1
|
Vazquez SR, Yates NY, Beavers CJ, Triller DM, McFarland MM. Differences in quality of anticoagulation care delivery according to ethnoracial group in the United States: A scoping review. J Thromb Thrombolysis 2024; 57:1076-1091. [PMID: 38733515 PMCID: PMC11315726 DOI: 10.1007/s11239-024-02991-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2024] [Indexed: 05/13/2024]
Abstract
Anticoagulation therapy is standard for conditions like atrial fibrillation, venous thromboembolism, and valvular heart disease, yet it is unclear if there are ethnoracial disparities in its quality and delivery in the United States. For this scoping review, electronic databases were searched for publications between January 1, 2011 - March 30, 2022. Eligible studies included all study designs, any setting within the United States, patients prescribed anticoagulation for any indication, outcomes reported for ≥ 2 distinct ethnoracial groups. The following four research questions were explored: Do ethnoracial differences exist in 1) access to guideline-based anticoagulation therapy, 2) quality of anticoagulation therapy management, 3) clinical outcomes related to anticoagulation care, 4) humanistic/educational outcomes related to anticoagulation therapy. A total of 5374 studies were screened, 570 studies received full-text review, and 96 studies were analyzed. The largest mapped focus was patients' access to guideline-based anticoagulation therapy (88/96 articles, 91.7%). Seventy-eight articles made statistical outcomes comparisons among ethnoracial groups. Across all four research questions, 79 articles demonstrated favorable outcomes for White patients compared to non-White patients, 38 articles showed no difference between White and non-White groups, and 8 favored non-White groups (the total exceeds the 78 articles with statistical outcomes as many articles reported multiple outcomes). Disparities disadvantaging non-White patients were most pronounced in access to guideline-based anticoagulation therapy (43/66 articles analyzed) and quality of anticoagulation management (19/21 articles analyzed). Although treatment guidelines do not differentiate anticoagulant therapy by ethnoracial group, this scoping review found consistently favorable outcomes for White patients over non-White patients in the domains of access to anticoagulation therapy for guideline-based indications and quality of anticoagulation therapy management. No differences among groups were noted in clinical outcomes, and very few studies assessed humanistic or educational outcomes.
Collapse
Affiliation(s)
- Sara R Vazquez
- University of Utah Health Thrombosis Service, 6056 Fashion Square Drive, Suite 1200, Murray, UT, 84107, USA.
| | - Naomi Y Yates
- Kaiser Permanente Clinical Pharmacy Services, 200 Crescent Center Pkwy, Tucker, GA, 30084, USA
| | - Craig J Beavers
- Anticoagulation Forum, Inc, 17 Lincoln Street, Suite 2B, Newton, MA, 02461, USA
- University of Kentucky College of Pharmacy, 789 S Limestone, Lexington, KY, 40508, USA
| | - Darren M Triller
- Anticoagulation Forum, Inc, 17 Lincoln Street, Suite 2B, Newton, MA, 02461, USA
| | - Mary M McFarland
- University of Utah Spencer S. Eccles Health Sciences Library, 10 N 1900 E, Salt Lake City, UT, 84112, USA
| |
Collapse
|
2
|
Todd KE, McGrady ME, Starbuck E, Previtera M, Luchtman-Jones L. A systematic review of adherence to anticoagulation regimens in pediatric patients. Pediatr Blood Cancer 2022; 69:e29698. [PMID: 35476901 DOI: 10.1002/pbc.29698] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 02/09/2022] [Accepted: 03/02/2022] [Indexed: 12/28/2022]
Abstract
Thromboembolic disease rates are increasing in pediatric patients. Anticoagulation is prescribed for treatment and prevention of thromboembolic disease. While nonadherence to anticoagulation regimens predicts poor health outcomes in adults, data in anticoagulated pediatric patients are limited. We systematically reviewed the rates, outcomes, and predictors of anticoagulation nonadherence in the pediatric population. Out of a total of 3581 unique articles identified for review, 17 studies met inclusion criteria. These studies primarily evaluated patients with cardiac disease treated with vitamin K antagonists. Overall nonadherence rates varied from 3% to 42%, based upon population, definition of adherence, and measurement strategy. Patient age, goal international normalized ratio (INR), and number of concurrent potentially interacting medications correlated with nonadherence. Data examining the relationship between nonadherence and health outcomes were included in only two studies. Limitations of current literature, as well as critical knowledge gaps that require future study, are discussed.
