Determinants of oral anticoagulation control in new warfarin patients: analysis using data from Clinical Practice Research Datalink

Macedo, Ana; Bell, J. Simon; McCarron, C.; Conroy, R.; Richardson, J. David; Scowcroft, Anna; Sunderland, Tom; Rotheram, Naj

doi:10.1016/j.thromres.2015.06.007

Cited by 49 publications

(68 citation statements)

References 52 publications

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“…It is widely verified that patient characteristics such as concomitant diseases and female sex -also significant in our study -can act as significant predictors of TTR [2,8,12,51,71]. Explanations for these observations are, however, scarce.…”

Section: Strength and Limitationssupporting

confidence: 54%

Anticoagulation Control in Swiss Primary Care: Time in Therapeutic Range Percentages Exceed Benchmarks of Phase III Trials

Djalali

Valeri

Gerber

et al. 2016

Clin Appl Thromb Hemost

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BACKGROUND: In randomized controlled trials, non-vitamin K antagonist oral anticoagulants (NOACs) demonstrated noninferiority to vitamin K antagonists (VKAs) in patients who spent limited time in therapeutic range (TTR). In real-life patients, TTR is known to vary significantly across countries and health-care settings. OBJECTIVE: We aim to evaluate the quality of VKA treatment in Swiss primary care (PC) by comparing patients' median TTR to levels achieved in the phase III NOAC trials RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE-AF-TIMI 48. Patient characteristics affecting TTR control shall be estimated. METHODS: This is a retrospective longitudinal study in Swiss PC patients receiving VKA for 6 months. We identified patients from the PC research database FIRE (Family medicine International Classification of Primary Care Research using Electronic medical records) and calculated TTR according to Rosendaal formula. Comparative data from NOAC trials were retrieved from medical literature. Linear regression models were used to assess predictors of TTR. RESULTS: Primary care encounters of 215 patients were analyzed. Like in the NOAC trials, median observation period was 2.2 years, but patients were older (67.9% vs 38% 75 years) and differed in terms of concomitant diseases and drugs. Median TTR was 75% (65% in the NOAC trials). Female sex was independently associated with a lower TTR and significantly modified by increasing age. CONCLUSION: Practitioners should consider that patients in NOAC trials are only partly representative of PC patients, particularly in terms of TTR control. Only a minority of the observed patients would require a therapy switch to NOACs due to inadequate TTR. Further research is needed in order to identify specific features of care management that are associated with these outcomes.

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Section: Strength and Limitationssupporting

confidence: 54%

Anticoagulation Control in Swiss Primary Care: Time in Therapeutic Range Percentages Exceed Benchmarks of Phase III Trials

Djalali

Valeri

Gerber

et al. 2016

Clin Appl Thromb Hemost

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“…Larger efforts (n=48,830) have assessed differences in anticoagulation control by indication; atrial fibrillation versus venous thromboembolism. However, due to the limited representation (<1%) of patients of African descent [33], differences in anticoagulation control by race were not assessed. Similarly, in recent clinical trials that have led to the approval of four NoACs, patients of African descent comprised <2.0% of all participants [3–6].…”

Section: Discussionmentioning

confidence: 99%

Quality of anticoagulation control and hemorrhage risk among African American and European American warfarin users

Limdi¹,

Brown

Shendre³

et al. 2017

Pharmacogenetics and Genomics

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Objective We evaluated whether PTTR, risk of over-anticoagulation (INR>4) and risk of hemorrhage differs by race. As PTTR is a strong predictor of hemorrhage risk, we also determined the influence of PTTR on risk of hemorrhage by race. Methods Among 1326 warfarin users, PTTR was calculated as the percentage of interpolated INR values within the target range of 2.0–3.0. PTTR was also categorized as poor (PTTR <60%), good (PTTR≥60<70%), or excellent (PTTR≥70%) anticoagulation control. Over-anticoagulation was defined as INR>4 and major hemorrhages included serious, life threatening and fatal bleeding episodes. Logistic regression and survival analyses were performed to evaluate association of race with PTTR (≥60 vs.<60) and major hemorrhages, respectively. Results Compared to African Americans, European Americans had higher PTTR (57.6% vs. 49.1%; p<0.0001) and were more likely to attain PTTR≥60<70% (22.9% vs. 13.1%; p<0.001) or PTTR≥70% (26.9% vs. 18.2%; p=0.001). Older (>65yrs) patients without venous thromboembolism indication and chronic kidney disease were more likely to attain PTTR≥60%. After accounting for clinical and genetic factors, and PTTR, African Americans had a higher risk of hemorrhage (HR: 1.58; 95%CI 1.04–2.41; p=0.034). Patients with PTTR≥60<70% (HR 0.62; 0.38–1.02; p=0.058) and PTTR≥70% (HR 0.27; 0.15–0.49; p<0.001) had a lower risk of hemorrhage compared to those with PTTR<60%. Conclusion Despite provision of warfarin management through anticoagulation clinics, African Americans achieve a lower overall PTTR and have a significantly higher risk of hemorrhage. Personalized medicine interventions tailored to the African American warfarin users need to be developed.

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“…Anticoagulant control in our study was marginally lower than that reported in the ORBIT atrial fibrillation registry, where the mean TTR of patients was 65%, but is better than that reported elsewhere, particularly in observational studies, reflecting the barriers to achieving good therapeutic control at a population level. The lower TTR that we found in younger patients has been noted elsewhere and may reflect low compliance in this group . The suboptimal population level TTR and lack of change over a decade should prompt stakeholders in our region to look at ways to improve therapeutic control.…”

Section: Discussionmentioning

confidence: 44%

International normalised ratio monitoring in the community populations of the Auckland and Northland regions of New Zealand: time in therapeutic range and frequency of testing

McAuliffe¹,

Silva²,

Upton³

et al. 2018

Internal Medicine Journal

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Determinants of oral anticoagulation control in new warfarin patients: analysis using data from Clinical Practice Research Datalink

Cited by 49 publications

References 52 publications

Anticoagulation Control in Swiss Primary Care: Time in Therapeutic Range Percentages Exceed Benchmarks of Phase III Trials

Anticoagulation Control in Swiss Primary Care: Time in Therapeutic Range Percentages Exceed Benchmarks of Phase III Trials

Quality of anticoagulation control and hemorrhage risk among African American and European American warfarin users

International normalised ratio monitoring in the community populations of the Auckland and Northland regions of New Zealand: time in therapeutic range and frequency of testing

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