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

Impact of a DSS-supported medication review on the safety of drug therapy and quality of life in patients with antithrombotic therapy

Polypharmacy is common among patients with antithrombotic medication, giving rise to concerns about Drug-Related Problems (DRPs). Therefore, these patients would benefit from a Medication Review (MR) along with pharmacist counselling to reduce the risks accompanying polymedication. This prospective study presents a concept for MRs that are applicable in German community pharmacies and can efficiently support pharmacist counselling and improve the safety of drug therapy. As this is a major challenge in everyday pharmacy practice, we used a Decision Support System (DSS) to evaluate its ability to support the process of pharmacist-led MRs. The primary endpoint was the impact of a community pharmacist on the reduction of DRPs. We investigated the impact of the interventions resulting from MRs on patients taking at least one antithrombotic drug as part of their polymedication regimen. Secondary endpoints were the reduction in the number of patients with bleeding risks and the improvement of patients' Quality of Life (QoL) and therapy adherence. Furthermore, the DSS used in the study was controlled for correct data assessment and plausibility of data. We selected adult patients who were taking no less than three different medications for long-term treatment, at least one of which had to be an antithrombotic drug, and who were customers in one of eight selected pharmacies over a period of 6 months. Data from 87 patients were analyzed with DSS-support. A total of 234 DRPs were identified by the pharmacist (2.7 DRPs per patient). MR reduced DRPs by 43.2% which, resulting to a reduction of 1.2 DRPs per patient. The intervention also led to a significant improvement in the patients' QoL (assessed via EQ-5D-5L questionnaire; p < 0.001) and enhanced therapy adherence (assessed via A14 questionnaire; p < 0.001). The control of correct data assessment (with 93.8% concordance) and plausibility of data (with 91.7% concordance) of the DSS software were conducted by an external auditor. No significant effect was found for overall bleeding risk. The results of this study indicate that DSS-supported and structured MR conducted by pharmacists can contribute to a reduction in DRPs and significantly improve patient's QoL and adherence to treatment.

Changing Perspectives of Local Therapists Eight Years after the Implementation of an Occupational Therapy Service in a Unique Himalayan Cross-Cultural Setting

Background. Whether concepts and principles of Occupational Therapy (OT) can successfully be applied to non-Western and cross-cultural settings is being intensively discussed. Aims/Objectives. We explored the changing perspectives of local occupational therapists (OTs) eight years after the implementation of an OT service in a Himalayan cross-cultural setting in terms of (1) treatment applied, (2) professional identity, and (3) cross-cultural interactions. Material and Methods. A qualitative study design was chosen, and semistructured interviews were conducted in all employed practitioners (a) during implementation and (b) eight years later (n = 7). Questions were carefully formulated in order to narrow down the intended issues but respecting crosscultural differences. The framework method was implemented for data analysis. Findings. Long-term empowering local OTs resulted in the successful development of a sustainable OT department in a unique Himalayan cross-cultural setting. Practitioners became aware of their therapeutic potentials, a clear sense of professional identity was developed, and it was recognised that sensitive cross-cultural practice is only achieved by an ongoing and intentional cultural learning process. Conclusions and Significance. Our findings suggest that OT can be applied to non-Western cross-cultural settings.

Proton pump inhibitors co-prescribed with warfarin reduce warfarin control as measured by time in therapeutic range

INTRODUCTION

Warfarin is an oral anticoagulant that requires ongoing monitoring with time in therapeutic range (TTR), a common measure of the quality of warfarin control and likelihood of adverse events including bleeds. Numerous factors can influence these warfarin outcomes including drug interactions. Proton pump inhibitors (PPIs) have been reported to interact with warfarin but there remain conflicting reports with regard to the impact on bleeds and limited data on TTR. Therefore, the aim of this study was to determine the effect of PPIs on warfarin control using TTR and bleeds as endpoints.

METHODS

Retrospective data were collected for patients managed by a warfarin management clinic in Queensland. Data collected included current medications, reported bleeds and INR results to calculate TTR. Patients were grouped as taking PPIs or not taking PPIs. Analysis of TTR and bleeds occurred for these groups both before and after exclusions of other medication reported to interact with warfarin.

RESULTS

Of the 4494 included patients, almost half (44.5%) were taking PPIs with esomeprazole most commonly (34.8%) prescribed. Patients taking PPIs had significantly reduced TTR compared with patients not taking PPIs both before (78.5 ± 9.7% vs 81.7 ± 10.2%, P < 0.0001) and after (84.4 ± 5.1% vs 89.4 ± 8.0%, P < 0.0001) excluding all other interacting medications with warfarin. Patients taking PPIs also had significantly higher incidence of minor bleeds compared with patients not taking PPIs (32.4% vs 26.1%, P = 0.0487).

DISCUSSION

Patients taking PPIs with warfarin had significantly lower TTRs and higher incidence of minor bleeds. This combination warrants additional caution and monitoring with warfarin control as measured by TTR potentially affected.

