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Rentta NN, Bennett J, Leung W, Webb R, Jack S, Harwood M, Baker MG, Lund M, Wilson N. Medical Treatment for Rheumatic Heart Disease: A Narrative Review. Heart Lung Circ 2022; 31:1463-1470. [PMID: 35987720 DOI: 10.1016/j.hlc.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 07/03/2022] [Accepted: 07/06/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are rare in high-income countries; however, in Aotearoa New Zealand ARF and RHD disproportionately affect Indigenous Māori and Pacific Peoples. This narrative review explores the evidence regarding non-surgical management of patients with clinically significant valve disease or heart failure due to RHD. METHODS Medline, EMBASE and Scopus databases were searched, and additional publications were identified through cross-referencing. Included were 28 publications from 1980 onwards. RESULTS Of the available interventions, improved anticoagulation management and a national RHD register could improve RHD outcomes in New Zealand. Where community pharmacy anticoagulant management services (CPAMS) are available good anticoagulation control can be achieved with a time in the therapeutic range (TTR) of more than 70%, which is above the internationally recommended level of 60%. The use of pharmacists in anticoagulation control is cost-effective, acceptable to patients, pharmacists, and primary care practitioners. There is a lack of local data available to fully assess other interventions; including optimal therapy for heart failure, equitable access to specialist RHD care, prevention, and management of endocarditis. CONCLUSION As RHD continues to disproportionately affect Indigenous and minority groups, pro-equity tertiary prevention interventions should be fully evaluated to ensure they are reducing disease burden and improving outcomes in patients with RHD.
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Affiliation(s)
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand.
| | - William Leung
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Rachel Webb
- Auckland District Health Board, Auckland, New Zealand; University of Auckland, Department of Paediatrics: Child and Youth Health, Auckland, New Zealand
| | - Susan Jack
- Public Health South, Southern District Health Board, Dunedin, New Zealand
| | - Matire Harwood
- General Practice and Primary Healthcare, University of Auckland, Auckland, New Zealand
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Mayanna Lund
- Counties Manukau District Health Board, Auckland, New Zealand
| | - Nigel Wilson
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand; Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
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Bussey HI, Nutescu EA, Harper P. Can clinical pharmacists utilize telehealth to double the safety and efficacy of oral anticoagulation while reducing health care costs and improving patient satisfaction in patients with atrial fibrillation? JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Edith A. Nutescu
- Department of Pharmacy Practice, Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy University of Illinois at Chicago Chicago Illinois USA
| | - Paul Harper
- Consultant Hematologist Palmerston North Hospital Palmerston North New Zealand
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Bartolazzi F, Ribeiro ALP, de Sousa WJFN, Vianna MS, da Silva JLP, Martins MAP. Relationship of health literacy and adherence to oral anticoagulation therapy in patients with atrial fibrillation: a cross-sectional study. J Thromb Thrombolysis 2021; 52:1074-1080. [PMID: 33855686 DOI: 10.1007/s11239-021-02432-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
Oral anticoagulant therapy (OAT) has increased substantially due to the aging population and prevalence rise of atrial fibrillation (AF). Medication adherence is important to achieve effectiveness and safety of OAT. The study aim was to investigate the relationship between health literary (HL) and the adherence to OAT in patients with atrial fibrillation (AF). This is a cross-sectional study conducted in a public cardiology clinic in Brazil, 2019. Sociodemographic and clinical data were collected by the review of medical records and interviews with patients. The relation between health literacy (HL) and adherence to OAT was investigated by a multiple logistic regression model. Overall, 100 AF patients were included in this study, with average age of 68.8 ± 13.8 years and predominance of women (54 %). Inadequate HL was found in 79 % of the patients and non-adherence was identified in 66 % of the participants. Sex was the only variable with a statistically significant association with non-adherence to OAT. Men presented a 2.54-fold greater chance of non-adherence to OAT, when compared to the women (Odds ratio (OR) = 2.54; 95 % confidence interval (CI): 1.03-6.62; p = 0.047). No statistically significant relationship was found between inadequate HL and non-adherence to OAT (OR 1.48; 95 % CI, 0.47-4.61; p = 0.49). High rates of inadequate HL and non-adherence to OAT were identified in this study; however, this relationship did not prove to be statistically significant. Further studies are needed to investigate factors associated with non-adherence to OAT in large samples of vulnerable populations and strategies for its improvement in public health.
