患者易低估华法林相关紧急情况的风险

《质量与患者安全联合委员会杂志》发表的一项调查显示，长期使用华法林的患者往往并未认识到抗凝药物相关情况——诸如卒中症状和药物管理不善——的临床严重性和紧迫性(Jt. Comm. J. Qual. Patient Saf. 2013;39:22-31)。

主要研究者、德克萨斯大学医学部的Christopher J. Moreland博士指出：“掌握华法林药理学的事实性知识并不能确保患者安全地使用该药。加强针对药物相关紧急情况的患者教育，将有助于缩小患者与医务人员之间的鸿沟，并降低药物不良事件的发生率。”研究者建议，应教会患者识别高危与低危情况，并在不同情况下采取正确的行动。

研究者最初从加州大学戴维分校医疗中心抗凝门诊随机选择了480名患者，其中184名长期使用华法林的患者参与了这项调查。在电话调查中，研究者询问受访者对于有关治疗的一般性知识的了解情况，并让受访者对不同的华法林相关危险情境打分，将其评为不紧急、中度紧急和紧急三类。所有的情境都事先由5名抗凝药剂师进行评估和分类。

结果显示，69%的受访者能正确回答有关华法林治疗的问题，然而“很多受访者对明确高危情境的识别能力较弱”。超过50%的受访者能正确识别6种紧急危险情境中的4种，包括：急性胸痛(95%)、服用错误剂量的华法林达1周或以上(79%)、头部创伤(56%)、突发头痛(87%)。而仅有25%的受访者意识到，急性单侧视力下降(提示卒中)是紧急情境，仅有20%认为头部受到击打或撞击(出血风险高)是紧急情境。“药物管理不善(例如某天不小心服用了错误剂量或开始使用某种新的药物)也是需要重视的问题，是患者误解的一个来源。”

受访者在21%的时间低估了紧急情境的严重性[95%置信区间(CI)，19.0%~23.9%]。共有59%的受访者与药剂师的意见一致(95%CI，57.3%~60.3%)。

研究者指出，患者在开始使用华法林或其他抗凝药物时需要更具体的考核指标和清楚的教育材料，而目前强制执行的联合委员会全国患者安全目标(NPSG)03.05.01和联合委员会静脉血栓栓塞(VTE)全国医院住院患者质量指标VTE-5还不够理想。他们认为，NPSG.03.05.01和住院患者质量指标VTE-5均未明确提出针对高危情境识别与处理的患者教育内容的合格标准。“希望联合委员会及其他全国性组织能再审和修订现行的抗凝教育指南。”

研究者无相关利益冲突。本项研究获得了卫生资源与服务管理局、国立卫生研究院和加州大学的经费支持。

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By: ARNESA A. HOWELL, Cardiology News Digital Network

Long-term users of warfarin had difficulty recognizing the clinical severity and urgency of anticoagulation-related situations such as stroke symptoms and medication mismanagement, the results of a survey indicated.

"Factual knowledge of the pharmacology of warfarin does not guarantee safe use of warfarin. Enhancing patient education regarding drug-related emergencies will likely narrow the gap between patient and health care provider and reduce the incidence of adverse drug events," said Dr. Christopher J. Moreland of the University of Texas Health Science Center, San Antonio, and his colleagues.

The researchers recommended that warfarin education programs implement patient-centered strategies that teach patients to discern high-risk from low-risk situations and take appropriate action based on those scenarios.

The survey participants were 184 long-term users of warfarin drawn from an initial pool of 480 randomly selected patients from the anticoagulation clinic at the University of California, Davis, Medical Center. Survey participants were contacted by phone and asked general-knowledge questions about their therapy. They also were asked to rate various warfarin-associated risk scenarios as not urgent, moderately urgent, or urgent. All scenarios had been previously reviewed and categorized by an expert panel of five anticoagulation pharmacists.

On average, 69% of patients correctly answered questions about warfarin therapy, but "certain high-risk scenarios appeared confusing to many respondents," the researchers wrote in the Joint Commission Journal on Quality and Patient Safety (Jt. Comm. J. Qual. Patient Saf. 2013;39:22-31).

More than 50% of respondents correctly identified four of six urgent risk scenarios: acute chest pain (95%), taking the wrong dose of warfarin for a week or more (79%), head trauma (56%), and sudden headache (87%). Just 25% of respondents, however, recognized the urgency of acute unilateral vision loss as a possible sign of stroke and 20% recognized the urgency of a hit or bump on the head for bleeding risk.

"Medication mismanagement (for example, inadvertently taking the wrong dose one day or starting a new medication) was also a clinically relevant area that remains a source of potential misunderstanding by patients," wrote Dr. Moreland and his associates.

Patients underestimated the seriousness of urgent situations 21% of the time (95% confidence interval, 19.0%-23.9%). Overall, 59% of participant responses agreed with the pharmacists’ determinations (95% CI, 57.3%-60.3%), indicating good agreement beyond chance.

More specific performance measures and clear education materials are needed for patients beginning warfarin or other anticoagulants, as currently mandated by Joint Commission National Patient Safety Goal NPSG.03.05.01 and the Joint Commission Venous Thromboembolism (VTE) National Hospital Inpatient Quality Measure VTE-5, the researchers said.

They stated that neither NPSG.03.05.01 nor Inpatient Quality Measure VTE-5 "overtly specifies educational content aimed at teaching patients how to identify (and manage) high-risk scenarios that might compromise patient safety." The National Quality Forum, the study noted, has "elected not to re-endorse VTE-5 because of concerns that the measure does not explicitly specify what constitutes ‘adequate warfarin education’ and that there is a lack of evidence indicating that the measure had led to an improvement in patient outcomes."

"I hope the Joint Commission and other national organizations will revisit and revise the national guidelines for anticoagulation education, particularly for warfarin, and potentially include patient-centered strategies," Dr. Moreland said in an interview.

Ann Watt, associate director for the department of quality measurement in the division of healthcare quality evaluation at the Joint Commission, said, "The Joint Commission is discussing with our technical advisory panel revisions/updates to all of the VTE measures, including VTE-5. We hope to incorporate some of the suggestions from the NQF Steering Committee that reviewed these measures as well as findings from recently published literature."

A Joint Commission spokesperson added that the commission has no plans to revise its National Patient Safety Goal NPSG.03.05.01 at this time.

The researchers had no financial conflicts related to their study. The study was supported by grants from Health Resources and Services Administration, the National Institutes of Health, and the University of California.