[The systemic approach to analysis of opinions of patients about medical service].

The maintenance of health of residents of the Northern Regions of Russia, including those living in the Arctic zone of the cbountry, is a condition of its advance development in XXI century. The percentage of Russian citizen vaccinated against the new coronavirus infection (COVID-19) does not exceed 50% after beginning of implementation of vaccination program. It can be conditioned by lower level of both of credence of citizen to health care system and health literacy.Purpose of the study is to establish determinants of vaccination of population against COVID-19 in circumpolar region of Russia as exemplified by the Arkhangelsk Oblast.The sociological survey was carried out using the interview technique of patients of medical organizations (n=433) and conditionally healthy residents of the Arkhangelsk Oblast (n=139). To evaluate the level of general health literacy the Russian version of questionnaire HLS19 - Q22-RU was applied. The most of conditionally healthy respondents and consumers of medical services looked for information about methods of prevention and treatment (80.4% and 58.2% correspondingly), had an experience of vaccination against COVID-19 (79% and 56.3% correspondingly). The relative chances of conditionally healthy respondents, women, and respondents having no children and no credence to national health care system to independently look for information related to COVID-19 is higher at 2.94, 2.08, 1.55 and 1.48-1.57 times correspondingly. The relative chances of conditionally healthy respondents having no children in family and assessing one's economic status as "higher than average" to be vaccinated against COVID-19 is higher at 4.02, 1.52, 1.53 times correspondingly. Availability of experience of vaccination against COVID-19 is conditioned by higher level of general health literacy.In the Arkhangelsk Oblast and other circumpolar regions of Russia the programs of increasing loyalty of citizen to measures of population prevention, including vaccine prevention, is to be implemented with consideration of established determinants of of vaccinations against COVID-19.

[Results of decision support system implementation for prescribing anticoagulants to patients with atrial fibrillation in hospital].

BACKGROUND: In 819% of patients with atrial fibrillation (AF) with anticoagulant therapy (ACT), hemorrhagic complications occur, including due to excess doses of AC. At the same time, ACT is necessary for patients with AF, since anticoagulants effectively reduces the risk of ischemic stroke. To make a decision on the appointment of ACT, it is necessary to correlate the risks of ischemic stroke and bleeding, this requires knowledge of current clinical using ACT recommendations and instructions. Among patients admitted to hospital, 30% receive ACT, so increasing adherence to clinical recommendations for prescribing AC to patients with AF by doctors of various profiles is an urgent task. AIM: To analyze the adherence of physicians to recommendations for prescribing ACT before and after the introduction of decision support system (DSS) in patients with AF in a multi-specialty hospital. MATERIALS AND METHODS: A single-center non-randomized study with historical control to assess adherence to recommendations based on the analysis of medical prescriptions and the structure of drug errors in patients with AF in a multi-specialty hospital in Moscow before and after the introduction of DSS. Compliance with the recommendations of physicians was evaluated in the sections indications /contraindications to AC and dosage regimen of AC. The presence of deviations from the clinical recommendations /instructions for medical use of AC was regarded as management of the patient with non-compliance with recommendations. Physicians adherence level to recommendations was calculated as the ratio of cases of compliance with recommendations to the total number of cases. RESULTS: In the control and experimental groups, there was a significant increase in the proportion of POAC at discharge in comparison with admission to hospital: from 54.5 to 76.8% (p=0.0005) and from 63 to 85.7% (p=0.0002), respectively. However, only in the experimental group it was possible to significantly reduce the number of patients without a prescribed ACT (if there are indications) from 7.6 to 1% (p=0.04) in comparison with admission. During the study, it was possible to significantly increase physicians adherence level to the recommendations for the AC dosage regimen in patients with AF from 59% (44 discrepancies for 107 prescriptions) to 84.6% (16 discrepancies for 104 prescriptions); p0.005. Before the introduction of the DSS, the analysis of drug prescriptions revealed 56 drug errors (0.5 errors per patient), after the introduction of the DSS, the number of drug errors significantly decreased to 21 (0.2 errors per patient); p0.05. After the introduction of DSS, the number of sub-therapeutic doses of AC was reduced from 31 (27.7%) to 8 (7.6%); p0.05. CONCLUSION: The level of adherence to the recommendations for prescribing ACT to patients with AF in the hospital is high. The use of DSS increases the level of adherence to the recommendations on the AC dosage regimen in patients with AF, as well as eliminates errors in calculating the risk of ischemic stroke and systemic thromboembolic complications, and contributes to reducing the frequency of prescribing sub-therapeutic doses of AC.

[Optimizing the prophylaxis of hospital-acquired deep vein thrombosis and pulmonary thromboembolism]. / Optimizatsiya profilaktiki vnutrigospital'nykh trombozov glubokikh ven i tromboembolii legochnoi arterii.

