Assessment of anticoagulation management in outpatients attending a warfarin clinic in Windhoek, Namibia

Comparison of anticoagulation control and outcomes between usual medical care and pharmacist-led anticoagulation service in ambulatory patients taking warfarin at tertiary hospital in Ethiopia: a quasi-experimental study

BACKGROUND

We aimed to compare anticoagulation control and outcomes between usual medical care (UMC) and pharmacist-led anticoagulation services (PLAS) in patients receiving warfarin at the Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia.

METHODS

A quasi-experimental study was conducted, including 350 (66.7%) and 175 (33.3%) patients from the UMC and PLAS groups, respectively, from 525 patients. The time in therapeutic range (TTR) was determined using the Rosendaal method, with a TTR ≥ 65% set as the cut-off for optimal anticoagulation. The two-sample Wilcoxon rank-sum (Mann-Whitney U) test was used to compare continuous variables between groups. Categorical variables were compared between groups using Pearson's chi-square test or Fisher's exact test. Logistic regression and negative binomial regression analyses were conducted to identify the factors associated with suboptimal TTR and secondary outcomes, respectively, at the p values < 0.05, and 95% confidence interval (CI).

RESULTS

Compared with the UMC group, the patients in the PLAC group showed a significantly higher median (IQR) TTR [60.89% (43.5-74.69%) vs. 53.65% (33.92-69.14%), p < 0.001]. A significantly higher optimal TTR (≥ 65%) was achieved in the PLAC group (41.7% vs. 31.7%) than in the UMC group (p = 0.002). The odds of having a poor TTR were reduced by 43% (AOR = 0.57, 95% CI = 0.36-0.88, p = 0.01) among patients in the PLAC group compared to those in the UMC group. There were no statistically significant differences in the secondary outcomes between the groups, except for all-cause emergency visits (p = 0.003). The incidence of bleeding events decreased by 3% (IRR = 0.97, 95% CI = 0.96-0.99, p < 0.001) for every increase in INR monitoring frequency. The incidence of thromboembolic events increased by a factor of 15.13 (IRR = 15.13, 95% CI = 1.47-155.52, p = 0.02) among patients with a high-risk CHA2DS2-VASc score compared with those with a moderate score.

CONCLUSION

Patients in the PLAC group had a significantly higher median TTR than those in the UMC group did. There were no statistically significant differences in the secondary outcomes between the groups, except for fewer all-cause emergency department visits in the PLAC group.

The Prevalence and Determinants of Inappropriate Oral Anticoagulant Use in Patients with Atrial Fibrillation, in Resource-Limited Setting

Introduction

Anticoagulation treatment is routinely underused in patients with atrial fibrillation (AF), particularly in settings with limited resources. The current study is aimed at evaluating the appropriateness of oral anticoagulation treatment among AF patients at the Yekatit 12 Hospital Medical College (Y12HMC), Addis Ababa, Ethiopia.

Methods

Institutional-based retrospective cross-sectional study conducted in Y12HMC from November 2019 to March 2020. During the study period, 256 patients' medical records were found; 231 of them met the eligibility criteria and were included in the study. The data were analyzed using SPSS version 25, descriptive statistics were used to summarize the data, and binary logistic regression was performed to identify predictors of inappropriate anticoagulation management.

Results

The majority of study participants were males (55.8%), and over half of them (57.6%) had a nonvalvular type of AF. The majority of patients (61.9%) were receiving anticoagulant treatment, and of them, warfarin was prescribed to most of the study subjects (71.3%). Nearly half (47.6%) of the study participants had inappropriate anticoagulation treatment; among these, the majority of them (69.1%) were from a valvular type of AF. Patients with a valvular type of AF and having the diagnosis of congestive heart disease as comorbidity showed a statistically significant association towards inappropriate anticoagulation management.

Conclusion

According to the study, a significant portion of AF patients received inappropriate anticoagulant treatment, which may play a significant role for the increased risk of stroke in these groups of patients. All of the inappropriate cases were due to failure to start anticoagulant treatment.

Health-related quality of life and healthcare consultations among adult patients before and after diagnosis with rheumatic heart disease in Namibia

BACKGROUND

Rheumatic Heart Disease (RHD) causes high morbidity and mortality rates among children and young adults, impacting negatively on their health-related quality of life (HRQoL). This study aimed to evaluate the HRQoL and healthcare consultations of adult patients with RHD in Namibia.

