@article {MouchouxA123, author = {Christelle Mouchoux and Sandrine Touzet and Cyrille Colin and Marie-Agn{\`e}s L{\'e}pine and Corinne Goubier-Vial and Sophie Wesolowski}, title = {257 Impact of intervention program on vitamin K antagonist prescription practices in elderly patients}, volume = {19}, number = {Suppl 1}, pages = {A123--A124}, year = {2010}, doi = {10.1136/qshc.2010.041624.76}, publisher = {BMJ Publishing Group Ltd}, abstract = {Background Venous thromboembolism and the prevention of thromboembolic risk during atrial fibrillation are two main indications for vitamin K antagonist (VKA) therapy in elderly patients. Due to the high risk of haemorrhages, prescribing a VKA treatment requires complying with practice guidelines. Furthermore, medical treatment of excess dosage must be adapted in order to minimise the risk of haemorrhage and thrombosis. This study aimed to assess the impact of intervention program on prescription of VKAs and medical treatment of excess dosage at a healthcare facility fir the elderly.Method A {\textquoteleft}before/after{\textquoteright} study was conducted at a 632-bed geriatric. All patients treated with VKAs were included and followed-up for a period of 2 months. The program assessed composed of two interventions. The first intervention, aiming to improve prescription practices, was based on the distribution of a guideline for VKAs treatment adapted to geriatric care and the local context. The three steps in conception these practices guidelines were: 1/in-depth bibliographical research by all physicians at the facility, followed by selection of pertinent references; 2/writing by a pharmacist and a physician; and 3/proofreading, correction and approval by all of the prescribing staff at the facility. After it was approved, the prescribing guidelines for VKA treatment was presented at an institutional meeting and then distributed at each physician and pharmacist and each care unit. The second intervention, aiming to improve treatment of excess dosage, was based on an oral presentation of recommendations for treatment of excess dosage by pharmacist.Results One hundred and ten and 115 patients were enrolled respectively before and after implementation of the intervention program. Implementation of the practices guidelines resulted in a significant increase in the prescription rate of warfarin (8\% vs 40\%, p\<0.001) and a significant decrease rate of acenocoumarol (21\% vs 6\%, p\<0.01). The incidence of excess dosage (6.4\% vs 2.6\%, p\>0.05) decreased between the two phases of the study. Medical treatment of the excess dosage was wrong with recommendations during the first phase of the study and did not change during the second phase.Discussion{\textemdash}conclusion The intervention program implemented at the facility resulted in a concrete, nearly immediate change in prescription practices, primarily concerning the choice of molecule. However, according to our analysis, the two interventions did have not the same impact on prescription practices and treatment of excess dosage. An {\textquoteleft}active{\textquoteright} intervention, such a conception of local guideline for VKAs treatment, has a greater impact than the oral presentation of guidelines for treating excess dosage. In order to improve the safety of VKA treatment in elderly, the improvement in prescription practices must be continued by means of enhancement: Training and awareness programs and tracking changes in practices: implementation of indicators.Contexte La maladie thromboembolique et la fibrillation auriculaire sont les deux principales indications des antivitamines K (AVK) chez les personnes {\^a}g{\'e}es. Compte-tenu du risque h{\'e}morragique, la prescription des AVK, tout particuli{\`e}rement chez les sujets {\^a}g{\'e}s, n{\'e}cessite d{\textquoteright}en conna{\^\i}tre les particularit{\'e}s et de respecter les recommandations afin de pr{\'e}venir la iatrog{\'e}nie. La prise en charge m{\'e}dicale des surdosages doit {\'e}galement {\^e}tre adapt{\'e}e afin de limiter les risques h{\'e}morragiques et thrombotiques.M{\'e}thode Une {\'e}tude {\guillemotleft} avant/apr{\`e}s {\guillemotright} a {\'e}t{\'e} r{\'e}alis{\'e}e dans un {\'e}tablissement g{\'e}riatrique de 632 lits. Tous les patients sous AVK ont {\'e}t{\'e} inclus et suivis pendant une p{\'e}riode de 2 mois. Le programme {\'e}valu{\'e} est compos{\'e} de deux interventions. La premi{\`e}re {\'e}tait bas{\'e}e sur la r{\'e}daction et la diffusion d{\textquoteright}un guide local de bon usage des AVK, adapt{\'e} {\`a} la g{\'e}riatrie et au contexte local. Les trois {\'e}tapes de la conception de ce guide ont {\'e}t{\'e}: 1/recherche bibliographique par l{\textquoteright}ensemble des prescripteurs de l{\textquoteright}{\'e}tablissement puis s{\'e}lection des r{\'e}f{\'e}rences pertinentes, 2/r{\'e}daction par un pharmacien et un m{\'e}decin, 3/relecture, correction et validation par tous les prescripteurs de l{\textquoteright}{\'e}tablissement. Apr{\`e}s sa validation, le guide local a {\'e}t{\'e} pr{\'e}sent{\'e} au cours d{\textquoteright}une r{\'e}union institutionnelle puis diffus{\'e} dans toutes les salles de soins et {\`a} l{\textquoteright}ensemble des prescripteurs et pharmaciens de fa{\c c}on nominative. La seconde intervention {\'e}tait bas{\'e}e sur une pr{\'e}sentation orale des recommandations de prise en charge m{\'e}dicale des surdosages lors d{\textquoteright}une r{\'e}union institutionnelle.R{\'e}sultats 110 et 115 patients ont {\'e}t{\'e} inclus respectivement avant et apr{\`e}s la mise en place du programme. Une augmentation significative de la prescription de warfarine (8\% vs. 40\%, p\<0.001) et une diminution significative de la prescription d{\textquoteright}ac{\'e}nocoumarol ont {\'e}t{\'e} observ{\'e}es suite {\`a} la r{\'e}daction et {\`a} la diffusion du guide local de bon usage. L{\textquoteright}incidence des surdosages (6,4\% vs. 2.6\%, p\>0.05) a diminu{\'e} suite {\`a} la mise en place du programme au sein de l{\textquoteright}{\'e}tablissement. Cependant, la prise en charge m{\'e}dicale des surdosages reste non-conforme au cours des deux phases de l{\textquoteright}{\'e}tudeDiscussion{\textemdash}conclusion Le programme d{\textquoteright}intervention mis en place au sein de l{\textquoteright}{\'e}tablissement a permis une {\'e}volution concr{\`e}te et quasi-imm{\'e}diate des pratiques de prescription, essentiellement sur le choix de la mol{\'e}cule. Cependant, d{\textquoteright}apr{\`e}s notre analyse, les deux interventions n{\textquoteright}ont pas eu le m{\^e}me impact sur les pratiques de prescription et de prise en charge des surdosages. D{\'e}sormais, il est essentiel de p{\'e}renniser la d{\'e}marche d{\textquoteright}am{\'e}lioration engag{\'e}e gr{\^a}ce {\`a} la consolidation de l{\textquoteright}am{\'e}lioration des pratiques (formation, sensibilisation) et au suivi de cette {\'e}volution (mise en place d{\textquoteright}indicateurs), tout cela dans le but de renforcer la s{\'e}curit{\'e} du traitement AVK chez la personne {\^a}g{\'e}e.}, issn = {1475-3898}, URL = {https://qualitysafety.bmj.com/content/19/Suppl_1/A123}, eprint = {https://qualitysafety.bmj.com/content/19/Suppl_1/A123.full.pdf}, journal = {BMJ Quality \& Safety} }