Use of signals and systems engineering to improve the safety of warfarin initiation.
Use of signals and systems engineering to improve the safety of warfarin initiation.
复制标题
利用信号和系统工程来提高华法林起始的安全性。
DOI：
10.1007/s11239-016-1402-z
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发表时间：
2016
影响因子：
4
通讯作者：
Gage,BF
中科院分区：
文献类型：
--
作者：
Hyun,G;Li,J;Bass,AR;Mohapatra,A;Woller,SC;Lin,H;Eby,C;McMillin,GA;Gage,BF
华法林给药算法结合联合收割机临床因素和给药史与当前国际标准化比值（INR）来估计华法林治疗剂量。不幸的是，如果INR过低，这些方法可能导致过量。我们的目标是开发一种基于既往INR和当前INR的警报机制。使用来自华法林预防DVT的遗传学信息学试验（GIFT）的数据，我们分析了第3天至第11天的华法林剂量估计值，其比前两次剂量估计值的平均值高≥ 10%。我们拟合一个逐步混合模型，以当前和先前的剂量估计，随后比较的根均方误差（RMSE）预测的最终治疗剂量使用GIFT算法与混合模型。从861份给药记录（从556例患者中获得）中，随机选择646份给药记录（75%）用于推导队列，215份给药记录（25%）用于验证队列。使用一个既往剂量估计值提高了华法林剂量估计值的准确性。与基于当前INR（GIFT算法）的剂量估计值相比，混合模型使推导队列的RMSE降低了0.0015 mg/天（RMSE 0.2079 vs. 0.2094; p = 0.039）。在验证队列中，RMSE降低不显著。基于当前和最近INR的剂量估计混合模型显示了改善华法林给药安全性的潜力。在INR低于预期值后，临床医生应谨慎地积极增加华法林剂量。
Warfarin-dosing algorithms combine clinical factors and dosing history with the current international normalized ratio (INR) to estimate the therapeutic warfarin dose. Unfortunately, these approaches can result in an overdose if the INR is spuriously low. Our goal was to develop an alert mechanism based on prior INRs in addition to the current INR. Using data from the Genetics InFormatics Trial (GIFT) of Warfarin to Prevent DVT, we analyzed warfarin dose estimates for days 3 through 11 that were ≥10 % higher than an average of the previous two dose estimates. We fit a stepwise mixed model to current and prior dose estimates, and subsequently compared the root-mean-square-error (RMSE) in predicting the final therapeutic dose using the GIFT algorithm versus the mixed model. From 861 dosing records (obtain from 556 patients), 646 dosing records (75 %) were randomly selected for the derivation cohort and 215 dosing records (25 %) for the validation cohort. Using one prior dose estimate improved the accuracy of the warfarin dose estimate. Compared to a dose estimate based on current INR (GIFT algorithm), the mixed model reduced the RMSE in the derivation cohort by 0.0015 mg/day (RMSE 0.2079 vs. 0.2094; p = 0.039). In the validation cohort, the RMSE reduction was not significant. A mixed model of dose estimates based on the current and most recent INRs shows potential to improve the safety of warfarin dosing. Clinicians should be cautious about aggressively escalating the warfarin dose after an INR that is lower than expected.