0 vs. 3.8%, P?=?0.148), and extreme total (8.4 vs. 5.8%, P?=?0.135), between the groups managed via HAC and OAC. Patients managed in the HAC were more stable on warfarin, with a higher percentage of INR values within the target therapeutic range (80.2 vs. 71.9%, P?=?0.005) and a lower incidence of supratherapeutic INR values (8.4 vs. 18.5%, P?=?0.001) compared to patients managed via OAC. Conclusion The management of oral anticoagulation therapy on-line yielded similar clinical outcomes compared to that achieved by management via the hospital, although the incidence of supra-therapeutic INR values was increased.     

基于医联体的COPD社区医药协作联盟模式探索

目的构建以药师为主导的慢性阻塞性肺疾病(COPD)社区医药协作联盟,通过学科协作,改善区域内COPD患者诊、治、防、管上下分离的问题,推动分级诊疗实施。方法我院与广州市白云区同德围街社区卫生服务中心合作试点,以医药协作门诊为工作核心,专科药品衔接工作为切入点,社区药事管理帮扶、家庭药师和健康宣教工作为辅助,构建以药师为主导的COPD社区医药协作联盟。结果2019年1~6月期间本项目落实情况如下:(1)COPD社区医药协作门诊开诊16次,肺功能筛查176人,落实向上转诊患者12人;(2)通过专科药品衔接工作社区呼吸系统药物新增13个品规,社区呼吸系统治疗药物品规数与我院的衔接度增幅达10.71%,增补后社区药物可覆盖COPD急性加重期与稳定期治疗;(3)社区药事管理工作进一步完善,处方点评合理率提升12.38%;(4)签约家庭药师8人,提供上门/电话随访药学服务次数38次;(5)举办社区健康宣教2场。结论以药师为主导的COPD社区医药协作联盟在一定程度上可改善COPD患者诊、治、防、管过程中上下分离的问题,并推动区域内分级诊疗实施。     

某院激素补充治疗用药监护药学门诊工作实践与效果

目的：介绍某院激素补充治疗（MHT）用药监护药学门诊工作实践与效果。方法：简述MHT用药监护药学门诊工作内容，收集2016年7月1日到2018年6月30日就诊的80例患者，分别于初诊时、MHT治疗1个月、3个月、12个月后对患者绝经相关症状、用药依从性进行评分，并统计年新增MHT用药率、MHT坚持用药率及不良反应发生情况。结果：完成随访患者73人，初诊时，MHT治疗1个月、3个月、12个月随访时的Kupperman评分随MHT用药时间的延长逐渐下降，用药依从性评分逐渐提高，差异均有统计学意义（与前次随访时比较，P<0.05）；年新增MHT用药率20.00%，MHT 1年及以上坚持用药率41.10%；不良反应发生率15.07%，72.73%发生于MHT 3个月内，随访期间无乳腺癌等严重不良反应发生。结论：通过开设MHT用药监护药学门诊，临床药师在患者MHT治疗中发挥了积极的作用，证明了药学门诊服务的价值，为其他药学专科门诊的开展提供了参考。