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Affiliation(s)
- Frederico Bartolazzi
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, Minas Gerais, CEP 30130-100, Brazil
| | - Antônio Luiz Pinho Ribeiro
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, Minas Gerais, CEP 30130-100, Brazil.,Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 110, Santa Efigênia, Belo Horizonte, Minas Gerais, CEP 30130-100, Brazil
| | - Waleska Jaclyn Freitas Nunes de Sousa
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, Minas Gerais, CEP 30130-100, Brazil
| | - Mayara Sousa Vianna
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6.627, Campus Pampulha, Belo Horizonte, Minas Gerais, CEP 31270-901, Brazil
| | - José Luiz Padilha da Silva
- Universidade Federal do Paraná, Edifício do Setor de Ciências Exatas - 2 o andar, Centro Politécnico, Jardim das Américas, Curitiba, Paraná, CEP 81531-980, Brazil
| | - Maria Auxiliadora Parreiras Martins
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, Minas Gerais, CEP 30130-100, Brazil. .,Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 110, Santa Efigênia, Belo Horizonte, Minas Gerais, CEP 30130-100, Brazil. .,Faculdade de Farmácia, Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6.627, Campus Pampulha, Belo Horizonte, Minas Gerais, CEP 31270-901, Brazil.
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Dhippayom T, Rattanachaisit N, Jhunsom S, Dilokthornsakul P, Chaiyakunapruk N, Devine B. Comparative effects of telemedicine and face-to-face warfarin management: A systematic review and network meta-analysis. J Am Pharm Assoc (2003) 2020; 60:880-891.e9. [PMID: 32703667 DOI: 10.1016/j.japh.2020.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 05/24/2020] [Accepted: 06/02/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine the comparative effects of different types of telemedicine on anticoagulation control and adverse outcomes in patients taking warfarin. DATA SOURCES A systematic search was conducted in PubMed, the Cochrane library, EMBASE, CINAHL, OpenGrey, and DART-Europe from inception to September 2019. STUDY SELECTION Randomized controlled trials, quasi-experimental and cohort studies were included if they evaluated the effect of telemedicine in patients using warfarin for 3 months or more. METHODS Two reviewers extracted and assessed the quality of studies by means of the Cochrane Effective Practice and Organization of Care Group. Network meta-analyses were performed using a random-effects model. Surface under the cumulative ranking curve (SUCRA) methods were used to rank different telemedicine types. RESULTS Of the 14,673 articles retrieved, 12 studies involving 11,478 patients met the inclusion criteria. The 5 types of telemedicine categorized were 1) laboratory draw with individual telephonic follow-up by health care (HC) providers (Lab/Tel/HC); 2) laboratory draw with individual telephonic follow-up with periodic, routine routine face-to-face (F2F) visit (Lab/Tel+F2F/HC); 3) laboratory draw with individual and group follow-up via online access (Lab/Online/HC); 4) patient self-test (PST) with telephonic or Web-based follow-up by automated management system (PST/Tel-Online/Auto); and 5) PST with telephonic follow-up by HC provider (PST/Tel/HC). PST/Tel-Online/Auto appears to be superior to F2F for TTR (mean difference 8.78%; 95% CI 0.06%-17.50%) and Lab/Online/HC for in-range INR (odds ratio 2.59; 95% CI 1.04-6.46). The SUCRAs suggested that PST/Tel-Online/Auto was preferred for both TTR and INR, at 84.2% and 93.9%, respectively, whereas Lab/Tel/HC was preferred to prevent major bleeding (74.1%) or thromboembolic event (70.7%). CONCLUSION According to the current evidence of uncertain quality, the best effects on anticoagulation control and adverse outcomes were achieved from different types of telemedicine. Variations in the effects of telemedicine on diverse outcomes should be considered before implementing telemedicine interventions in patients taking warfarin.
