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Ferguson C, Shaikh F, Allida SM, Hendriks J, Gallagher C, Bajorek BV, Donkor A, Inglis SC. Clinical service organisation for adults with atrial fibrillation. Cochrane Database Syst Rev 2024; 7:CD013408. [PMID: 39072702 PMCID: PMC11285297 DOI: 10.1002/14651858.cd013408.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is an increasingly prevalent heart rhythm condition in adults. It is considered a common cardiovascular condition with complex clinical management. The increasing prevalence and complexity in management underpin the need to adapt and innovate in the delivery of care for people living with AF. There is a need to systematically examine the optimal way in which clinical services are organised to deliver evidence-based care for people with AF. Recommended approaches include collaborative, organised multidisciplinary, and virtual (or eHealth/mHealth) models of care. OBJECTIVES To assess the effects of clinical service organisation for AF versus usual care for people with all types of AF. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL to October 2022. We also searched ClinicalTrials.gov and the WHO ICTRP to April 2023. We applied no restrictions on date, publication status, or language. SELECTION CRITERIA We included randomised controlled trials (RCTs), published as full texts and as abstract only, involving adults (≥ 18 years) with a diagnosis of any type of AF. We included RCTs comparing organised clinical service, disease-specific management interventions (including e-health models of care) for people with AF that were multicomponent and multidisciplinary in nature to usual care. DATA COLLECTION AND ANALYSIS Three review authors independently selected studies, assessed risk of bias, and extracted data from the included studies. We calculated risk ratio (RR) for dichotomous data and mean difference (MD) or standardised mean difference (SMD) for continuous data with 95% confidence intervals (CIs) using random-effects analyses. We then calculated the number needed to treat for an additional beneficial outcome (NNTB) using the RR. We performed sensitivity analyses by only including studies with a low risk of selection and attrition bias. We assessed heterogeneity using the I² statistic and the certainty of the evidence according to GRADE. The primary outcomes were all-cause mortality and all-cause hospitalisation. The secondary outcomes were cardiovascular mortality, cardiovascular hospitalisation, AF-related emergency department visits, thromboembolic complications, minor cerebrovascular bleeding events, major cerebrovascular bleeding events, all bleeding events, AF-related quality of life, AF symptom burden, cost of intervention, and length of hospital stay. MAIN RESULTS We included 8 studies (8205 participants) of collaborative, multidisciplinary care, or virtual care for people with AF. The average age of participants ranged from 60 to 73 years. The studies were conducted in China, the Netherlands, and Australia. The included studies involved either a nurse-led multidisciplinary approach (n = 4) or management using mHealth (n = 2) compared to usual care. Only six out of the eight included studies could be included in the meta-analysis (for all-cause mortality and all-cause hospitalisation, cardiovascular mortality, cardiovascular hospitalisation, thromboembolic complications, and major bleeding), as quality of life was not assessed using a validated outcome measure specific for AF. We assessed the overall risk of bias as high, as all studies had at least one domain at unclear or high risk of bias rating for performance bias (blinding) in particular. Organised AF clinical services probably result in a large reduction in all-cause mortality (RR 0.64, 95% CI 0.46 to 0.89; 5 studies, 4664 participants; moderate certainty evidence; 6-year NNTB 37) compared to usual care. However, organised AF clinical services probably make little to no difference to all-cause hospitalisation (RR 0.94, 95% CI 0.88 to 1.02; 2 studies, 1340 participants; moderate certainty evidence; 2-year NNTB 101) and may not reduce cardiovascular mortality (RR 0.64, 95% CI 0.35 to 1.19; 5 studies, 4564 participants; low certainty evidence; 6-year NNTB 86) compared to usual care. Organised AF clinical services reduce cardiovascular hospitalisation (RR 0.83, 95% CI 0.71 to 0.96; 3 studies, 3641 participants; high certainty evidence; 6-year NNTB 28) compared to usual care. Organised AF clinical services may have little to no effect on thromboembolic complications such as stroke (RR 1.14, 95% CI 0.74 to 1.77; 5 studies, 4653 participants; low certainty evidence; 6-year NNTB 588) and major cerebrovascular bleeding events (RR 1.25, 95% CI 0.79 to 1.97; 3 studies, 2964 participants; low certainty evidence; 6-year NNTB 556). None of the studies reported minor cerebrovascular events. AUTHORS' CONCLUSIONS Moderate certainty evidence shows that organisation of clinical services for AF likely results in a large reduction in all-cause mortality, but probably makes little to no difference to all-cause hospitalisation compared to usual care. Organised AF clinical services may not reduce cardiovascular mortality, but do reduce cardiovascular hospitalisation compared to usual care. However, organised AF clinical services may make little to no difference to thromboembolic complications and major cerebrovascular events. None of the studies reported minor cerebrovascular events. Due to the limited number of studies, more research is required to compare different models of care organisation, including utilisation of mHealth. Appropriately powered trials are needed to confirm these findings and robustly examine the effect on inconclusive outcomes. The findings of this review underscore the importance of the co-ordination of care underpinned by collaborative multidisciplinary approaches and augmented by virtual care.