Collapse
Affiliation(s)
- Kevin E Todd
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Meghan E McGrady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Patient Family and Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | - Lori Luchtman-Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| |
Collapse
|
3
|
Sun JW, Bourgeois FT, Haneuse S, Hernández-Díaz S, Landon JE, Bateman BT, Huybrechts KF. Development and Validation of a Pediatric Comorbidity Index. Am J Epidemiol 2021; 190:918-927. [PMID: 33124649 DOI: 10.1093/aje/kwaa244] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/01/2020] [Accepted: 10/07/2020] [Indexed: 12/28/2022] Open
Abstract
Comorbidity scores are widely used to help address confounding bias in nonrandomized studies conducted within health-care databases, but existing scores were developed to predict all-cause mortality in adults and might not be appropriate for use in pediatric studies. We developed and validated a pediatric comorbidity index, using health-care utilization data from the tenth revision of the International Classification of Diseases. Within the MarketScan database of US commercial claims data, pediatric patients (aged ≤18 years) continuously enrolled between October 1, 2015, and September 30, 2017, were identified. Logistic regression was used to predict the 1-year risk of hospitalization based on 27 predefined conditions and empirically identified conditions derived from the most prevalent diagnoses among patients with the outcome. A single numerical index was created by assigning weights to each condition based on its β coefficient. We conducted internal validation of the index and compared its performance with existing adult scores. The pediatric comorbidity index consisted of 24 conditions and achieved a C statistic of 0.718 (95% confidence interval (CI): 0.714, 0.723). The index outperformed existing adult scores in a pediatric population (C statistics ranging from 0.522 to 0.640). The pediatric comorbidity index provides a summary measure of disease burden and can be used for risk adjustment in epidemiologic studies of pediatric patients.
Collapse
|
4
|
Abstract
Warfarin is the most commonly prescribed anticoagulant for children in the outpatient setting in Australia. Pediatric patients likely have different challenges to warfarin adherence compared with their adult counterparts; however, little is known about warfarin adherence among this population. This study aimed to understand warfarin adherence among community-based pediatric patients by using an online survey design. The survey instrument incorporated parent or patient self-reported warfarin doses missed in the preceding month, a validated warfarin adherence assessment tool, the 13-item Self-Efficacy for Appropriate Medication use Scale (SEAMS-13), and an open-ended question asking about the challenges of warfarin adherence. The indication of warfarin administration and patient's time in therapeutic range were obtained from medical records. The study recruited outpatients managed by a tertiary pediatric hospital who had previously consented to participate in warfarin research. In total, 53 families were contacted with 43 responses (81% response rate) and 41 completed surveys. The median age of the children from participating families was 10.6 years (range, 4.1 to 18.9 y). The majority of these children (n=42) used warfarin prophylactically and only 1 child used it to treat deep venous thrombosis. The time in therapeutic range achievement of this cohort was 64.4% (95% confidence interval, 58.7-70.2). The mean SEAMS-13 score was 33.5 (95% confidence interval, 31.75-35.37) and the total missed doses was 2.5%. Participants also identified barriers and enablers of warfarin adherence. This study was the first of its kind and thus it provides baseline data for future research. The warfarin adherence of this cohort was likely optimized because of frequent clinical contact and access to self-testing. Future studies are required to examine the different approaches aiming to improve the anticoagulant adherence after the emergence of direct oral anticoagulants with a wider therapeutic index and minimal monitoring that could contribute to less clinical contact.
