Quality of Anticoagulation Control and Costs of Monitoring Warfarin Therapy among Patients with Atrial Fibrillation in Clinic Settings: A Multi-Site Managed-Care Study

Menzin, Joseph; Boulanger, Luke; Hauch, Ole; Friedman, Mark; Marple, Cheryl Beadle; Wygant, Gail; Hurley, Judith S.; Pezzella, S.; Kaatz, Scott

doi:10.1345/aph.1e169

Cited by 70 publications

(54 citation statements)

References 22 publications

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“…[15][16][17][18][19][20][21][22][23][24][25][26][27][28] Our updated systematic search from January 2005 through February 2008 (as depicted in Figure 1) identified an additional 536 studies for full text review, of which 526 were excluded. Of the studies excluded, most were excluded because they were not conducted in the United States, or they were not a primary study.…”

Section: ■■ Resultsmentioning

confidence: 99%

“…14,15,19,[22][23][24][25][27][28][29][30][32][33][34]36,37 Thus, 8 studies, including a total of 14 study groups, met all of the inclusion criteria and were included in the final analysis (Table 1). 17,18,20,21,26,31,35,38 The study groups enrolled a median of 317 patients (interquartile range, 150 to 482 patients; total = 22,237 warfarintreated patients), 31 who were followed for a median of 272.3 patient-years (range, 123.9 to 980.8 patient-years; total = 41,471.9 patient-years). Patients spent a median of 146.6 patient-years (range, 74.9 to 524 patient-years; total = 23,752.1 patient-years) within the therapeutic INR range.…”

Section: ■■ Resultsmentioning

confidence: 99%

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Meta-Analysis to Assess the Quality of Warfarin Control in Atrial Fibrillation Patients in the United States

Baker

Cios²,

Sander³

et al. 2009

JMCP

364

223

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BACKGROUND: Atrial fibrillation (AF) affects a significant proportion of the American population and increases ischemic stroke risk by 4-to 5-fold. Oral vitamin K antagonists, such as warfarin, can significantly reduce this stroke risk but can be difficult to dose and monitor. Previous research on the effects of setting (e.g., randomized controlled trials, anticoagulation management by specialty clinics, usual care by community physicians) on the proportion of time spent within therapeutic range for the international normalized ratio (INR) has not specifically examined anticoagulation in AF patients.OBJECTIVES: Use traditional meta-analytic and meta-regressive techniques to evaluate the effect of specialty clinic versus usual care by community physicians on anticoagulation control, measured as the proportion of time spent in therapeutic INR range, for AF patients that received warfarin anticoagulation in the United States.METHODS: Studies included in a previously published meta-analysis (van Walraven et al., 2006), which systematically searched reports between 1987 and 2005, were also screened for inclusion in our analysis. A subsequent systematic literature search of MEDLINE, EMBASE, and the Cochrane Central Register of Clinical Trials from January 2005 through February 2008 was conducted. Studies were included if they (a) contained at least 1 warfarin-treated group including more than 25 patients for whom INR control was monitored for at least 3 weeks; (b) included patients treated for AF in the United States; (c) used a patient-time approach (patient-year) to report outcomes; and (d) reported data on the proportion of time spent in traditional therapeutic INR ranges (i.e., a lower limit INR between 1.8 and 2.0 and an upper limit INR between 3.0 and 3.5. Studies with INR goals outside this range were excluded). The proportion of time spent within the therapeutic INR range for each study group was expressed as an incidence density using a person-time approach (in years). All studies were pooled using a random effects model and were weighted by the inverse of the variance of proportion of time spent in the therapeutic range. In order to determine how study setting influenced the proportion of time spent within a therapeutic INR range, both subgroup and meta-regression analyses were conducted.RESULTS: This analysis included 8 studies and a total of 14 unique warfarin-treated groups; 3 of the 8 studies and 4 of the warfarin groups were not included in the previous meta-analysis (van Walraven et al., 2006). Overall, patients spent a mean 55% (95% CI = 51%-58%) of their time in the therapeutic INR range. Meta-regression suggested that AF patients treated in a community usual care setting compared with an anticoagulation clinic spent 11% (95% CI = 2%-20%, n = 6 studies with 9 study groups) less time in range.CONCLUSIONS: In the United States, AF patients spend only about one-half the time within therapeutic INR. Anticoagulation clinic services are associated with somewhat better INR control compared with stan...

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Section: ■■ Resultsmentioning

confidence: 99%

Section: ■■ Resultsmentioning

confidence: 99%

Meta-Analysis to Assess the Quality of Warfarin Control in Atrial Fibrillation Patients in the United States

Baker

Cios²,

Sander³

et al. 2009

JMCP

364

223

View full text Add to dashboard Cite

show abstract

“…44 Translated to 1-year costs, AF patients who received warfarin (2005) indicate that if 50% of the 2.2 million persons in the United States with AF received warfarin, the costs of monitoring warfarin therapy would exceed $300 million annually. 29 Another cost of regular laboratory monitoring to consider is the cost to patients, such as the cost of transportation and time lost from work. Hwang et al (2011) determined the average cost of round-trip transportation to be $10.78 in 2010 U.S. dollars weighted for all transportation modes based on a 60-patient survey at an urban anticoagulation clinic.…”