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Affiliation(s)
- Caleb Ferguson
- Centre for Chronic & Complex Care Research, Western Sydney Local Health District, Sydney, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Fahad Shaikh
- Centre for Chronic & Complex Care Research, Western Sydney Local Health District, Sydney, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Sabine M Allida
- Centre for Chronic & Complex Care Research, Western Sydney Local Health District, Sydney, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Jeroen Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health and Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health and Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Beata V Bajorek
- Heart and Brain Program, Hunter Medical Research Institute, Newcastle, Australia
- College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, Australia
- Department of Pharmacy, Hunter New England Local Health District, Newcastle, Australia
| | - Andrew Donkor
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Sally C Inglis
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
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Yu Z, Chen D, Zheng Y, Wang X, Huang S, Lin T, Lin Y, Zhang Y, Huang Y, Ou Q, Huang J. Development and validation of a diagnostic model for AFP-negative hepatocellular carcinoma. J Cancer Res Clin Oncol 2023; 149:11295-11308. [PMID: 37368120 DOI: 10.1007/s00432-023-04997-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
PURPOSE AFP appears to be negative in about 30% of overall hepatocellular carcinoma (HCC). Our study aimed to develop a nomogram model to diagnose AFP-negative HCC (AFPN-HCC). PATIENTS AND METHODS The training set included 294 AFPN-HCC patients, 159 healthy objects, 63 patients with chronic hepatitis B(CHB), and 64 patients with liver cirrhosis (LC). And the validation set enrolled 137 healthy controls objects, 47 CHB patients and 45 patients with LC. LASSO, univariate, and multivariable logistic regression analysis were performed to construct the model and then transformed into a visualized nomogram. The receiver operating characteristic (ROC) curves, the calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were further used for validation. RESULTS Four variables including age, PIVKA-II, platelet (PLT) counts, and prothrombin time (PT) were selected to establish the nomogram. The area under the curve (AUC) of the ROC to distinguish AFPN-HCC patients was 0.937(95% CI 0.892-0.938) in training set and 0.942(95% CI 0.921-0.963) in validation set. We also found that the model had high diagnostic value for small-size HCC (tumor size < 5 cm) (AUC = 0.886) and HBV surface antigen-positive AFPN-HCC (AUC = 0.883). CONCLUSIONS Our model was effective for discrimination of AFPN-HCC from patients with benign liver diseases and healthy controls, and might be helpful for the diagnosis for AFPN-HCC.
