Quality of Anticoagulation Monitoring in Nonvalvular Atrial Fibrillation Patients: Comparison of Anticoagulation Clinic versus Usual Care

Nichol, Michael B.; Knight, Tara K.; Dow, Tom; Wygant, Gail; Borok, Gerald M.; Hauch, Ole; O’Connor, Richard D.

doi:10.1345/aph.1k157

Cited by 49 publications

(43 citation statements)

References 23 publications

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“…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%

“…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. Patient-years data were calculated in 5 of the included studies, 17,18,20,26,38 whereas the other 3 studies reported the required data. 21,31,35 Four groups (31%) were treated in anticoagulation clinics, 17,26,35,38 while 9 (69%) were treated in community practice.…”

Section: ■■ Resultsmentioning

confidence: 99%

“…21,31,35 Four groups (31%) were treated in anticoagulation clinics, 17,26,35,38 while 9 (69%) were treated in community practice. 17,18,20,21,31,38 One group in the study by Matchar (2003) 20 could not be classified as either an anticoagulation clinic or community practice because warfarin control was reported in this group of patients prior to their use or nonuse of an anticoagulation clinic. No randomized controlled trials (RCTs) met our inclusion criteria; thus, no RCTs were available for evaluation in our study.…”

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

359

212

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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%

Section: ■■ Resultsmentioning

confidence: 99%

See 1 more Smart Citation

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

Baker

Cios²,

Sander³

et al. 2009

JMCP

359

212

View full text Add to dashboard Cite

show abstract

“…Warfarin has a narrow therapeutic index, so achieving effective yet safe anticoagulation is challenging, 1 especially in frail elderly patients, who are at high risk of bleeding. 2 To minimize the risks associated with anticoagulant therapy, anticoagulation clinics have been developed and shown to improve outcomes more than standard care.…”

mentioning

confidence: 99%

Improving Anticoagulation Control in Hospitalized Elderly Patients on Warfarin

Gouin‐Thibault

Lévy

Pautas

et al. 2010

J American Geriatrics Society

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OBJECTIVES:To determine the effect of patient characteristics and of specific guidelines that were developed for managing warfarin therapy in older adults and included in an in-house computer program on anticoagulation quality. DESIGN: Thirteen-month observational study. SETTING: Acute care, extended care, and rehabilitation geriatric wards of a teaching hospital in Paris, France. PARTICIPANTS: Hospitalized patients (N 5 307, mean age 86.1 AE 6.1) treated with warfarin with a therapeutic international normalized ratio range of 2.0 to 3.0. INTERVENTION: Patients were assigned according to care unit to the computer-generated dosing group (CGD) or the standard management group (SM; usual physician-based care). MEASUREMENTS: Relationships between anticoagulation quality criteria and covariates (age, sex, warfarin indication, treatment phase, follow-up duration, model of care). RESULTS: According to multivariate analysis, only model of care and follow-up duration independently influenced anticoagulation control; the proportion of time within therapeutic INR range 2.0 to 3.0 was significantly greater in the CGD group than in the SM group (59% vs 48%, P 5.004). When a wider INR range was analyzed (1.8-3.2), the proportion of time within range was 73% versus 64% (P 5.006). Use of the computer was associated with fewer days with INRs greater than 3, a smaller percentage of INRs of 4 or greater, a longer time to the first INR of 4.0 or greater, and a smaller mean number of INRs per month than SM (all Po.01). CONCLUSION: Initiation regimen and long-term rules that have specifically been developed and included in a computerized dosage program improve quality of anticoagulation in elderly inpatients, allowing them to benefit from a quality of care as high as that of younger ambulatory patients. J Am Geriatr Soc 58:242-247, 2010.

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“…However, in light of the high prevalence of patients in need of anticoagulant treatment, it does not seem feasible that solely ACCs could take care of these patients, and self-monitoring may not be feasible for everyone [15][16][17][18][19][20][21][22][25][26][27][28][29].…”

Section: Introductionmentioning

confidence: 99%

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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Quality of Anticoagulation Monitoring in Nonvalvular Atrial Fibrillation Patients: Comparison of Anticoagulation Clinic versus Usual Care

Abstract: Results from this observational study reinforce the positive impact that anticoagulation services have on anticoagulation therapy outcomes, emphasizing the importance of providing such services for patients undergoing treatment with warfarin.

Cited by 49 publications

References 23 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

Improving Anticoagulation Control in Hospitalized Elderly Patients on Warfarin

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

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