IT-systemer til dosering af coumarin-derivater Ivan Brandslund, Klinisk Biokemi, Vejle Amt

1
IT-systemer til dosering af coumarin-derivater
Ivan Brandslund, Klinisk Biokemi, Vejle Amt

• Agenda
• Status i Vejle Amt / Præsentation af systemet
• Kvaliteten i behandlingen
• Perspektiverne

2
Status AK behandlingen i Vejle

• Systemet er udviklet i tæt dialog med læger og
  understøtter de daglige arbejdsrutiner
• Systemet har kørt på amtets 5 hospitaler i 2 år
• Systemet er tilgængeligt for alle praktiserende
  læger i amtet på Sundhed.dk fra november 2004
  november 2005, eller ?
• Systemet bliver sat i drift i løbet af 2006 med
  selvtestende patienter.

3
Agreement between the CSO/AK computer system and the doctors prescription Agreement between the CSO/AK computer system and the doctors prescription Agreement between the CSO/AK computer system and the doctors prescription
N
100 dose agreement /- 3 in mg deviation /- 3-5 in mg deviation /- 5-8 in mg deviation gt /- 5-8 in mg deviation, but safe gt/- 8 and unsafe Total 215 30 30 9 5 0 289 74.4 10.4 10.4 3.1 1.7 0 100
4
Comparison between manually or paper based AC and
computer CSO/AC guided ACAbility to obtain
correct target area at the next visit
Paper based 382 Paper based 382 Computer based ) 326 Computer based ) 326
N N
Correct hit interval 268 70.1 223 68.4
Deviation lt /- 0.5 INR 93 24.5 74 22.6
Deviation lt /- 1.0 INR 18 4.7 24 7.4
Deviation gt 1.0 INR 3 0.8 5 1.5
) CSO/AC was followed, - in daily practise only used as a guideline ) CSO/AC was followed, - in daily practise only used as a guideline ) CSO/AC was followed, - in daily practise only used as a guideline ) CSO/AC was followed, - in daily practise only used as a guideline ) CSO/AC was followed, - in daily practise only used as a guideline
5
Major non-fatal hemorrhage, treated in hospital during AC Major non-fatal hemorrhage, treated in hospital during AC Major non-fatal hemorrhage, treated in hospital during AC Major non-fatal hemorrhage, treated in hospital during AC Major non-fatal hemorrhage, treated in hospital during AC Major non-fatal hemorrhage, treated in hospital during AC
Diagnosis Indication for AC INR at admission Caused by AC Amplified by AC Unrelated
Colon polyposis Unspecified 2.6 0 0 1
Colon polyposis Artif.heart valves 1.5 0 0 1
Colon polyposis Artif.heart valves 7.6 0 1 0
Gastrointestinal Isch.heart dis. 1.6 0 0 1
Gastric ulcer Artif. Heart valves 3.6 0 1 0
Haemorrhoids Artif.heart valves 7.2 0 1 0
Haemorrhoids Atrial fib. 3.6 0 1 0
Rectal bleeding DVT pulm. Emb. 2.5 0 1 0
Haemoptysis Pulm. Embol. 4.5 0 1 0
Haemoptysis Atrial fib. 1.9 0 1 0
Haemoptysis Atrial fib. 1.9 0 1 0
Hematuria Atrial fib. 4.7 0 1 0
Hematuria Atrial fib. 5.6 1 0 0
Cerebral hem. Artif.heart valves 1.7 0 0 1
Subdural traum. Unspecified 2.3 0 1 0
Oesophag. ulcer Vascul.prosthesis 2.5 0 1 0
Epistaxis Unspecified 1.1 0 0 1
Vaginal Atrial fib. 15.0 1 0 0
6
Non-fatal thromboembolism, treated in hospital during AC Non-fatal thromboembolism, treated in hospital during AC Non-fatal thromboembolism, treated in hospital during AC Non-fatal thromboembolism, treated in hospital during AC Non-fatal thromboembolism, treated in hospital during AC
Diagnosis Indication INR at admission Caused by insuff. AC unrelated
Thrombosis ext. Inf. DVT atrial fib. 1.6 1 0
Cerebral infarct Artif. Heart valves 4.0 0 1
Cerebral ischemia Artif. Heart valves 2.2 0 1
7
Deaths among 741 patients on AC during 1 year Deaths among 741 patients on AC during 1 year Deaths among 741 patients on AC during 1 year Deaths among 741 patients on AC during 1 year Deaths among 741 patients on AC during 1 year Deaths among 741 patients on AC during 1 year Deaths among 741 patients on AC during 1 year
Indication No of patients Deaths Age Causes of death Causes of death Causes of death
Not related to AC (terminal cancer etc.) Thromboembolism Hemorrhagia
Atrial fibrillation 329 22 80.6 15 4 3
Deep venouos thrombosis 68 5 70.2 5 0 0
Artificial heart valves 62 0 - 0 0 0
Pulmonary embolus 43 2 60.0 2 0 0
Cerebral ischemia 30 0 - 0 0 0
Cardiac disease 19 1 79.0 1 0 0
Thrombophilia genes, anti-phosfolipid syndrome and other causes 190 10 69.8 7 1 2
Total 741 40 ?73.3 ?77.0 30 5 5
8
Beslutningsstøtte til det integrerede
behandlingsforløbSygehus praksis patientaksen

• Beslutningsstøtte i fælles journal på
  specialistniveau føres ud til praksis og
  patient.
• Patienter tabes ikke mellem 2 instanser
• - Kan overdrages / overtages, men ansvaret
  klæber (auto-reminders).
• Patienters brug af systemet kræver ikke
  længerevarende skoling af patienten
• - selvtest kontra selvstyring

9
CoaguChekXSfra Roche Diagnostics

XS for eXtra

• Small
• Simple
• FaSt
• PreciSe
• Safe

10
Storyboard Selvtestende patienter  
En selvtestende patient logger på CSO/AKs
patientgrænseflade (01.gif)
11
Efter login vises patienten den nuværende status
(02.gif)
12
Efter at have målt INR ved hjælp af det
udleverede udstyr, indtaster patienten nu den
målte INR-værdi (03.gif)
13
Patienten får en kvittering for at svaret er
modtaget (04.gif)
14
Denne patient vælger at få vist sin journal, for
at se om INR-målingen er modtaget (05.gif)
    Vi springer nu over til behandlerens
grænseflade, hvor behandleren allerede er logget
ind...
15
Behandleren undersøger om der er ubehandlede
laboratoriesvar (06.gif)
16
... og konstaterer at en selvtestende patient har
inddateret en måling. Behandlingen startes.
(07.gif)
17
Der doseres (08.gif)
18
Tidspunkt for næste kontrol bestemmes og der
genereres et doseringsbrev... (09.gif)
19
Behandlingen er afsluttet, brevet er genereret,
men behandleren undlader at printe det ud.
(10.gif)
20
  Patienten modtager automatisk en email med
besked om at der er foretaget en ny dosering
(11.gif)  
21
Patienten (som i dette tilfælde stadig er logget
på patientgrænsefladen) åbner sin journal og
konstaterer at behandlingen er foretaget (12.gif)
22
Patienten åbner doseringsbrevet og kan efter eget
valg printe det ud eller læse det direkte fra
skærmen (13.gif)
23
Selvstyring
6 mdr. uddannelseHistorisk tilbagemelding til
lægen på papir Lille andel af ptt. kompetente
(20-25)
Selvtestning
2-3 timer uddannelseReal-tids overvågningStor
andel af ptt. kompetente (gt50?)