风湿性心脏病左房室瓣狭窄伴心房纤颤临床路径中的药学服务研究

Pharmaceutical Care Pathway for Rheumatic Mitral Stenosis With Atrial Fibrillation

目的评价药学服务对风湿性心脏病左房室瓣狭窄伴心房纤颤患者临床路径的干预效果。方法根据原卫生部颁发的《风湿性左房室瓣狭窄(内科)临床路径》(2010版)设计风湿性心脏病左房室瓣狭窄伴心房纤颤药学服务路径,采用随机、平行对照临床研究,选取2012年1月—2014年1月山东大学附属临沂市人民医院心内科收治的风湿性心脏病左房室瓣狭窄伴心房纤颤患者200例,采用随机数字表法分为药学服务组102例,对照组98例,排除不符合标准者后,药学服务组60例,对照组60例,药学服务组在常规临床路径管理的基础上由临床药师主导药学服务过程,优化药物选择,对患者进行药学监护。以患者的抗凝治疗达标率〔国际标准化比值(INR)达标率〕、药物不良事件(出血/栓塞事件)发生率、住院时间、药品费用、住院总费用、药占比为观察指标。结果两组患者住院期间INR达标率间差异无统计学意义〔32.1%(44/137)与21.7%(28/129);χ2=3.648,P=0.056〕,出院时INR达标率间差异无统计学意义〔41.7%(25/60)与26.7%(16/60);χ2=3.001,P=0.083〕,药学服务组患者住院期间INR<1.6或INR>3.0的发生率较对照组降低〔39.4%(54/137)与63.6%(82/129);χ2=15.507,P<0.001〕。对于两组中入院首次监测INR不达标患者,药学服务组患者出院时INR达标率高于对照组,差异有统计学意义〔38.1%(16/42)与13.3%(6/45);χ2=7.050,P=0.008〕。两组患者不良事件发生率比较,差异无统计学意义(P>0.05);两组患者住院时间、药品费用、住院总费用、药占比比较,差异均无统计学意义(P>0.05)。结论以药学服务路径对风湿性心脏病左房室瓣狭窄伴心房纤颤临床路径住院患者进行全程化的药学服务,可明显提高患者住院期间的抗凝治疗达标率,且安全性较好。

Objective To evaluate the effects of pharmaceutical care（ PC） pathway on rheumatic mitral stenosis（ RMS） with atrial fibrillation（ AF）. Methods This study designed a pharmaceutical care pathway for RMS patients combined with AF according to ＂ Clinical Pathway of Rheumatic Mitral Stenosis（ Medicine）（ 2010 Edition） ＂ and divided 200 patients randomly into groups PC（ n = 102）,control（ n = 98）,after exclusion of those who did not meet standards,the groups PC,control,60 in each. They choiced form Linyi People＇s Hospital from January 2012 to January 2014. PC group were given pharmacist-leading-process PC based on conventional clinical pathway management,drug choice optimized. The observational indicators were control rates of anticoagulant therapy 〔International Normalized Ratio（ INR） compliance rate〕,incidences of adverse events, hospital stay, drug costs, total hospital costs, medicine proportion. Results No significant difference was noted in INR compliance rate between 2 groups during hospitalization 〔32. 1%（ 44 /137） vs. 21. 7%（ 28 /129）; χ2= 3. 648,P = 0. 056〕,before discharge 〔41. 7%（ 25 /60） vs. 26. 7%（ 16 /60）; χ2= 3. 001,P = 0. 083 〕. The incidence of INR〈 1. 6 or INR 〉3. 0 was lower in PC group than control group 〔39. 4%（ 54 /137） vs. 63. 6%（ 82 /129）; χ2= 15. 507,P〈0. 001〕. For the patients who had INR below the standards in first monitoring at admission,INR compliance rate was higher in PC group than in control group before discharge 〔38. 1%（ 16 /42） vs. 13. 3%（ 6 /45）; χ2= 7. 050,P = 0. 008〕. There was no significant difference incidence of adverse events between 2 groups（ P〉0. 05）,there was no difference in hospital stay,drug costs,total hospital costs,medicine proportion（ P〉0. 05）. Conclusion PC pathway for RMS patients combined with AF can improve remarkably the control rate of anticoagulant therapy and be safe.