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Guede-Fernández F, Silva Pinto T, Semedo H, Vital C, Coelho P, Oliosi ME, Azevedo S, Dias P, Londral A. Enhancing postoperative anticoagulation therapy with remote patient monitoring: A pilot crossover trial study to evaluate portable coagulometers and chatbots in cardiac surgery follow-up. Digit Health 2024; 10:20552076241269515. [PMID: 39139188 PMCID: PMC11319326 DOI: 10.1177/20552076241269515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/25/2024] [Indexed: 08/15/2024] Open
Abstract
Objective Prior research has not assessed the value of remote patient monitoring (RPM) systems for patients undergoing anticoagulation therapy after cardiac surgery. This study aims to assess whether the clinical follow-up through RPM yields comparable outcomes with the standard protocol. Methods A crossover trial assigned participants to SOC-RPM or RPM-SOC, starting with the standard of care (SOC) for the first 6 months after surgery and using RPM for the following 6 months, or vice-versa, respectively. During RPM, patients used the Coaguchek© to accurately measure International Normalized Ratio values and a mobile text-based chatbot to report PROs and adjust the therapeutic dosage. The study assessed patients' and clinicians' experience with RPM and compared direct costs. Results Twenty-seven patients participated. The median time in therapeutic range (TTR) levels during RPM were 72.2% and 50.6% for the SOC-RPM and RPM-SOC arms, respectively, and during SOC, they were 49.4% and 58.4% for SOC-RPM and RPM-SOC arms, respectively. Patients and the clinical team reported high trust and satisfaction with the proposed digital service. Statistically significant differences were only found in the cost of RPM in the RPM-SOC, which was higher than SOC in the SOC-RPM arm. Conclusions Portable coagulometers and chatbots can enhance the remote management of patients undergoing anticoagulation therapy, improving patient experience. This presents a promising alternative to the current standard procedure. The results of this study seem to suggest that RPM may have a higher value when initiated after a SOC period rather than starting RPM immediately after surgery.Trial registration: ClinicalTrials.gov NCT06423521.
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Affiliation(s)
- Federico Guede-Fernández
- Value for Health CoLAB, Lisboa, Portugal
- LIBPhys (Laboratory for Instrumentation, Biomedical Engineering and Radiation Physics), NOVA School of Science and Technology, NOVA University of Lisbon, Caparica, Portugal
| | - Tiago Silva Pinto
- Área de Coração, Vasos e Tórax - Cirurgia Cardíaca, Hospital de Santa Marta, Unidade Local de Saúde São José, Lisboa, Portugal
- Centro Clínico Académico de Lisboa, Lisboa, Portugal
| | - Helena Semedo
- Área de Coração, Vasos e Tórax - Cirurgia Cardíaca, Hospital de Santa Marta, Unidade Local de Saúde São José, Lisboa, Portugal
- Centro Clínico Académico de Lisboa, Lisboa, Portugal
| | - Clara Vital
- Área de Coração, Vasos e Tórax - Cirurgia Cardíaca, Hospital de Santa Marta, Unidade Local de Saúde São José, Lisboa, Portugal
- Centro Clínico Académico de Lisboa, Lisboa, Portugal
| | - Pedro Coelho
- Área de Coração, Vasos e Tórax - Cirurgia Cardíaca, Hospital de Santa Marta, Unidade Local de Saúde São José, Lisboa, Portugal
- Centro Clínico Académico de Lisboa, Lisboa, Portugal
- Comprehensive Health Research Center, NOVA Medical School, NOVA University of Lisbon, Lisboa, Portugal
| | - Maria Eduarda Oliosi
- Value for Health CoLAB, Lisboa, Portugal
- LIBPhys (Laboratory for Instrumentation, Biomedical Engineering and Radiation Physics), NOVA School of Science and Technology, NOVA University of Lisbon, Caparica, Portugal
| | - Salomé Azevedo
- Value for Health CoLAB, Lisboa, Portugal
- CEG-IST, Instituto Superior Técnico, University of Lisbon, Lisbon, Portugal
| | - Pedro Dias
- Value for Health CoLAB, Lisboa, Portugal
- Comprehensive Health Research Center, NOVA Medical School, NOVA University of Lisbon, Lisboa, Portugal
| | - Ana Londral
- Value for Health CoLAB, Lisboa, Portugal
- Comprehensive Health Research Center, NOVA Medical School, NOVA University of Lisbon, Lisboa, Portugal
- REAL Translation and Innovation Towards Global Health, NOVA School of Science and Technology, NOVA University of Lisbon, Caparica, Portugal