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Affiliation(s)
- Zhou Yu
- Department of Laboratory Medicine, Fujian Key Laboratory of Laboratory Medicine, Gene Diagnosis Research Center, Fujian Clinical Research Center for Laboratory Medicine of Immunology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, Fujian, China
- Department of Laboratory Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, Fujian, China
| | - Dongmei Chen
- Department of Laboratory Medicine, Fujian Key Laboratory of Laboratory Medicine, Gene Diagnosis Research Center, Fujian Clinical Research Center for Laboratory Medicine of Immunology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, Fujian, China
- Department of Laboratory Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, Fujian, China
| | - Yansong Zheng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian Province, China
| | - Xuedan Wang
- Department of Pathology Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian Province, China
| | - Shuna Huang
- Department of Clinical Research and Translation Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Tiansheng Lin
- Department of Hepatobiliary Surgery, Fujian Provincial Hospital, Fuzhou, 350001, Fujian Province, China
| | - Yihan Lin
- Department of Gastroenterology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian Province, China
| | - Yanfang Zhang
- Department of Laboratory Medicine, Fujian Key Laboratory of Laboratory Medicine, Gene Diagnosis Research Center, Fujian Clinical Research Center for Laboratory Medicine of Immunology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, Fujian, China
- Department of Laboratory Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, Fujian, China
| | - Yingna Huang
- Fujian Medical University, Fuzhou, 350005, Fujian Province, China
| | - Qishui Ou
- Department of Laboratory Medicine, Fujian Key Laboratory of Laboratory Medicine, Gene Diagnosis Research Center, Fujian Clinical Research Center for Laboratory Medicine of Immunology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, Fujian, China.
- Department of Laboratory Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, Fujian, China.
| | - Jinlan Huang
- Department of Laboratory Medicine, Fujian Key Laboratory of Laboratory Medicine, Gene Diagnosis Research Center, Fujian Clinical Research Center for Laboratory Medicine of Immunology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, Fujian, China.
- Department of Laboratory Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, Fujian, China.
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Huang Y, Huang L, Han Z. Combining portable coagulometers with the Internet: A new model of warfarin anticoagulation in patients following mechanical heart valve replacement. Front Surg 2022; 9:1016278. [PMID: 36311931 PMCID: PMC9608170 DOI: 10.3389/fsurg.2022.1016278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022] Open
Abstract
Heart valve replacement, as a safe and effective treatment for severe valvular heart disease, can significantly improve hemodynamics in patients. However, such patients then require lifelong anticoagulant therapy. Warfarin, a cheap and highly effective vitamin K antagonist, remains the major anticoagulant recommended for lifelong use following mechanical heart valve replacement. However, the effect of warfarin anticoagulant therapy is complicated by physiological differences among patients and non-compliance with treatment at different degrees. Effective management of warfarin therapy after heart valve replacement is currently an important issue. Portable coagulometers and the emergence of the Internet have provided new opportunities for long-term management of anticoagulation therapy, but the safety and affordability of this approach remain to be fully evaluated. This paper reviews recent progress on the use of portable coagulometers and the Internet in the management of warfarin anticoagulation therapy following mechanical heart valve replacement, which offers opportunities for reducing complications during postoperative anticoagulation and for facilitating patient compliance during follow-up.
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Çelik M, Durko AP, Head SJ. Anticoagulation after mechanical aortic valve implantation: is it time to act after PROACT? ANNALS OF TRANSLATIONAL MEDICINE 2019; 6:S16. [PMID: 30613591 DOI: 10.21037/atm.2018.09.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Mevlüt Çelik
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Andras P Durko
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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Ma QH, Fang JH. International normalized ratio for the guidance of warfarin treatment in elderly patients after cardiac valve replacement. Exp Ther Med 2018; 17:1486-1491. [PMID: 30680032 DOI: 10.3892/etm.2018.7078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 09/13/2018] [Indexed: 11/06/2022] Open
Abstract
Thus far, the target value for international normalized ratio (INR) has remained to be determined. The current study aimed to further explore the INR value of the anti-coagulation drug warfarin after cardiac valve replacement. The clinical data of 213 patients who underwent cardiac valve replacement at Linyi Central Hospital (Linyi, China) between January 2010 and May 2013 were retrospectively analyzed. The warfarin dosage, prothrombin time (PT) and INR were compared among patients with hemorrhage or embolism, and those with no complications. A total of 31 cases (14.6%) developed adverse reactions and complications during the medication period, including 21 cases with hemorrhage (9.9%, hemorrhage group) and 10 cases with embolism (4.7%, embolism group), while 182 patients did not (85.4%, normal group). The average dosage of warfarin was 2.0±0.6, 3.1±0.7 and 1.7±0.6 mg/day in the normal, hemorrhage and embolism groups, respectively. The dosage of warfarin, the PT and the INR in the hemorrhage group were all significantly greater than those in the normal group and the embolism group (all P<0.05). INR monitoring is recommended to ensure the safety of the anti-coagulant drug warfarin, but further study is still required to determine a reasonable target INR value.