Section: ■■ Discussionmentioning

confidence: 99%

“…An analysis of 600 adult patients with nonvalvular AF in the United States receiving warfarin at 1 of 3 anticoagulation clinics between 1996 and 1998 was performed. 29 Patients had an average of 18 clinic contacts over a mean follow-up of 10.5 months. Patients were within the recommended INR for 62% of the time, with 25% of days below range and 13% of days above range.…”

Section: ■■ Design Overall Costs Of Af To Health Care Systemsmentioning

confidence: 99%

Cost Implications of Formulary Decisions on Oral Anticoagulants in Nonvalvular Atrial Fibrillation

Biskupiak¹,

Ghate²,

Jiao³

et al. 2013

JMCP

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In the European Union, 4.5 million people are estimated to have AF.2 Patients with untreated AF are at a 4-to 5-fold increased risk of stroke compared with those without the disease. Vitamin K antagonists (VKAs), such as warfarin, have been successfully used for many years to provide prophylaxis against stroke in patients with AF. A large meta-analysis of randomized trials showed that adjusted-dose warfarin reduced the incidence of stroke by 64%. 4 However, in a real-world analysis of Medicare patients with AF, the reduction in stroke with warfarin was lower than in the meta-analysis, at 27%. 5While effective, VKAs are associated with a number of limitations: they have numerous drug and food interactions; their effect is influenced by genetic factors; and they have a narrow therapeutic range, requiring frequent international normalized ratio (INR) monitoring and dose adjustments.6 As a result of these factors, there is considerable variability in the amount of time patients spend within the therapeutic range (INR, 2.0-3.0), which exposes them to stroke when they are below the range and bleeding when they are above the range.New anticoagulants have been developed to reduce the risk of stroke in patients with AF. These oral agents are direct inhibitors of single coagulation factors and include dabigatran, rivaroxaban, and apixaban.7 They meet the need for predictable anticoagulation with fixed dosing, without the need for laboratory monitoring. As may be expected, these anticoagulants are more expensive per unit than warfarin.7 However, the

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“…[39][40][41][42] The monthly cost of anticoagulation care management, including staff time, laboratory tests and administrative cost, was estimated from economic analyses on anticoagulation care. 43 The potential increment of anticoagulation service cost to improve anticoagulation control was examined from a range of no increment to three-fold of the anticoagulation service cost, for extra costs due to increased INR testing frequency and hiring more experienced clinicians to the service. The monthly warfarin drug cost was estimated from retail pricing of generic warfarin.…”

Section: Utility and Cost Inputsmentioning

confidence: 99%

Novel Oral Anticoagulants Versus Warfarin Therapy at Various Levels of Anticoagulation Control in Atrial Fibrillation—A Cost-Effectiveness Analysis

You

2013

J GEN INTERN MED

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BACKGROUND:The decision as to whether to use more expensive novel oral anticoagulants (NOACs) or invest resources for quality improvement of warfarin therapy requires input from both clinical and economic analyses. OBJECTIVE: Cost-effectiveness of NOACs compared to warfarin therapy at various levels of patient-time in therapeutic range (TTR) in patients with atrial fibrillation was examined, from the healthcare provider's perspective. DESIGN, SUBJECTS AND INTERVENTION:A Markov model was used to compare life-long economic and treatment outcomes of warfarin and NOACs in a hypothetical cohort of 65-year-old atrial fibrillation patients with CHADS 2 scores of 2 or above. Model inputs were derived from clinical trials published in the literature. MAIN MEASURES: The outcome measure was incremental cost per quality-adjusted life-year (QALY) gained (ICER). KEY RESULTS: Using United States Dollar (USD) 50,000 as the threshold of willingness-to-pay per QALY, NOACs therapy was cost-effective when TTR of warfarin therapy was 60 % or below, or monthly cost of warfarin management increased by two-fold or more to achieve 70 % TTR. Warfarin therapy was cost-effective when TTR of warfarin was 70 % with up to a 1.5-fold increment in monthly cost of care, or when TTR reached 75 % with monthly cost of warfarin care increased up to three-fold. At TTR 60 %, 70 % and 75 %, NOACs was cost-effective when monthly drug cost was < USD 200, < USD 122-185 and < USD 85-145, respectively. 10,000 Monte Carlo simulations showed NOACs to be cost-effective 83.6 %, 50.7 % and 32.7 % of the time at TTR of 60 %, 70 % and 75 %, respectively. CONCLUSIONS: The acceptance of NOACs as costeffective was highly dependent upon drug cost, anticoagulation control for warfarin, and anticoagulation service cost.KEY WORDS: novel oral anticoagulants; warfarin; atrial fibrillation; cost-effectiveness.

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Quality of Anticoagulation Control and Costs of Monitoring Warfarin Therapy among Patients with Atrial Fibrillation in Clinic Settings: A Multi-Site Managed-Care Study

Abstract: In 3 geographically diverse health plans, anticoagulation clinics provided a generally higher quality of control than previously reported in other observational studies. This study highlights the costs of obtaining this level of control.

Cited by 70 publications

References 22 publications

Meta-Analysis to Assess the Quality of Warfarin Control in Atrial Fibrillation Patients in the United States

Meta-Analysis to Assess the Quality of Warfarin Control in Atrial Fibrillation Patients in the United States

Cost Implications of Formulary Decisions on Oral Anticoagulants in Nonvalvular Atrial Fibrillation

Novel Oral Anticoagulants Versus Warfarin Therapy at Various Levels of Anticoagulation Control in Atrial Fibrillation—A Cost-Effectiveness Analysis

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