METHODS

From June 2019 to March 2020, a questionnaire was administered to 83 RHD patients during routine follow-ups. The EQ-5D-5L instrument was used to assess the health-related quality of life before diagnosis and at the time of the survey. The Ethiopian value set for EQ-5D-5L was used to calculate Quality-Adjusted Life Years (QALY).

RESULTS

Most respondents were women (77%), young adults below the age of 30 years (42%), and individuals who grew up in rural areas (87%). The mean QALY statistically significantly improved from 0.773 pre-diagnosis to 0.942 in the last 12 months (p < 0.001). Sixty-six patients who had surgery reported a better QALY. Healthcare visits statistically significantly increased from on average 1.6 pre-diagnosis to 2.7 days in the last 12 months (p < 0.001). The mean distance to the nearest facility was 55 km, mean cost of transport was N$65, and mean time spent at the clinic was 3.6 h. The median time from diagnosis to the survey was 7 years (quartiles 4 and 14 years).

CONCLUSION

Treatment and surgery can improve HRQoL substantially among RHD patients. Being diagnosed with RHD affects patients living in socioeconomically disadvantaged rural areas through cost and time for healthcare visits. It would be valuable with further research to understand differences between disease severities.

Anticoagulation Management in Patients Receiving Warfarin at Private Cardiac Centers in Addis Ababa, Ethiopia

Introduction

Anticoagulants are the cornerstone therapy for thromboembolism prevention and treatment. Warfarin is the frequently prescribed drug and remains the oral anticoagulant of choice in low- and middle-income countries, including Ethiopia. It is a narrow therapeutic index drug that needs high-quality anticoagulation monitoring with frequent international normalization ratio (INR) testing.

Objective

The study aimed to assess anticoagulation management with warfarin among adult outpatients at two selected private cardiac centers in Addis Ababa, Ethiopia.

Methods

A hospital-based retrospective study design that enrolled 374 patients receiving warfarin was employed at two private cardiac centres in Addis Ababa, Ethiopia. The time in the therapeutic range (TTR) was calculated using the Rosendaal method. The data were analyzed using Statistical Package for Social Science version 25.

Results

The mean age of the patients was 57 years, and 218 (58.3%) participants were females. Out of 3384 INR tests, 1562 (46.5%) were within the therapeutic range and the mean percentage of TTR was 47.24%. Only 25.67% of the patients spent their TTR ≥ 65%. The present study revealed that dose adjustments were required 1764 times. In non-therapeutic INR values of 1764 that required warfarin dose adjustment, 59.7% of the doses were adjusted. About 262 (70.1%) of co-prescribed medications had interaction with warfarin. Sixty-four patients (17.11%) experienced bleeding events.

Conclusion

Anticoagulation management with warfarin was suboptimal in private cardiac Addis Ababa, Ethiopia, private cardiac centers. Warfarin adjustment practice for nontherapeutic INR values was not minimal, and many patients encountered bleeding during their course of therapy.

Rheumatic heart disease prevalence in Namibia: a retrospective review of surveillance registers

BACKGROUND

Rheumatic heart disease (RHD) is the most commonly acquired heart disease in children and young people in low and middle-income settings. Fragile health systems and scarcity of data persist to limit the understanding of the relative burden of this disease. The aims of this study were to estimate the prevalence of RHD and to assess the RHD-related health care systems in Namibia.

METHODS

Data was retrieved from outpatient and inpatient registers for all patients diagnosed and treated for RHD between January 2010 to December 2020. We used descriptive statistics to estimate the prevalence of RHD. Key observations and engagement with local cardiac clinicians and patients helped to identify key areas of improvement in the systems.

RESULTS

The outpatient register covered 0.032% of the adult Namibian population and combined with the cumulative incidence from the inpatient register we predict the prevalence of clinically diagnosed RHD to be between 0.05% and 0.10% in Namibia. Young people (< 18 years old) are most affected (72%), and most cases are from the north-eastern regions. Mitral heart valve impairment (58%) was the most common among patients. We identified weaknesses in care systems i.e., lack of patient unique identifiers, missing data, and clinic-based prevention activities.

CONCLUSION

The prevalence of RHD is expected to be lower than previously reported. It will be valuable to investigate latent RHD and patient follow-ups for better estimates of the true burden of disease. Surveillance systems needs improvements to enhance data quality. Plans for expansions of the clinic-based interventions must adopt the "Awareness Surveillance Advocacy Prevention" framework supported by relevant resolutions by the WHO.