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Li Y, Dong L, Xiang D, Zhang Y, Chen X, Long J, Liu X, Li H, Yi Y, Fan Y, Gong Q, Luo M. Patient compliance with an anticoagulation management system based on a smartphone application. J Thromb Thrombolysis 2020; 48:263-269. [PMID: 31028513 DOI: 10.1007/s11239-019-01859-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We developed a novel anticoagulation management system (Anticlot Assistant) based on a smartphone application (App). This study was performed to evaluate patient compliance with Anticlot Assistant. This prospective case series study involved patients receiving warfarin therapy. The eligible patients were managed via Anticlot Assistant, and outcome data were analyzed. Thirty patients were recruited. The mean time within the therapeutic range (TTR) was 56.5% ± 26.2% and the mean patient compliance with Anticlot Assistant was 52.7% ± 40.4%. The patients in good compliance group had higher TTR (65.6 ± 25.0% vs. 40.0 ± 21.0%, P = 0.009), lower time in the extremely low range (9.4 ± 10.6% vs. 27.4 ± 13.2%, P = 0.000) and in the extremely high range (1.3 ± 2.8% vs. 14.1 ± 22.3%, P = 0.004) than those in poor compliance group. Logistic regression analysis revealed that receiving an education of > 6 years was the only independent predictor of good compliance (odds ratio 8.400, 95% confidence interval 1.274-55.394, P = 0.027). Patient compliance is critical important for good outcomes and it might increase with improvements in education and more widespread use of information technology. Although further improvement is needed, Anticlot Assistant is promising and this study offered valuable experiences for further research.
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Affiliation(s)
- Yetao Li
- Department of Cardiac Surgery, West China Hospital, Sichuan University, Chendu, 610041, Sichuan, China.,Department of Cardiovascular Surgery, Guizhou Provincial People's Hospital, Guiyang, 550002, Guizhou, China
| | - Li Dong
- Department of Cardiac Surgery, West China Hospital, Sichuan University, Chendu, 610041, Sichuan, China.
| | - Daokang Xiang
- Department of Cardiovascular Surgery, Guizhou Provincial People's Hospital, Guiyang, 550002, Guizhou, China
| | - Yongchun Zhang
- Department of Cardiovascular Surgery, Guizhou Provincial People's Hospital, Guiyang, 550002, Guizhou, China
| | - Xinbu Chen
- Department of Hepatobiliary Surgery, Guizhou Provincial People's Hospital, Guiyang, 550002, Guizhou, China
| | - Juan Long
- Department of Hepatobiliary Surgery, Guizhou Provincial People's Hospital, Guiyang, 550002, Guizhou, China
| | - Xiulun Liu
- Department of Cardiovascular Surgery, Guizhou Provincial People's Hospital, Guiyang, 550002, Guizhou, China
| | - Hailin Li
- Information Center, Guizhou Provincial People's Hospital, Guiyang, 550002, Guizhou, China
| | - Yile Yi
- Department of Cardiovascular Surgery, Guizhou Provincial People's Hospital, Guiyang, 550002, Guizhou, China
| | - Yongfeng Fan
- Department of Cardiac Surgery, West China Hospital, Sichuan University, Chendu, 610041, Sichuan, China.,Department of Cardiovascular Surgery, Guizhou Provincial People's Hospital, Guiyang, 550002, Guizhou, China
| | - Qihua Gong
- Department of Cardiovascular Surgery, The Third Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Min Luo
- Oncology Department, Guizhou Provincial People's Hospital, Guiyang, 550002, Guizhou, China
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Hawes EM, Lambert E, Reid A, Tong G, Gwynne M. Implementation and evaluation of a pharmacist-led electronic visit program for diabetes and anticoagulation care in a patient-centered medical home. Am J Health Syst Pharm 2018; 75:901-910. [DOI: 10.2146/ajhp170174] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Emily M. Hawes
- Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC
- UNC Eshelman School of Pharmacy, Chapel Hill, NC
| | - Erika Lambert
- UNC Medical Center, Chapel Hill, NC
- UNC Eshelman School of Pharmacy, Chapel Hill, NC
| | - Alfred Reid
- Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC
| | - Gretchen Tong
- UNC Family Medicine Center, Chapel Hill, NC
- Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC
| | - Mark Gwynne
- UNC Health Alliance, Chapel Hill, NC
- Department of Family Medicine, UNC School of Medicine, Chapel Hill, NC