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Daniels PR, Manning DM, Moriarty JP, Bingener-Casey J, Ou NN, O'Meara JG, Roellinger DL, Naessens JM. Improving inpatient warfarin therapy safety using a pharmacist-managed protocol. BMJ Open Qual 2018; 7:e000290. [PMID: 29713691 PMCID: PMC5922568 DOI: 10.1136/bmjoq-2017-000290] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/27/2018] [Accepted: 03/24/2018] [Indexed: 12/19/2022] Open
Abstract
Introduction Safe management of warfarin in the inpatient setting can be challenging. At the Mayo Clinic hospitals in Rochester, Minnesota, we set out to improve the safety of warfarin management among surgical and non-surgical inpatients. Methods A multidisciplinary team designed a pharmacist-managed warfarin protocol (PMWP) which designated warfarin dosing to inpatient pharmacists with guidance from computerised dosing algorithms. Ordering this protocol was ultimately designed as an ‘opt out’ practice. The primary improvement measure was frequency of international normalised ratio (INR) greater than 5; secondary measures included adoption rate of the protocol, a counterbalance INR metric (INR <1.7 three days after first inpatient warfarin dose), and complication rates, including bleeding and thrombosis events. An interrupted time series analysis was conducted to compare outcomes. Results Among over 50 000 inpatient warfarin recipients, the PMWP was adopted for the majority of both surgical and non-surgical inpatients during the study period (1 January 2005 to 31 December 2011). The primary improvement measure decreased from 5.6% to 3.4% for medical patients and from 5.2% to 2.4% for surgical patients during the preimplementation and postimplementation periods, respectively. The INR counterbalance measure did not change. Postoperative bleeding decreased from 13.5% to 11.1% among surgical patients, but bleeding was unchanged among medical patients. Conclusion Our PMWP led to achievement of improved INR control for inpatient warfarin recipients and to less near-term bleeding among higher risk, surgical patients.
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Affiliation(s)
- Paul R Daniels
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Dennis M Manning
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - James P Moriarty
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Narith N Ou
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota, USA
| | - John G O'Meara
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel L Roellinger
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - James M Naessens
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
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Zhao S, Zhao H, Wang X, Gao C, Qin Y, Cai H, Chen B, Cao J. A prospective study investigating the causes of warfarin under-utilization in Chinese patients. Int J Clin Pharm 2016; 38:1286-93. [PMID: 27488309 DOI: 10.1007/s11096-016-0367-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
Background Warfarin is efficacious for ischemic stroke prevention in intermediate- to high-risk patients with atrial fibrillation; thus, warfarin is the recommended treatment according to evidence-based guidelines. Objective This prospective study evaluated the reasons for under-utilization of warfarin in Chinese patients with non-valvular atrial fibrillation (NVAF). Setting The People's Hospital of Henan Province of Zhengzhou City, which is a 3900-bed tertiary-care teaching institution. Methods We extracted data from an existing patient database. Patients at risk for thromboembolism were categorized based on CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 (doubled), diabetes, prior stroke (doubled), vascular disease, age 65-74 years, and sex category (female)] scores. Main outcome measure The percent of warfarin utilization was estimated in recruited patients. Any demographic and clinical factors associated with warfarin under-utilization were identified using a logistic regression model. Results Among the patient sample (n = 612), 569 patients had a CHA2DS2-VASc score of ≥1. At presentation, warfarin under-utilization was estimated to be 27.1 %. Only 120 patients (25.1 %) considered to be at the highest risk were prescribed warfarin. Binary logistic regression analysis indicated that previous stroke, age ≥75 years, and anti-platelet therapy were associated with warfarin under-utilization. Conclusion Patients with CHA2DS2-VASc scores ≥1 who were admitted with NVAF were under prescribed warfarin, and 138 patients were not treated with either warfarin or other antithrombotic therapies. In conclusion, a more aggressive approach for stroke prevention in NVAF patients is required.