Differences in the quality of oral anticoagulation therapy with vitamin K antagonists in German GP practices - results of the cluster-randomized PICANT trial (Primary Care Management for Optimized Antithrombotic Treatment)

Background

In Germany, patients receiving oral anticoagulation (OAC) are often treated by general practitioners (GPs), and large proportions of patients receive vitamin K antagonists (VKAs). The quality of OAC in German GP practices, differences between various practices, and improvement potential through implementation of case management, have not yet been investigated satisfactorily.

Based on results of a cluster-randomized controlled trial, we aimed to assess whether OAC quality can be improved, any variations between practices exist and determine practice- and patient-level factors.

Methods

The PICANT trial (2012–2015) was performed in 52 GP practices in Hesse, Germany. Adult patients with long-term indication for OAC received best practice case management in the intervention group. International normalized ratio (INR) values were recorded from anticoagulation passes. The Rosendaal method was used to calculate Time in Therapeutic Range (TTR) at patient level, and mean pooling to obtain center-specific TTR (cTTR) at practice level. The quality of OAC was assessed by TTR and cTTR. Linear model analyses were used to investigate associations between practice−/ patient-level factors and TTR.

Results

Inclusion of 736 patients (49.6% intervention and 50.4% control patients); 690 (93.8%) received phenprocoumon. Within 24 months, the TTR was 75.1% (SD 17.6) in the intervention versus 74.3% (SD 17.8) in the control group (p = 0.670). The cTTR averaged 75.1% (SD 6.5, range: 60.4 to 86.7%) in the intervention versus 74.3% (SD 7.2, range: 52.7 to 85.7%) in the control group (p = 0.668). At practice level, the TTR was significantly lower in practices with a male physician and certification in quality management. At patient level, the TTR was significantly higher in patients with moderate to high compliance, in men, and in patients that performed self-management. The TTR was significantly lower in patients with certain comorbidities, and who were hospitalized.

Conclusions

The intervention did not effectively improve OAC quality compared to routine care. Quality of INR control was generally good, but considerable variation existed between GP practices. The variability indicates optimization potential in some practices. The demonstrated association between patient-level factors and TTR highlights the importance of considering patient characteristics that may impede achieving high quality therapeutic outcomes.

Trial registration

ISRCTN registry, ISRCTN41847489, registered 27 February 2012.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4372-y) contains supplementary material, which is available to authorized users.

Optimizing quality care for the oral vitamin K antagonists (VKAs)

Vitamin K antagonists (VKAs) have been the only oral anticoagulants for decades. The management of anticoagulant therapy with VKA is challenging because of the intricate pharmacological properties of these agents. The success of VKA therapy depends on the quality of treatment that is ensured through continuing comprehensive communication and education. The educational program should address important issues of the VKA therapy such as beginning of treatment, pharmacological, dietary, and drug-drug interactions, as well as treatment temporary suspension during surgical interventions or invasive maneuvers. In addition, the initial and continuing patient education is of imperative importance. A major role in the educational process may be addressed by patient associations. The quality of treatment is better reached if patients are followed in anticoagulation clinics. Moreover, a federation of anticoagulation clinics may improve patient care through regular meetings to update knowledge on VKA treatment. Learning objectives of this paper is to allow readers to correctly approach patients starting VKA treatment, recognize possible pitfalls of treatment, and provide adequate solutions.

American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy

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.

Dedicated warfarin care programme results in superior warfarin control in Queensland, Australia

BACKGROUND

Warfarin is used to prevent stroke in patients with atrial fibrillation (AF). Ongoing monitoring of International normalised ratio (INR) and time in therapeutic range (TTR) commonly used to assess the quality of warfarin management are required. Anticoagulant clinics have demonstrated improved TTRs, particularly in countries with poorer control in primary care settings. Reported TTR in Australia has been relatively high; so, it is unknown if benefit would be seen from dedicated warfarin clinics in Australia. The aim of this study was to compare the level of warfarin control in patients managed by their general practitioner (GP) and a warfarin care programme (WCP) by Sullivan Nicolaides Pathology.

METHOD

Retrospective data were collected for AF patients enrolled in the warfarin care programme at WCP, and included patients with INR tests available while managed by their GP. INR tests were used to calculate TTR and frequency of testing for the time managed by GP and WCP, with mean data used for analysis and comparison.

RESULTS

The eligible 200 warfarin patients had a TTR of 69% with GP management and 82% with WCP management (<.0001). Significant differences were also found between GP and WCP management in the percentage of tests in range, total number of tests and frequency of testing. WCP had a reduced time to repeat test at extremes of INR results.

CONCLUSION

Australian warfarin control was good when managed by either GP or WCP, but WCP management increased TTR by 13%. Dedicated warfarin programmes can improve warfarin control and optimise therapy for patients.