Collapse
|
5
|
Dinh CN, Moffett BS, Galati M, Lee-Kim Y, Yee DL, Mahoney D. A Critical Evaluation of Enoxaparin Dose Adjustment Guidelines in Children. J Pediatr Pharmacol Ther 2019; 24:128-133. [PMID: 31019405 DOI: 10.5863/1551-6776-24.2.128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The purposes of this study are to perform a large-scale evaluation of the standardized dosage adjustment nomogram recommended by the American College of Chest Physicians (CHEST) for the management of enoxaparin in hospitalized pediatric patients and to determine the necessity of routine and repeated anti-factor Xa (anti-Xa) levels. METHODS A retrospective cohort study was designed, and charts were reviewed in a single tertiary care institution for all patients who received enoxaparin between October 1, 2010, through September 30, 2016. Patients were included if they were receiving treatment doses of enoxaparin according to the pediatric CHEST guidelines, had a subtherapeutic or supratherapeutic anti-Xa level drawn at 3.5 to 6 hours after a dose, had a dose changed in an attempt to attain a therapeutic anti-Xa level, and had a second anti-Xa level drawn 3.5 to 6 hours after the dose change. Descriptive statistical methods were used to characterize the ability of dose adjustment via a nomogram to attain an anti-Xa of 0.5 to 1 unit/mL. RESULTS A total of 467 patients were identified who received the appropriate initial dose and dosage adjustment and whose levels were drawn according to the CHEST guidelines. In patients who had an initial anti-Xa level of <0.35 units/mL and received the nomogram recommended dose increase of 25% ± 5%, 28 out of 96 patients (29.2%) reached therapeutic levels. Of 197 patients who had an initial anti-Xa level between 0.35 and 0.49 units/mL and who received the nomogram recommended dose increase of 10% ± 5%, 116 (58.9%) reached therapeutic levels. Of 50 patients with an initial anti-Xa level between 1.1 and 1.5 units/mL and who received the nomogram dose decrease of 20% ± 5%, 31 (62%) reached therapeutic levels. CONCLUSIONS The current dosage adjustment nomogram recommended by the CHEST guidelines does not reliably lead to therapeutic anti-Xa levels when used to adjust enoxaparin doses in pediatric patients.
Collapse
|
6
|
Abstract
Pulmonary embolism is an uncommon but potentially life-threatening event in children. There has been increasing awareness of pulmonary embolism in children with improved survival in children with systemic disease and advancements in diagnostic modalities. However, literature regarding pulmonary embolism in children is sparse, and thus current guidelines for management of pulmonary embolism in children are extrapolated from adult literature and remain controversial. This article reviews the background and pathophysiology of venous thromboembolism, as well as current diagnostic approach and recommended management of pulmonary embolism in children.
Collapse
|
7
|
Kubitza D, Willmann S, Becka M, Thelen K, Young G, Brandão LR, Monagle P, Male C, Chan A, Kennet G, Martinelli I, Saracco P, Lensing AWA. Exploratory evaluation of pharmacodynamics, pharmacokinetics and safety of rivaroxaban in children and adolescents: an EINSTEIN-Jr phase I study. Thromb J 2018; 16:31. [PMID: 30534007 PMCID: PMC6278122 DOI: 10.1186/s12959-018-0186-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 10/29/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The EINSTEIN-Jr program will evaluate rivaroxaban for the treatment of venous thromboembolism (VTE) in children, targeting exposures similar to the 20 mg once-daily dose for adults. METHODS This was a multinational, single-dose, open-label, phase I study to describe the pharmacodynamics (PD), pharmacokinetics (PK) and safety of a single bodyweight-adjusted rivaroxaban dose in children aged 0.5-18 years. Children who had completed treatment for a venous thromboembolic event were enrolled into four age groups (0.5-2 years, 2-6 years, 6-12 years and 12-18 years) receiving rivaroxaban doses equivalent to 10 mg or 20 mg (either as a tablet or oral suspension). Blood samples for PK and PD analyses were collected within specified time windows. RESULTS Fifty-nine children were evaluated. In all age groups, PD parameters (prothrombin time, activated partial thromboplastin time and anti-Factor Xa activity) showed a linear relationship versus rivaroxaban plasma concentrations and were in line with previously acquired adult data, as well as in vitro spiking experiments. The rivaroxaban pediatric physiologically based pharmacokinetic model, used to predict the doses for the individual body weight groups, was confirmed. No episodes of bleeding were reported, and treatment-emergent adverse events occurred in four children and all resolved during the study. CONCLUSIONS Bodyweight-adjusted, single-dose rivaroxaban had predictable PK/PD profiles in children across all age groups from 0.5 to 18 years. The PD assessments based on prothrombin time and activated partial thromboplastin time demonstrated that the anticoagulant effect of rivaroxaban was not affected by developmental hemostasis in children. TRIAL REGISTRATION ClinicalTrials.gov number, NCT01145859.