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Affiliation(s)
- Qing-Hua Ma
- Department of Cardiology, Linyi Central Hospital, Linyi, Shandong 276400, P.R. China
| | - Jian-Hai Fang
- Department of Cardiology, Linyi Central Hospital, Linyi, Shandong 276400, P.R. China
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Witt DM, Nieuwlaat R, Clark NP, Ansell J, Holbrook A, Skov J, Shehab N, Mock J, Myers T, Dentali F, Crowther MA, Agarwal A, Bhatt M, Khatib R, Riva JJ, Zhang Y, Guyatt G. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv 2018; 2:3257-3291. [PMID: 30482765 PMCID: PMC6258922 DOI: 10.1182/bloodadvances.2018024893] [Citation(s) in RCA: 304] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE). OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants. CONCLUSIONS Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti-factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding.
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Affiliation(s)
- Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation and Anemia Service, Kaiser Permanente Colorado, Aurora, CO
| | - Jack Ansell
- School of Medicine, Hofstra Northwell, Hempstead, NY
| | - Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jane Skov
- Unit for Health Promotion Research, Department of Public Health, University of Southern Denmark, Esbjerg, Denmark
| | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Meha Bhatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL; and
| | - John J Riva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Res LCS, Lubberts B, Shah SH, DiGiovanni CW. Health-related quality of life after adverse bleeding events associated with antithrombotic drug therapy - A systematic review. Hellenic J Cardiol 2018; 60:3-10. [PMID: 29908761 DOI: 10.1016/j.hjc.2018.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 06/07/2018] [Accepted: 06/08/2018] [Indexed: 12/29/2022] Open
Abstract
Little is known about the health-related quality of life (HRQOL) following adverse bleeding events associated with antithrombotic drug therapy. This systematic review assesses the HRQOL of patients who suffered a bleeding event related to antithrombotic drug use. A literature search was performed using PubMed, EMBASE, and the Cochrane Library from inception through June 16, 2017. Studies measuring HRQOL after a bleeding event related to antithrombotic drug therapy for primary or secondary prevention of a thromboembolic event were included. Four studies with a total of 13,209 patients met the inclusion criteria, and of them, 3,649 patients developed a bleeding event. Patients who were included received antithrombotic drugs because of acute myocardial infarction or atrial fibrillation. EQ-5D, SF-36, and GHP MOS-13 were used to measure HRQOL. The follow-up time ranged from 6 to 29 months. Patients who suffered a bleeding event reported worse HRQOL compared to those who did not (EQ-5D - average increase on all domains of 0.09, p-values ranging from <0.001 to 0.003; SF-36 - average decrease on all domains of 21.4, p < 0.001; and GHP MOS-13 score - decrease of 11.9 points, p < 0.05) and an increased health concern (13.4-point increase; p < 0.05). In conclusion, adverse bleeding events occurring because of the use of antithrombotic agents are associated with a clinically relevant lower HRQOL and hence deserve more attention as part of the shared decision-making process between patients and providers. These data should be valuable for facilitating more substantive care and risk discussions regarding potential changes in outcome and rehabilitation.