Factors influencing warfarin control in Australia and Singapore

INTRODUCTION

Warfarin is widely used for patients with non-valvular atrial fibrillation (NVAF). Variations in warfarin control, as measured by time in therapeutic range (TTR), have been reported across different regions and ethnicities, particularly between Western and Asian countries. However, there is limited data on comparative factors influencing warfarin control in Caucasian and Asian patients. Therefore, the aim of this study was to determine warfarin control and potential factors influencing this in patients with NVAF in Australia and Singapore.

METHODS

Retrospective data was collected for patients receiving warfarin for January to June 2014 in Australia and Singapore. TTR was calculated for individuals with mean patient TTR used for analysis. Possible influential factors on TTR were analysed including age, gender, concurrent co-morbidities, and concurrent medication.

RESULTS

The mean TTR was significantly higher in Australia (82%) than Singapore (58%). At both sites, chronic kidney disease significantly lowered this TTR. Further factors influencing control were anaemia and age<60years in Australia, and vascular disease, CHA₂DS₂-VASc score of 6, and concurrent platelet inhibitor therapy in Singapore.

DISCUSSION

Warfarin control was significantly higher in Australia compared to Singapore, however chronic kidney disease reduced control at both sites. The different levels of control in these two countries, together with patient factors further reducing control may impact on anticoagulant choice in these countries with better outcomes from warfarin in Australia compared to Singapore.

Does a complex intervention increase patient knowledge about oral anticoagulation? - a cluster-randomised controlled trial

Background

Oral anticoagulation therapy (OAT) is a challenge in general practice, especially for high-risk groups such as the elderly. Insufficient patient knowledge about safety-relevant aspects of OAT is considered to be one of the main reasons for complications. The research question addressed in this manuscript is whether a complex intervention that includes practice-based case management, self-management of OAT and additional patient and practice team education improves patient knowledge about anticoagulation therapy compared to a control group of patients receiving usual care (as a secondary objective of the Primary Care Management for Optimised Antithrombotic Treatment (PICANT) trial).

Methods

The cluster-randomised controlled PICANT trial was conducted in 52 general practices in Germany, between 2012 and 2015. Trial participants were patients with a long-term indication for oral anticoagulation. A questionnaire was used to assess knowledge at baseline, after 12, and after 24 months. The questionnaire consists of 13 items (with a range of 0 to 13 sum-score points) covering topics related to intervention. Differences in the development of patient knowledge between intervention and control groups compared to baseline were assessed for each follow-up by means of linear mixed-effects models.

Results

Seven hundred thirty-six patients were included at baseline, of whom 95.4% continued to participate after 12 months, and 89.3% after 24 months. The average age of patients was 73.5 years (SD 9.4), and they mainly suffered from atrial fibrillation (81.1%). Patients in the intervention and control groups had similar knowledge about oral anticoagulation at baseline (5.6 (SD 2.3) in both groups). After 12 months, the improvement in the level of knowledge (compared to baseline) was significantly larger in the intervention group than in the control group (0.78 (SD 2.5) vs. 0.04 (SD 2.3); p = 0.0009). After 24 months, the difference between both groups was still statistically significant (0.6 (SD 2.6) vs. -0.3 (SD 2.3); p = 0.0001).

Conclusion

Since this intervention was effective, it should be established in general practice as a means of improving patient knowledge about oral anticoagulation.

Trial registration

Current controlled trials ISRCTN41847489; Date of registration: 13/04/2012

Impact of self-funding on patient experience of oral anticoagulation self-monitoring: a qualitative study

OBJECTIVE

To explore the impact self-funding has on patient experience of oral anticoagulation therapy self-monitoring.

DESIGN

Semistructured, qualitative interviews were conducted. Transcripts were analysed thematically using constant comparison.

SETTING

England.

PARTICIPANTS

Interviewees were participants of the Cohort Study of Anticoagulation Self-Monitoring (CASM). Cohort members were recruited as they bought a monitor from the major manufacturer in the UK. A purposive sample was invited to be interviewed on completion of the 12-month cohort follow-up.

DATA

Patient narratives on their experiences of self-monitoring their oral anticoagulation therapy in non-trial conditions.

RESULTS

26 interviews were completed. Interviewees viewed purchasing the monitoring device as a long-term commitment balancing the limitations of clinic-based monitoring against the cost. They were unable to try out the monitor prior to purchase and therefore had to be confident in their own ability to use it. The variable provision of self-monitoring equipment caused resentment, and interviewees were uncomfortable negotiating with healthcare professionals. High test strip usage while learning how to use the monitor caused anxiety that was exacerbated by worries about their cost. However, self-funding did mean that interviewees felt a sense of ownership and were determined to persevere to overcome problems.

CONCLUSIONS

Self-funding has negative implications in terms of equity of access; however, the money invested acts as a barrier to discontinuation. If oral anticoagulation therapy self-monitoring devices and consumables were provided free of charge in routine care, the training and support available in England may need to be reviewed to prevent discontinuation rates rising to those observed in clinical trials.