AIM: To reduce the number of preventable hospital-acquired venous thromboembolic events (HA-VTE) and to improve the quality of VTE prophylaxis at multiprofile hospital. MATERIAL AND METHODS: A comprehensive approach to preventing HA-VTE was developed, which involved the global trigger tool method to assess adverse events, as well as the computerized clinical decision support system (CDSS) to prevent HA-VTE on the basis of relevant clinical practice guidelines, and HA-VTE registry. RESULTS: A total of 50 patients (15 men, 35 women; their median age was 70.5 years) with HA-VTE were included in the HA-VTE registry in January 2014 to June 2015. Assessment of a trend in the prevalence of HA-VTE when introducing CDSS to prevent VTE showed its statistically significant decline in the total number of HA-VTE cases (χ2=7.325, df=1; p=0.0068) and in that of HA-VTE in surgical patients (χ2=7.266, df=1; p=0.0070). The statistical significance of χ2 for linear trend was not achieved for medical patients, which is probably due to the small sample size (χ2=2.764, df=1; p=0.0964). While introducing CDSS, there was a statistically significant reduction in the incidence of postoperative VTE from 8.76 to 4.17 cases per 1000 interventions (χ2=5.347, df=1; p=0.0208; the absolute values of HA-VTE and surgical interventions were used for the calculation). CONCLUSION: The proposed comprehensive approach can substantially increase the detection rate of HA-VTE and decrease its incidence rates. This requires a personified assessment of the risk of VTE and hemorrhage in all hospitalized patients on day 1 of their admission, timely initiation of recommended VTE prophylaxis, and dynamic assessment of the risk of VTE and hemorrhage for timely correction of the prophylaxis.

Decision support systems in clinical practice: The case of venous thromboembolism prevention.

BACKGROUND: Today medicine is facing a "knowledge crisis" in that explosively expanding medical knowledge encounters limited abilities to disseminate new practices [1]. Clinical practice guidelines (CPGs) are intended to promote high standards of care in specific areas of medicine by summarizing best clinical practice based on careful reviews of current research. However, doctors are often short of time to study these documents and check their updates, have little motivation for strict adherence to them. A systematic review of 11 studies reporting on 29 recommendations has found that median adherence to all recommendations was 34%, suggesting that potential benefits for patients from health research may be lost [2].Clinical decision support systems (CDSS) can serve as a knowledge translation tool, mediator between clinical guidelines and physicians by providing the right information to the right person at the right time. OBJECTIVE: To evaluate the effectiveness of implementation of international and national CPGs for venous thromboembolism (VTE) prevention with the help of CDSS in a general hospital. METHODS: A multifunctional CDSS based on national and international guidelines on the VTE prevention was developed and implemented in the Medical Center of the Bank of Russia (MC). The system has the following functionalities: 1) it supports the decision on the VTE prevention based on individual risk assessment of thrombosis (scales of Caprini, Rogers and Khorana, Padua Prediction Score, additional risk factors) and bleeding (IMPROVE scale for non-surgical patients, major bleeding scale for surgical patients and major orthopedic surgeries, hemorrhagic complications risk in cancer patients); 2) generates the summary containing the grade of recommendations and the level of evidence, personalized recommendations on regimen and duration of preventive antithrombotic therapy, dose correction according to creatinine clearance; 3) provides an audit form for and statistical analysis of VTE cases; 3) automatically generates a quality register for VTE prevention.CDSS was implemented in June 2014. We analyzed VTE cases identified by triggers (deep vein thrombosis diagnosed by Doppler ultrasound and pulmonary embolism at the chest CT) that occurred in 2014 before and after CDSS implementation, as well as in the first half of 2015. Patients with VTE diagnosed during the first 48 hours of hospitalization or receiving anticoagulants in therapeutic doses were excluded from the analysis. Chi-square test for linear trend and non-parametric methods of descriptive statistics were used for data analysis. RESULTS: CDSS utilization was regulated by a special hospital-wide policy; lectures were organized to educate doctors how to use the system. Although international recommendations require VTE risk assessment for all hospitalized patients (except those receiving anticoagulant in therapeutic doses), the doctors filled forms for only 306 patients during the first 6 months of CDSS functioning (14.1% of discharges with length of stay >48 hours during this period). In the first half of 2015 the coverage of VTE risk assessment with CDSS was 19% (n = 506). Correctness of filling out the forms was 78.4%, in the rest of cases doctors made mistakes in choosing patient's profile or when filling in risk scales.Doctors adhere to given recommendations in 85.4% of cases. Most often (47.5%) pharmacotherapy with low molecular weight heparin (LMWH), preventive doses, was recommended by the system, and in this category the adherence to recommended practice was the lowest (74.6%). Among patients who underwent pharmacoprophylaxis, in 21.1% cases the use of anticoagulants was inconsistent with clinical guidelines or drug package insert (typically inappropriate choice of LMWH prophylactic doses, delaying or reducing the duration of prophylaxis).The rate of hospital-acquired VTE significantly decreased after CDSS implementation and was 11.71, 8.28 and 4.84 per 1,000 hospitalizations in the first and second half of 2014 and in the first half of 2015, respectively (χ2 = 7.325, df = 1, p = 0.0068). The rate of postoperative VTE for the same period amounted to 8.76, 3.39 and 4.17 per 1,000 operations, respectively (χ2 = 7.266, df = 1, p = 0.007), reaching a level of the correspondent AHRQ safety indicator (4.99 per 1,000 operations) [3]. Deviations from clinical guidelines or anticoagulant package inserts were revealed in 74% of VTE cases; and more than 1/3 of deviations affected treatment outcomes. CONCLUSIONS: Coverage of hospitalized patients with documented VTE risk assessment gradually increased after the CDSS implementation, but remained at a low level (19% of eligible patients). Partly it may be attributed to the lack of CDSS integration in electronic health record or computerized physician order entry systems that would facilitate routine documentation of VTE and bleeding risks. However, the introduction of CDSS has allowed reducing significantly the rate of hospital-acquired VTE. This can be explained by drawing doctor's attention to the VTE problem and by training effect of CDSS. After receiving appropriate recommendations doctors adhere to them, on average, in 85.4% of cases, although for LMWH pharmacoprophylaxis this level was lower (74.6%). Development of hospital-acquired VTE in most cases (74%) was accompanied by non-compliance with CPGs recommendations, emphasizing the importance of additional measures for better adherence to evidence-based clinical practices.