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Affiliation(s)
- Lodewijk C S Res
- Orthopaedic Foot and Ankle Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Bart Lubberts
- Orthopaedic Foot and Ankle Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Shivesh H Shah
- Orthopaedic Foot and Ankle Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Christopher W DiGiovanni
- Orthopaedic Foot and Ankle Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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Kantito S, Saokaew S, Yamwong S, Vathesatogkit P, Katekao W, Sritara P, Chaiyakunapruk N. Cost-effectiveness analysis of patient self-testing therapy of oral anticoagulation. J Thromb Thrombolysis 2017; 45:281-290. [PMID: 29181693 DOI: 10.1007/s11239-017-1588-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patient Self-testing (PST) could be an option for present anticoagulation therapy monitoring, but current evidence on its cost-effectiveness is limited. This study aims to estimate the cost-effectiveness of PST to other different care approaches for anticoagulation therapy in Thailand, a low-to-middle income country (LMIC). A Markov model was used to compare lifetime costs and quality-adjusted life years (QALYs) accrued to patients receiving warfarin through PST or either anticoagulation clinic (AC) or usual care (UC). The model was populated with relevant information from literature, network meta-analysis, and database analyses. Incremental cost-effectiveness ratios (ICERs) were presented as the year 2015 values. A base-case analysis was performed for patients at age 45-year-old. Sensitivity analyses including one-way and probabilistic sensitivity analyses (PSA) were constructed to determine the robustness of the findings. From societal perspective, PST increased QALY by 0.87 and costs by 112,461 THB compared with UC. Compared with AC, PST increased QALY by 0.161 and costs by 21,019 THB. The ICER with PST was 128,697 (3625 USD) and 130,493 THB (3676 USD) per QALY gained compared with UC and AC, respectively. The probability of PST being cost-effective is 74.1% and 51.9%, compared to UC and AC, respectively, in Thai context. Results were sensitive to the efficacy of PST, age and frequency of hospital visit or self-testing. This analysis suggested that PST is highly cost-effective compared with usual care and less cost-effective against anticoagulation clinic. Patient self-testing strategy appears to be economically valuable to include into healthcare system within the LMIC context.
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Affiliation(s)
- Sutat Kantito
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Center of Pharmaceutical Outcomes Research (CPOR), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor Darul Ehsan, Malaysia
- Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor, Malaysia
| | - Sukit Yamwong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prin Vathesatogkit
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wisuit Katekao
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Piyamitr Sritara
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nathorn Chaiyakunapruk
- Center of Pharmaceutical Outcomes Research (CPOR), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor Darul Ehsan, Malaysia.
- Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor, Malaysia.
- School of Pharmacy, University of Wisconsin, Madison, USA.
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Price LM, Hinton E. Effect of International Normalized Ratio monitoring at home versus the clinic on monitoring adherence in adults taking oral anticoagulant medications: a systematic review protocol. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2017; 15:905-913. [PMID: 28398977 DOI: 10.11124/jbisrir-2016-003116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The objective of this review is to compare International Normalized Ratio (INR) monitoring adherence in two different settings: the outpatient INR clinic and the patient's home or residence. The review seeks to identify non-adherence trends in both settings to help providers determine which setting is best for patients on warfarin to improve INR monitoring adherence. Improved INR monitoring adherence correlates with maintaining routine INR testing.Specifically, the review question is what is the effect of home point-of-care INR monitoring compared to clinic monitoring on INR monitoring adherence in adults taking oral anticoagulant medications?
