Trends in Warfarin Monitoring Practices Among New York Medicare Beneficiaries, 2006–2011

Differences in quality of anticoagulation care delivery according to ethnoracial group in the United States: A scoping review

Anticoagulation therapy is standard for conditions like atrial fibrillation, venous thromboembolism, and valvular heart disease, yet it is unclear if there are ethnoracial disparities in its quality and delivery in the United States. For this scoping review, electronic databases were searched for publications between January 1, 2011 - March 30, 2022. Eligible studies included all study designs, any setting within the United States, patients prescribed anticoagulation for any indication, outcomes reported for ≥ 2 distinct ethnoracial groups. The following four research questions were explored: Do ethnoracial differences exist in 1) access to guideline-based anticoagulation therapy, 2) quality of anticoagulation therapy management, 3) clinical outcomes related to anticoagulation care, 4) humanistic/educational outcomes related to anticoagulation therapy. A total of 5374 studies were screened, 570 studies received full-text review, and 96 studies were analyzed. The largest mapped focus was patients' access to guideline-based anticoagulation therapy (88/96 articles, 91.7%). Seventy-eight articles made statistical outcomes comparisons among ethnoracial groups. Across all four research questions, 79 articles demonstrated favorable outcomes for White patients compared to non-White patients, 38 articles showed no difference between White and non-White groups, and 8 favored non-White groups (the total exceeds the 78 articles with statistical outcomes as many articles reported multiple outcomes). Disparities disadvantaging non-White patients were most pronounced in access to guideline-based anticoagulation therapy (43/66 articles analyzed) and quality of anticoagulation management (19/21 articles analyzed). Although treatment guidelines do not differentiate anticoagulant therapy by ethnoracial group, this scoping review found consistently favorable outcomes for White patients over non-White patients in the domains of access to anticoagulation therapy for guideline-based indications and quality of anticoagulation therapy management. No differences among groups were noted in clinical outcomes, and very few studies assessed humanistic or educational outcomes.

The patients' perspective of international normalized ratio self-testing, remote communication of test results and confidence to move to self-management

AIMS AND OBJECTIVES

To elicit the perceptions of patients, who self-tested their international normalized ratio and communicated their results via a text or phone messaging system, to determine their satisfaction with the education and support that they received and to establish their confidence to move to self-management.

BACKGROUND

Self-testing of international normalized ratio has been shown to be reliable and is fast becoming common practice. As innovations are introduced to point of care testing, more research is needed to elicit patients' perceptions of the self-testing process.

DESIGN

This three site study used a cross-sectional prospective descriptive survey.

METHODS

Three hundred and thirty patients who were prescribed warfarin and using international normalized ratio self-testing were invited to take part in the study. The anonymous survey examined patient profile, patients' usage, issues, perceptions, confidence and satisfaction with using the self-testing system and their preparedness for self-management of warfarin dosage.

RESULTS

The response rate was 57% (n = 178). Patients' confidence in self-testing was high (90%). Patients expressed a high level of satisfaction with the support received, but expressed the need for more information on support groups, side effects of warfarin, dietary information and how to dispose of needles. When asked if they felt confident to adjust their own warfarin levels 73% agreed. Chi-squared tests for independence revealed that none of the patient profile factors examined influenced this confidence. The patients cited the greatest advantages of the service were reduced burden, more autonomy, convenience and ease of use. The main disadvantages cited were cost and communication issues.

CONCLUSION

Patients were satisfied with self-testing. The majority felt they were ready to move to self-management.

RELEVANCE TO CLINICAL PRACTICE

The introduction of innovations to remote point of care testing, such as warfarin self-testing, needs to have support at least equal to that provided in a hospital setting.