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Phelps E, Delate T, Witt DM, Shaw PB, McCool KH, Clark NP. Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service. Thromb Res 2018; 163:54-59. [PMID: 29407629 DOI: 10.1016/j.thromres.2018.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/05/2018] [Accepted: 01/14/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clinical pharmacy anticoagulation services have improved the quality of anticoagulant therapy and are associated with lower rates of bleeding and thromboembolism compared to usual care. Several studies have found that higher time-in-therapeutic range (TTR) during warfarin therapy is associated with better warfarin outcomes. However, whether increasing TTR over time within an established anticoagulation service is associated with further reduction in bleeding and thromboembolic outcomes is unknown. METHODS This was a retrospective cohort study of patients with atrial fibrillation conducted at an integrated healthcare delivery system with a centralized, pharmacist-managed anticoagulation service. Clinical outcomes (clinically-relevant bleeding, ischemic stroke or systemic embolism, and all-cause mortality) and TTR were compared between two distinct time periods: 1/1/2006 through 12/31/2007 (control group) and 1/1/2012 through 12/31/2013 (observation group) with regression modeling to adjustment for potential confounders. RESULTS There were 3641 and 4764 patients in the control and observation groups, respectively. The mean age was 74.3 years and 54.4% of the cohort was female. Mean TTR was higher in the observation group (70.5% vs. 63.4%, p < 0.001). The composite outcome of clinically-relevant bleeding, thromboembolism and all-cause mortality occurred in 4.6% and 3.6% of the control and observation groups, respectively (adjusted odds ratio = 0.69; 95% confidence interval 0.54-0.87). Individual rates of stroke/systemic embolism and all-cause mortality were each lower in the observation group (both p < 0.05) while clinically-relevant bleeding was not significantly different (p = 0.256). CONCLUSION Increased TTR within a clinical pharmacy anticoagulation management service was associated with a lower risk of the composite outcomes of bleeding, thromboembolism and death in a large atrial fibrillation population receiving warfarin.
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Affiliation(s)
- Elise Phelps
- Ambulatory Care Department, Virginia Garcia Memorial Health Center, Portland, OR, United States
| | - Thomas Delate
- Clinical Pharmacy Research Team, Kaiser Permanente Colorado, Aurora, CO, United States; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States
| | - Daniel M Witt
- University of Utah Skaggs School of Pharmacy, Salt Lake City, UT, United States
| | - Paul B Shaw
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States; Department of Cardiology, Kaiser Permanente Colorado, Lafayette, CO, United States
| | - Kathleen H McCool
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States; Clinical Pharmacy Anticoagulation and Anemia Service, Kaiser Permanente Colorado, Aurora, CO, United States
| | - Nathan P Clark
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States; Clinical Pharmacy Anticoagulation and Anemia Service, Kaiser Permanente Colorado, Aurora, CO, United States.
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McCahon D, Baker JM, Murray ET, Fitzmaurice DA. Assessing the utility of an online registry for patients monitoring their own warfarin therapy. J Clin Pathol 2015; 69:331-6. [PMID: 26519487 DOI: 10.1136/jclinpath-2015-203168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/21/2015] [Indexed: 11/04/2022]
Abstract
AIMS To evaluate the utility of an online self-report registry for patient self-monitoring and self-management (PSM) of warfarin therapy. METHODS A prospective observational study of UK-based patients undertaking PSM and recording their international normalised ratio (INR) data via an online registry. Consenting participants recorded INR test dates, results and warfarin dosages using the online registry for a period of 12 months. Participants reported demographic data, disease characteristics and treatment-related adverse events and provided feedback via a survey. Data accuracy was assessed through comparison of INR results recorded online with results stored on 19 INR testing devices. Percentage time spent within therapeutic time in range (TTR) was also examined. RESULTS Eighty-seven per cent (39/45) completed the study period. Age ranged from 26 to 83 years, 44% had undertaken PSM for >5 years. Sixty-six per cent (25/38) reported that the registry was easy to navigate and use. Forty-two participants contributed a total of 1669 INR results. Agreement between self-reported INR results and source INR data was high (99%). Mean TTR was 76% (SD 18.58) with 83% having >60% TTR. CONCLUSIONS Findings suggest that an online PSM registry is feasible, accurate and acceptable to patients. These findings require confirmation in a larger cohort of PSM patients. An online self-report registry could provide a valuable resource for gathering real world evidence of clinical effectiveness and safety of these developing models of care.