Evaluation of patients' knowledge of warfarin at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

Objective

The study was to assess the knowledge of warfarin in patients using the validated anticoagulation knowledge assessment questionnaire and to evaluate the predictors of the level of knowledge among outpatients receiving warfarin at the Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Methods

It was a prospective cross-sectional study carried out from October 2019–January 2020. During the study period a total 401 of them were included in the study. Anticoagulation Knowledge Assessment questionnaire has 29 question items, a single patient should answer at least 21 of the question to be considered as knowledgeable about his/her medication. The data was exported into SPSS version 25 and a one way ANOVA and post hoc were conducted.

Results

The mean age of the study participants were 36 years old (SD ± 11.83), which was ranges from 18 to 82 and majority of the participants were females (69.6%). Almost in one-third of the participants (35.7%), the reasons for warfarin therapy were Chronic Rheumatic Valvular Heart Disease. The overall AKA mean ± SD score of the respondents was 7.4 (±2.6) that ranges from 2 to 22. From those only (4.2%) of the study participants had succeeds the passing score. Educational level and the duration of warfarin therapy were independent predictors towards patient’s warfarin knowledge.

Conclusion

The overall patient’s knowledge about warfarin treatment was poor when it was compared to most other studies. The longer duration of warfarin therapy and advanced educational level showed favored relationship towards better warfarin knowledge of the study participants.

Anticoagulation Control, Outcomes, and Associated Factors in Patients with Atrial Fibrillation Receiving Warfarin at Tertiary Care Hospital in Ethiopia

Anticoagulation is the cornerstone in the prevention of stroke in atrial fibrillation. This study aimed at assessing the anticoagulation control and outcome and predictive factors in atrial fibrillation patients on warfarin therapy. A retrospective chart review was used to evaluate patients with atrial fibrillation who were on warfarin during two years follow up at the anticoagulation clinic of the hospital. The time in therapeutic range (TTR) was calculated using Rosendaal's method. Data were analyzed using SPSS software version 25. Univariable and multivariable analyses were computed to determine factors affecting TTR and bleeding events. We included 300 patients in this study. The mean percentage TTR was 42.03 ± 18.75. Only 38 (12.67%) patients achieved a TTR of above 65%. The average international normalized ratio (INR) testing frequency was 35 days (16.3-67.2 days). Taking 1 or 2 drugs along with warfarin was found to be better in achieving good TTR as compared to taking more than two drugs (p = .014). Having heart failure was associated with a 2.45 times odds of poor anticoagulation control (TTR< 65%) (p = .047). Male study participants were 2.53 times more likely of developing bleeding events than females (p = .009). Bleeding events were observed in 62 (20.67%) patients. Study participants, who didn't have Diabetic Mellitus and those not receiving aspirin were at lower odds developing bleeding events (AOR = .196; C.I. = .060-.638; p−.007 and AOR = .099; CI. = .024-.416; p−.02), respectively. In summary, the time spent in the therapeutic range was minimal in this population of patients with AF on warfarin managed at a hospital run anticoagulation clinic in Ethiopia. Moreover, the number of co-prescribed medications, and having heart failure were associated with poor TTR. Bleeding events were high and affected by male sex, having DM comorbidity, and using aspirin.

Improving anticoagulation in sub-Saharan Africa: What are the challenges and how can we overcome them?

Patients in sub-Saharan Africa generally have poor anticoagulation control. We review the potential reasons for this poor control, as well as the potential solutions. Challenges include the affordability and centralisation of anticoagulation care, problems with access to medicines and international normalised ratio monitoring, the lack of locally validated standardized dosing protocols, and low levels of anticoagulation knowledge among healthcare workers and patients. Increasing numbers of patients will need anticoagulation in the future because of the increasing burden of noncommunicable disease in the region. We propose that locally developed "warfarin care bundles" which address multiple anticoagulation challenges in combination may be the most appropriate solution in this setting currently.

Anticoagulation in sub-Saharan Africa: Are direct oral anticoagulants the answer? A review of lessons learnt from warfarin

Warfarin has existed for >7 decades and has been the anticoagulant of choice for many thromboembolic disorders. The recent introduction of direct-acting oral anticoagulants (DOACs) has, however, caused a shift in preference by healthcare professionals all over the world. DOACs have been found to be at least as effective as warfarin in prevention of stroke in patients with atrial fibrillation and in treatment of venous thromboembolism. In sub-Saharan Africa, however, the widespread use of DOACs has been hampered mainly by their higher acquisition costs. As the drugs come off patent, their use in sub-Saharan Africa is likely to increase. However, very few trials have been conducted in African settings, and safety concerns will need to be addressed with further study before widespread adoption into clinical practice.