| Objective To explore the warfarin anticoagulation management mode for patients with atrial fibrillation under the guidance of telemedicine technology,evaluate the feasibility and clinical appilcation of this model,improve management efficiency and increase safety,convenience and economy of patients,so as to realize the systematization and standardization of anticoagulation management and to provide evidence support for the application of telemedicine to warfarin anticoagulation management.Methods A remote follow-up management model of community-family chronic cardiovascular disease was established under the guidance of regional large hospitals under the technical support of telemedicine,and on this basis,anticoagulation management was conducted for patients with atrial fibrillation.The study was divided into feasibility analysis stage and clinical practice evaluation stage.(1)In the feasibility analysis stage,a total of 98 patients who were diagnosed with atrial fibrillation in Subei People hospital hospital from October to December 2016 were enrolled in the study.The management model was used to complete the 6-month follow-up management.Based on the guideline treatment,the study was designed.The chronic cardiovascular platform and the corresponding mobile phone terminal were used for remote follow-up and regular outpatient follow-up(1 remote visit every 1 month,1 follow-up visit every 3 months).The INR compliance and its influencing factors like the knowledge of warfarin anticoagulant therapy,the influencing factors of anticoagulation compliance and scores of the quality of life were compared before and after follow-up.The feasibility of telemedicine for warfarin anticoagulation management in patients with atrial fibrillation was evaluated.(2)In the clinical practice evaluation stage,a total of 329 patients who were diagnosed with atrial fibrillation in Subei People hospital hospital from January to November 2017 were enrolled in the study.Through the random number table method,patients were randomly divided into trial group and control group,trial group for remote follow-up intervention group and control group for conventional outpatient follow-up group respectively.The management model was used to complete the 12-month follow-up management.Finally we collected relevant data statistical analysis,compared two groups of patients with INR demonstrating compliance,emergency treatment and the times of bleeding and thrombosis to preliminary assess the effect of clinical practice of the model.Results(1)At the stage of feasibility analysis and clinical practice evaluation,the study sample size was 93 cases(shedding rate was 5.10%)and 309 cases(shedding rate was 6.08%)respectively.(2)In the feasibility analysis stage,a total of 571 follow-up course records were collected through the mobile medical platform after the follow-up,including 502 routine follow-up records,69 copies were uploaded when patients suddenly changed his condition,and 56 missing follow-up records.The follow-up completion rate was 89.96%.The proportion of people who did not meet the INR standard in the first month,the third month and the sixth month were 30.11%,17.20%and 8.60%respectively.The difference between March and January was statistically significant(P=0.04),and there was a significant difference between June and January(P<0.01).Among the factors influencing the compliance rate of INR,like drug administration,food or drug interaction,and alcohol consumption showed statistically significant differences with the extension of follow-up time compared with the first month(P<0.05).Warfarin anticoagulant knowledge scale results show that there was a statistically significant difference in aspects like in the risk of atrial fibrillation,whether atrial fibrillation requires anticoagulation,anticoagulant purposes,the role of warfarin,the significance of monitoring INR,the target range of INR,the frequency of INR monitoring and food intaking vitamin K-rich before and after follow-up(P<0.05).There were no significant differences in the INR drug,food and self-monitoring bleeding tendency before and after follow-up(P>0.05).According to the score of the Warfarin Anticoagulation Compliance Questionnaire,there were 80 people with good anticoagulation compliance and 13 with poor anticoagulation.The differences in marital status,comorbidity,WRKS score,and income level were statistically significant(P<0.05),but there was no significant difference in gender,age,education,occupation,smoking history,drinking history,HAS-BLED score and the number of combined drugs(P>0.05).The quality of life of patients after follow-up was significantly different between the five dimensions of PF,GH,VT,SF and MH compared with that before the follow-up(P<0.05).There was no statistical difference between the three dimensions of RP,BP and RE(P>0.05).According to the HAMA/HAMD score,16 patients were anxious,11 were depressed,5 were anxious with depression,and 61 were without anxiety or depression.The quality of life scores of all dimensions of anxiety/depression patients were lower than those without anxiety/depression,and the differences were statistically significant(P<0.05).After 6 months of follow-up,the overall satisfaction of the enrolled patients with the whole platform system was 94.62%,the satisfaction with the usability of the system was 90.32%,the satisfaction with the practicability of the system was 93.55%,and the satisfaction with thediagnosis and treatment mode was 90.32%.(3)In the clinical practice evaluation stage,the INR compliance rates of the remote follow-up group in the first,third,sixth,ninth and the twelfth months were 77.71%,81.53%,89.17%,93.00%,and 94.90%respectively.The difference in INR compliance rate between the twelfth month and the first month was statistically significant(P<0.05).The INR compliance rates of the outpatient group in the first,third,sixth,ninth and the twelfth months were 82.24%,71.05%,69.08%,73.03%,and 78.95%respectively,and there was no significant difference in the INR compliance rate between the twelfth month and the first month(P>0.05).There was no significant difference in the rate of INR compliance in the first month(P>0.05).The difference in INR compliance rate was significant in the third,sixth,ninth,and twelfth months(P<0.05).The average number of emergency visits in the remote follow-up group in the third,sixth,ninth,and twelfth months was 1.87,1.71,1.38,and 1.53 respectively.The difference between the average number of emergency visits in the twelfth month and the third month was statistically significant(P<0.05).The average number of emergency visits in the regular outpatient group in the third,sixth,ninth,and twelfth months was 1.96,2.05,1.92 and 2.01 respectively,and there was no significant difference in the average number of emergency visits between the twelfth month and the third month(P>0.05).There was no significant difference in the average number of emergency visits between the two groups in the third month(P>0.05).The average number of emergency visits in the sixth,ninth,and twelfth months was significant(P<0.05).The incidence of mild hemorrhage in the remote follow-up group and the routine outpatient group were 9.55%and 17.76%,respectively.There was a statistically significant difference between the two groups(P<0.05),while the incidence of moderate and severe bleeding was 1.91%(3 cases of moderate bleeding)and 4.61%(6 cases of moderate bleeding,1 case of severe bleeding),the difference between the two groups was not statistically significant(P>0.05).The incidence of ischemic stroke in the remote follow-up group and the regular outpatient group were 1.27%and 5.92%,respectively,and the difference between the two groups was statistically significant(P<0.05).Conclusion This study shows that the warfarin anticoagulation management model of patients with atrial fibrillation under the guidance of telemedicine technology is safe and feasible.It improved INR compliance,anticoagulation knowledge,anticoagulation compliance,mental state,the quality of life of patients and reduced the number of emergency department patients on the premise of safety,so as to improve the prognosis of patients with atrial fibrillation,and ultimately achieve anticoagulation optimization,which is worthy of popularization and application. |
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