Collapse
Affiliation(s)
- Dagmar Kubitza
- Bayer AG, Global Drug Discovery – Clinical Sciences, Clinical Pharmacology Cardiovascular, Aprather Weg 18a, Gebäude 429, 42113 Wuppertal, Germany
| | - Stefan Willmann
- Bayer AG, Global Drug Discovery – Clinical Sciences, Clinical Pharmacology Cardiovascular, Aprather Weg 18a, Gebäude 429, 42113 Wuppertal, Germany
| | - Michael Becka
- Research and Clinical Sciences, Bayer AG, Wuppertal, Germany
| | - Kirstin Thelen
- Bayer AG, Global Drug Discovery – Clinical Sciences, Clinical Pharmacology Cardiovascular, Aprather Weg 18a, Gebäude 429, 42113 Wuppertal, Germany
| | - Guy Young
- Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA USA
| | - Leonardo R. Brandão
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul Monagle
- Department of Haematology Royal Children’s Hospital, Department of Paediatrics, University of Melbourne, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Christoph Male
- Thrombosis & Haemostasis Unit, Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Anthony Chan
- McMaster Children’s Hospital/Hamilton Health Sciences Foundation Pediatric Thrombosis and Hemostasis, Hamilton, Canada
| | - Gili Kennet
- National Hemophilia Center & Thrombosis Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Ida Martinelli
- A.Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Saracco
- Pediatric Hematology, University Hospital Città della Salute e della Scienza, Torino, Italy
| | | |
Collapse
|
8
|
Bauer TM, Johnson AP, Dukleska K, Beck J, Dworkin MS, Patel K, Cowan SW, Merli GJ. Adherence to Inpatient Venous Thromboembolism Prophylaxis: A Single Institution’s Concurrent Review. Am J Med Qual 2018; 34:402-408. [DOI: 10.1177/1062860618808378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hospital-acquired venous thromboembolism (VTE) affects morbidity and mortality and increases health care costs. Poor adherence to recommended prophylaxis may be a potential cause of ongoing events. This study aims to identify institutional adherence rates and barriers to optimal VTE prophylaxis. The authors performed patient and nurse interviews and a concurrent review of clinical documentation, utilizing a cloud-based, HIPAA-compliant tool, on a convenience sample of hospitalized patients. Adherence and agreement between different assessment modalities were calculated. Seventy-six patients consented for participation. Nurse documented adherence was 66% (29/44), 44% (27/61), and 89% (50/56) for mechanical, ambulatory, and chemoprophylactic prophylaxis, respectively. Patient report and nurse documentation showed moderate agreement for mechanical and no agreement for ambulatory adherence (κ = 0.51 and 0.07, respectively). Concurrent review using a cloud-based tool can provide robust, timely, and relevant information on adherence to recommended VTE prophylaxis. Iterative concurrent reviews can guide efforts to improve adherence and reduce rates of hospital-acquired VTE.
Collapse
Affiliation(s)
| | | | | | - Johanna Beck
- Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Kamini Patel
- Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Geno J. Merli
- Thomas Jefferson University Hospital, Philadelphia, PA
| |
Collapse
|