Construction and Evaluation of Standardized Anticoagulant Management Model of Atrial Fibrillation in Primary Medical Institutions Under Hierarchical Diagnosis and Treatment System

To organize experts to formulate a standardized anticoagulation management plan and process for atrial fibrillation in grass-roots medical institutions

1. Write the first draft of "standardized anticoagulation management plan and process of atrial fibrillation in primary medical institutions" By searching the anticoagulation management guidelines and expert consensus of atrial fibrillation at home and abroad, do a comparative study, determine the main points of anticoagulation management; analyzing the baseline clinical database of patients with multicenter atrial fibrillation, combined with quantitative and qualitative research, to explore the anticoagulation management needs of patients with atrial fibrillation. Based on the above results, the first draft of standardized anticoagulation management plan and process of atrial fibrillation in grass-roots medical institutions was written.
2. Organize expert group interviews. A multidisciplinary expert group was identified, including cardiology, neurology, general medicine, nursing and pharmacy, with 1 or 2 middle-level and above professionals selected in each discipline. Design the interview outline, according to the interview outline, a senior general practitioner encourages and guides the team members to express their own views on the subject. The main contents include: how scientific is this anticoagulation management scheme? What is the value of clinical application? What are the difficulties in the implementation process? What are the contents that need to be further improved?
3. Revision and improvement of "standardized anticoagulation management scheme and process for atrial fibrillation in primary medical institutions" According to the results of the expert group interview, revise and further improve the "standardized anticoagulation management plan and process of atrial fibrillation in primary medical institutions" to generate the final intervention plan.

To evaluate the clinical effect of standardized anticoagulation management scheme and process for atrial fibrillation.

1. Observation indicators Main outcome measures: the rate of anticoagulant therapy, the rate of reaching the standard of INR, the incidence of bleeding and thromboembolic events at 3 months, 6 months, 9 months, 12 months, 18 months and 24 months.

Secondary indicators: anticoagulant compliance rate and knowledge awareness rate of atrial fibrillation at 6 months, 12 months and 18 months. Blood routine: hemoglobin, platelet; biochemistry: glutamic pyruvic transaminase, glutamic oxaloacetic transaminase, serum creatinine, urea nitrogen, glomerular filtration rate; electrocardiogram / dynamic electrocardiogram, echocardiography. 2. Follow-up plan Patients' symptoms and signs, diet and exercise in the process of anticoagulation management were followed up once a month, and when unmanageable new symptoms or drug side effects appeared, they were referred to secondary or tertiary hospitals for treatment in time; a regular comprehensive physical examination was arranged once a year, including blood routine, biochemical, ECG / dynamic electrocardiogram, echocardiography, etc., and the follow-up period was 2 years.