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Affiliation(s)
- Lynndi M Price
- 1School of Nursing, University of Mississippi Medical Center, Jackson, Mississippi, United States 2Rowland Medical Library, University of Mississippi Medical Center, Jackson, Mississippi, United States 3UMMC School of Nursing Evidence Based Practice and Research Team: a Joanna Briggs Institute Affiliated Group, Jackson, Mississippi, United States 4The Center for Translational Research: a Joanna Briggs Institute Center of Excellence, Fort Worth, Texas, United States
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Phibbs CS, Love SR, Jacobson AK, Edson R, Su P, Uyeda L, Matchar DB. At-Home Versus In-Clinic INR Monitoring: A Cost-Utility Analysis from The Home INR Study (THINRS). J Gen Intern Med 2016; 31:1061-7. [PMID: 27234663 PMCID: PMC4978674 DOI: 10.1007/s11606-016-3700-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 11/16/2015] [Accepted: 03/28/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Effective management of patients using warfarin is resource-intensive, requiring frequent in-clinic testing of the international normalized ratio (INR). Patient self-testing (PST) using portable at-home INR monitoring devices has emerged as a convenient alternative. As revealed by The Home INR Study (THINRS), event rates for PST were not significantly different from those for in-clinic high-quality anticoagulation management (HQACM), and a cumulative gain in quality of life was observed for patients undergoing PST. OBJECTIVE To perform a cost-utility analysis of weekly PST versus monthly HQACM and to examine the sensitivity of these results to testing frequency. PATIENTS/INTERVENTIONS In this study, 2922 patients taking warfarin for atrial fibrillation or mechanical heart valve, and who demonstrated PST competence, were randomized to either weekly PST (n = 1465) or monthly in-clinic testing (n = 1457). In a sub-study, 234 additional patients were randomized to PST once every 4 weeks (n = 116) or PST twice weekly (n = 118). The endpoints were quality of life (measured by the Health Utilities Index), health care utilization, and costs over 2 years of follow-up. RESULTS PST and HQACM participants were similar with regard to gender, age, and CHADS2 score. The total cost per patient over 2 years of follow-up was $32,484 for HQACM and $33,460 for weekly PST, representing a difference of $976. The incremental cost per quality-adjusted life year gained with PST once weekly was $5566 (95 % CI, -$11,490 to $25,142). The incremental cost-effectiveness ratio (ICER) was sensitive to testing frequency: weekly PST dominated PST twice weekly and once every 4 weeks. Compared to HQACM, weekly PST was associated with statistically significant and clinically meaningful improvements in quality of life. The ICER for weekly PST versus HQACM was well within accepted standards for cost-effectiveness, and was preferred over more or less frequent PST. These results were robust to sensitivity analyses of key assumptions. CONCLUSION Weekly PST is a cost-effective alternative to monthly HQACM and a preferred testing frequency compared to twice weekly or monthly PST.
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Affiliation(s)
- Ciaran S Phibbs
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA. .,Department of Pediatrics and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA, USA. .,Health Economist, VA Health Economics Resource Center, 795 Willow Road (152MPD), Menlo Park, CA, 94025, USA.
| | - Sean R Love
- Health Services and Systems Research Program, Duke-National University of Singapore Graduate Medical School, Singapore, Singapore.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alan K Jacobson
- Jerry L. Pettis VA Medical Center, Research and Development Service (151), Loma Linda, CA, USA.,Department of Internal Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Robert Edson
- VA Palo Alto Health Care System, Cooperative Studies Program Coordinating Center (151 K), Palo Alto, CA, USA
| | - Pon Su
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Lauren Uyeda
- VA Palo Alto Health Care System, Cooperative Studies Program Coordinating Center (151 K), Palo Alto, CA, USA
| | - David B Matchar
- Health Services and Systems Research Program, Duke-National University of Singapore Graduate Medical School, Singapore, Singapore.,Durham VA Medical Center, Durham, NC, USA.,Division of General Medicine, Department of Medicine, and Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC, USA
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11
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Sundt TM, Schaff HV, Soltesz EG, Uva MS, Adams DH. Mechanical vs Biologic Valves: Our Modern Day Conundrum. Semin Thorac Cardiovasc Surg 2016; 28:404-417. [PMID: 28043453 DOI: 10.1053/j.semtcvs.2016.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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12