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Affiliation(s)
- Deborah McCahon
- Department of Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Jennifer M Baker
- Department of Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Ellen T Murray
- Department of Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - David A Fitzmaurice
- Department of Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
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Baumann Kreuziger LM, Kim B, Wieselthaler GM. Antithrombotic therapy for left ventricular assist devices in adults: a systematic review. J Thromb Haemost 2015; 13:946-55. [PMID: 25845489 DOI: 10.1111/jth.12948] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVADs) have dramatically increased the survival of adults with end-stage systolic heart failure. However, rates of bleeding and thromboembolism remain high. OBJECTIVES We completed a systematic review to evaluate outcomes of adults with LVADs treated with various anticoagulant and antiplatelet strategies. METHODS Databases were searched using the terms 'assist device', 'thrombosis', and 'anticoagulant' or 'platelet aggregation inhibitor' with appropriate synonyms, device names and manufacturers. RESULTS AND CONCLUSIONS Of 977 manuscripts, 24 articles met the inclusion criteria of adults with implanted LVADs where clinical outcomes were defined based on anticoagulant and/or antiplatelet regimen. Most studies reported treatment with unfractionated heparin post-operatively which was transitioned to a vitamin K antagonist (VKA). Goal INR varied between 1.5-3.5. Antiplatelet regimens ranged from no treatment to dual therapy. Definition of major bleeding differed between trials and incidence varied between 0% and 58%. The available evidence could not demonstrate a clear benefit of aspirin compared with VKA therapy alone [stroke RR 1.02 (95% CI 0.49-2.1)]. There was a suggestion that treatment with aspirin and dipyridamole decreased the risk of thromboembolism compared to aspirin [RR 0.50 (0.36-0.68)], but the comparison is limited by differences in demographics, devices, and INR goals among studies. Additionally, most studies did not blind investigators to outcomes thus contributing to an increased risk for bias. Clinical equipoise exists as to the most appropriate antithrombotic therapy in LVAD patients. Randomization between regimens within a prospective trial is needed to define the treatment regimen that minimizes both bleeding and thrombotic complications.
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Affiliation(s)
- L M Baumann Kreuziger
- Department of Medicine/Hematology and Oncology, Blood Center of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B Kim
- University of California San Francisco, San Francisco, CA, USA
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Ferrando F, Mira Y. Effective and Safe Management of Oral Anticoagulation Therapy in Patients Who Use the Internet-Accessed Telecontrol Tool SintromacWeb. Interact J Med Res 2015; 4:e10. [PMID: 25900775 PMCID: PMC4420842 DOI: 10.2196/ijmr.3610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 11/24/2014] [Accepted: 02/19/2015] [Indexed: 01/04/2023] Open
Abstract
Background Despite the existing evidence that highlights the benefits of oral anticoagulation therapy (OAT) self-testing and self-management by patients in comparison with conventional control, significant progress is still needed in the implementation of computer-based, Internet-assisted systems for OAT within health care centers. The telecontrol tool “SintromacWeb” is a previously validated system for OAT management at home, which is currently operative and accessed by patients through a hospital Web portal. Objective The intent of the study was to assess the effectiveness and safety of OAT management in patients using the SintromacWeb telecontrol system in reference to control in patients using the conventional system (management at the hematology department), in terms of time in therapeutic range (TTR) of International Normalized Ratio (INR). Methods In this observational prospective study, patients were identified by their physician and divided in two groups according to the OAT management system that they were already using (conventional control or telecontrol with SintromacWeb). For 6 months, patients were required to visit the hematology department every time their physician considered it necessary according to usual clinical practice. Sociodemographic and clinical variables for the study were collected at first visit (baseline) and at those visits closest to 2, 4, and 6 months after first visit. Results A total of 173 patients were evaluated, 87 with conventional control and 86 with telecontrol. Follow-up time was a median of 6.3 (range 5.2-8.1) months. The average time of OAT treatment prior to enrollment was 9.2 (SD 6.4) years. Patients in the telecontrol group tested their INR a median of 21 (range 4-22) days versus a median of 35 (range 14-45) days in patients in the conventional control group (P<.001). TTR in the telecontrol group was 107 (SD 37) days versus 94 (SD 37) days in the conventional control group (an increase of 12.6%; P=.02). In all visits, the percentage of TTR was higher in the telecontrol group (at the third visit: 59% vs 48%; P=.01). Higher TTR (positive coefficient) was associated with patients under OAT telecontrol (P=.03). Under-anticoagulation (INR<1.5) and over-anticoagulation (INR>5) were observed in 34 (19.7%, 34/173) and 38 (22.0%, 38/173) patients, respectively (no differences between treatment groups). Seven thrombotic and/or bleeding events were serious, 12 were non-serious, and most of them (5 and 10, respectively) occurred in the conventional control group. Conclusions In clinical practice, OAT management with the Internet-based tool SintromacWeb is effective and safe for those patients who are eligible for OAT telecontrol.