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Affiliation(s)
- Shujuan Zhao
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Hongwei Zhao
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Xianpei Wang
- Department of Cardiovascular Medicine, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Chuanyu Gao
- Department of Cardiovascular Medicine, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Yuhua Qin
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China.
| | - Haixia Cai
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Boya Chen
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Jingjing Cao
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
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Daniels LM, Barreto JN, Kuth JC, Anderson JR, Zhang B, Majka AJ, Morgenthaler TI, Tosh PK. Failure mode and effects analysis to reduce risk of anticoagulation levels above the target range during concurrent antimicrobial therapy. Am J Health Syst Pharm 2016; 72:1195-203. [PMID: 26150569 DOI: 10.2146/ajhp140632] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE A failure mode and effects analysis (FMEA) was conducted to analyze the clinical and operational processes leading to above-target International Normalized Ratios (INRs) in warfarin-treated patients receiving concurrent antimicrobial therapy. METHODS The INRs of patients on long-term warfarin therapy who received a course of trimethoprim-sulfamethoxazole, metronidazole, fluconazole, miconazole, or voriconazole (highly potentiating antimicrobials, or HPAs) between September 1 and December 31, 2011, were compared with patients on long-term warfarin therapy who did not receive any antimicrobial during the same period. A multidisciplinary team of physicians, pharmacists, and a systems analyst was then formed to complete a step-by-step outline of the processes involved in warfarin management and concomitant HPA therapy, followed by an FMEA. RESULTS Patients taking trimethoprim-sulfamethoxazole, metronidazole, or fluconazole demonstrated a significantly increased risk of having an INR of >4.5. The FMEA identified 134 failure modes. The most common failure modes were as follows: (1) electronic medical records did not identify all patients receiving warfarin, (2) HPA prescribers were unaware of recommended warfarin therapy when HPAs were prescribed, (3) HPA prescribers were unaware that a patient was taking warfarin and that the drug interaction is significant, and (4) warfarin managers were unaware that an HPA had been prescribed for a patient. CONCLUSION An FMEA determined that the risk of adverse events caused by concomitantly administering warfarin and HPAs can be decreased by preemptively identifying patients receiving warfarin, having a care process in place, alerting providers about the patient's risk status, and notifying providers at the anticoagulation clinic.
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Affiliation(s)
- Lisa M Daniels
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Jason N Barreto
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - John C Kuth
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Jeremy R Anderson
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Beilei Zhang
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Andrew J Majka
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Timothy I Morgenthaler
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN
| | - Pritish K Tosh
- Lisa M. Daniels, M.D., is Resident Physician, Department of Internal Medicine; Jason N. Barreto, Pharm.D., is Assistant Professor of Pharmacy and Pharmacist, Pharmacy Services; John C. Kuth, Pharm.D., is Regional Director of Patient Safety and Pharmacist, Quality Resources; Jeremy R. Anderson, Pharm.D., is Pharmacist, Pharmacy Services; Beilei Zhang, Ph.D., is Systems Analyst, Division of Systems and Procedures; Andrew J. Majka, M.D., is Assistant Professor of Medicine and Physician, Division of General Internal Medicine; Timothy I. Morgenthaler, M.D., is Professor of Medicine and Physician, Division of Pulmonary and CriticalCare Medicine; and Pritish K. Tosh, M.D., is Assistant Professor of Medicine and Physician, Division of Infectious Diseases, Mayo Clinic Rochester, Rochester, MN.
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