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Schaefer C, Wuillemin WA, Kessels A, Jacobson A, Nagler M. Predictors of anticoagulation quality in 15 834 patients performing patient self-management of oral anticoagulation with vitamin K antagonists in real-life practice: a survey of the International Self-Monitoring Association of Orally Anticoagulated Patients. Br J Haematol 2016; 175:677-685. [PMID: 27468696 DOI: 10.1111/bjh.14273] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 06/17/2016] [Indexed: 12/19/2022]
Abstract
Although patient self-management (PSM) of oral anticoagulation with vitamin K antagonists is recommended for patients requiring long-term anticoagulation, important aspects are still unclear. Using data from a large international survey (n = 15 834; median age 72 years; 30·1% female), we studied predictors of poor anticoagulation control (percentage of International Normalized Ratio values within therapeutic range below 75%) and developed a simple prediction model. The following variables were identified as risk factors for poor anticoagulation control and included in the final model: higher intensity of therapeutic range (odds ratio [OR] on every level 1·9; 95% confidence interval [CI] 1·8-2·0), long intervals between measurements (>14 d; 1·5; 95% CI 1·3-1·7), female sex (OR 1·3; 95% CI 1·2-1·4), and management other than PSM (OR 1·4; 95% CI 1·2-1·6). At a threshold of 0·2 (at least one variable present), the model predicted poor anticoagulation control with a sensitivity of 85·3% (95% CI: 84·0, 86·4) and a specificity of 28·5% (27·6, 29·5). The area under the receiver operated characteristic curve was 0·65. Using the proposed prediction model, physicians will be able to identify patients with a low chance of performing well, considering additional training, regular follow-up, or adjustment of therapeutic ranges.
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Affiliation(s)
- Christian Schaefer
- International Self-Montioring Association of Oral Anticoagulated Patients (ISMAAP), Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, University of Bern, Bern, Switzerland.,University of Bern, Bern, Switzerland
| | - Alfons Kessels
- Department of Anaesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Alan Jacobson
- Department of Internal Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Michael Nagler
- University Clinic of Haematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Clinical Research, University of Bern, Bern, Switzerland
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13
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Karaca S, Bozkurt NC, Cesuroglu T, Karaca M, Bozkurt M, Eskioglu E, Polimanti R. International warfarin genotype-guided dosing algorithms in the Turkish population and their preventive effects on major and life-threatening hemorrhagic events. Pharmacogenomics 2015. [PMID: 26216670 DOI: 10.2217/pgs.15.58] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
AIM To determine the accuracy of international warfarin pharmacogenetic algorithms developed on large multiethnic cohorts (comprising more than 1000 subjects) to predict therapeutic warfarin doses in Turkish patients. MATERIALS & METHODS We investigated two Turkish warfarin-treated cohorts: patients with no history of hemorrhagic or thromboembolic event and patients with major and life-threatening hemorrhagic events. RESULTS International pharmacogenetic algorithms showed good performances in predicting the therapeutic dose of patients with no history of bleedings, but they did not significantly detect the incorrect warfarin dose of patients with major and life-threatening hemorrhagic events. CONCLUSION Although genetic information can predict the therapeutic warfarin dose, the accuracy of the international pharmacogenetic algorithms is not sufficient to be used for warfarin screening in Turkish patients.
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Affiliation(s)
- Sefayet Karaca
- School of Health Science, Aksaray University, Aksaray, Turkey.,GENAR Institute for Public Health & Genomics Research, Ankara, Turkey
| | - Nujen Colak Bozkurt
- Department of Endocrinology & Metabolism, Diskapi Yildirim Beyazit Training & Research Hospital, Ankara, Turkey
| | - Tomris Cesuroglu
- GENAR Institute for Public Health & Genomics Research, Ankara, Turkey.,Department of Social Medicine, Maastricht University, Maastricht, The Netherlands
| | - Mehmet Karaca
- Department of Biology, Faculty of Science & Arts, Aksaray University, Aksaray, Turkey
| | - Mehmet Bozkurt
- Department of Cardiology, Ataturk Training & Research Hospital, Ankara, Turkey
| | - Erdal Eskioglu
- Metabolism Unit, Numune Training & Research Hospital, Ankara, Turkey
| | - Renato Polimanti
- Department of Psychiatry, Yale University School of Medicine, West Haven, Connecticut, USA
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