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Affiliation(s)
- Fernando Ferrando
- Hospital Universitari i Politècnic La Fe, Unidad de Hemostasia y Trombosis, Valencia, Spain.
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Bereznicki LRE, Jackson SL, Peterson GM. Supervised patient self-testing of warfarin therapy using an online system. J Med Internet Res 2013; 15:e138. [PMID: 23853350 PMCID: PMC3713938 DOI: 10.2196/jmir.2255] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 02/19/2013] [Accepted: 05/31/2013] [Indexed: 12/02/2022] Open
Abstract
Background Point-of-care international normalized ratio (INR) monitoring devices simplify warfarin management by allowing selected patients to monitor their own therapy in their homes. Patient self-testing (PST) has been shown to improve the clinical outcomes of warfarin therapy compared to usual care. Objective To compare management of warfarin therapy using PST combined with online supervision by physicians via a custom system with usual warfarin management, which involved laboratory testing and physician dosing. Methods Interested patients were recruited via community pharmacies to participate in a warfarin PST training program. Participants were required to have a long-term indication for warfarin, have been taking warfarin for at least 6 months, and have Internet access in their home. The training involved two sessions covering theoretical aspects of warfarin therapy, use of the CoaguChek XS, and the study website. Following training, patients monitored their INR once weekly for up to 3 months. Patients and physicians utilized a secure website to communicate INR values, dosage recommendations, and clinical incidents. Physicians provided a 6-12 month history of INR results for comparison with study results. The percentage of time spent within the therapeutic INR range (TTR) was the primary outcome, with participants acting as their own historical controls. The percentage of INR tests in range and participant satisfaction were secondary outcomes. Results Sixteen patients completed training requirements. The mean age of participants was 69.8 (SD 10.1) years. TTR improved significantly from 66.4% to 78.4% during PST (P=.01), and the number of tests within the target range also improved significantly (from 66.0% at prior to the study to 75.9% during PST; P=.04). Patients and physicians expressed a high degree of satisfaction with the monitoring strategy and online system. Conclusions PST supported by an online system for supervision was associated with improved INR control compared to usual care in a small group of elderly patients. Further research is warranted to investigate the clinical outcomes and cost-effectiveness of online systems to support patients monitoring medications and chronic conditions in the home.
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Affiliation(s)
- Luke Ryan Elliot Bereznicki
- Unit for Medication Outcomes Research and Education, School of Pharmacy, University of Tasmania, Hobart 7001, Australia.
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Kummervold PE, Johnsen JAK, Skrøvseth SO, Wynn R. Using noninferiority tests to evaluate telemedicine and e-health services: systematic review. J Med Internet Res 2012; 14:e132. [PMID: 23022989 PMCID: PMC3510769 DOI: 10.2196/jmir.2169] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 07/15/2012] [Accepted: 09/04/2012] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND An increasing number of studies within the field of telemedicine and e-health are designed as noninferiority studies, aiming to show that the telemedicine/e-health solution is not inferior to the traditional way of treating patients. OBJECTIVE The objective is to review and sum up the status of noninferiority studies within this field, describing advantages and pitfalls of this approach. METHODS PubMed was searched according to defined criteria, and 16 relevant articles were identified from the period 2008-June 2011. RESULTS Most of the studies were related to the fields of psychiatry and emergency medicine, and most were published in journals relating to these fields or in general scientific or general medicine journals. All the studies claimed to be noninferiority studies, but 7 out of 16 tested for statistical differences as a proxy of noninferiority. CONCLUSIONS The methodological quality of the studies varied. We discuss optimal procedures for future noninferiority studies within the field of telemedicine and e-health and situations in which this approach is most appropriate.
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