Outcomes of Oral Anticoagulant Therapy Managed by Telephone vs In-Office Visits in an Anticoagulation Clinic Setting

The digital journey: 25 years of digital development in electrophysiology from an Europace perspective

AIMS

Over the past 25 years there has been a substantial development in the field of digital electrophysiology (EP) and in parallel a substantial increase in publications on digital cardiology.In this celebratory paper, we provide an overview of the digital field by highlighting publications from the field focusing on the EP Europace journal.

RESULTS

In this journey across the past quarter of a century we follow the development of digital tools commonly used in the clinic spanning from the initiation of digital clinics through the early days of telemonitoring, to wearables, mobile applications, and the use of fully virtual clinics. We then provide a chronicle of the field of artificial intelligence, a regulatory perspective, and at the end of our journey provide a future outlook for digital EP.

CONCLUSION

Over the past 25 years Europace has published a substantial number of papers on digital EP, with a marked expansion in digital publications in recent years.

Potential Association of Holidays on Internationalized Normalized Ratio in Warfarin-Users at a Multidisciplinary Clinic

Background

Warfarin is approved by the United States Food and Drug Administration for numerous clinical indications. The effectiveness of warfarin is highly dependent on the time-in-therapeutic range based on the international normalized ratio (INR) goal, which may be altered by changes in diet, alcohol intake, concomitant drugs, and travel, all of which are prevalent during the holidays. At this time, there are no published studies assessing the impact of holidays on INR in warfarin-users.

Methods

A retrospective chart review was conducted on all adult patients taking warfarin and managed at a multidisciplinary clinic. Patients were included if they were taking warfarin at home regardless of indication for anticoagulation. The INR pre- and post-holiday was assessed.

Results

Of a total of 92 patients, the mean age was 71.5 ± 14.3 years, and most patients were on warfarin with an INR goal of 2 - 3 (89%). There were significant differences in INR before and after Independence Day (2.55 vs. 2.81, P = 0.043) and Columbus Day (2.39 vs. 2.82, P < 0.001). The remaining holidays showed no significant differences in INR before and after each respective holiday.

Conclusions

There may be factors related to Independence and Columbus Day that are increasing the level of anticoagulation in warfarin-users. Although the mean post-holiday INR values, in essence, maintained within the typical target of 2 - 3, our study underscores the specialized care that is warranted in higher risk patients to prevent a continued increase in INR and subsequent toxicities. We hope our results would be hypothesis-generating and aid in the development of larger, prospective evaluations to validate the findings of our present study.

Decentralization and Virtualization of INR-based Anticoagulation Control During the COVID-19 Pandemic

OBJECTIVE

To investigate the effectiveness of the decentralization and virtualization of anticoagulation clinics just before and during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

We conducted a cohort study investigation at Prince Sultan Cardiac Clinics PSCC Qassim region, Saudi Arabia. To evaluate the effectiveness of the virtual coagulation clinic, we calculated the time in therapeutic range (TTR), Morisky score for adherence, and satisfaction. Demographics of the patients were analyzed to group patients based on their regions or districts to facilitate the visits. Thirteen different PHCs/Hospitals were allocated for decentralization based on patient density in that region. Intensive courses were provided for all general practitioners (GPs) regarding warfarin anticoagulation and point of care testing (POCT) using iSTAT. All appointments were scheduled by WhatsApp, with no more actual visits to the main center.

RESULTS

Among the included participants (n = 5616), 61.1% were females, 38.9% were males, and the mean age was 60.5 (18-85) years. The total number of clinic visits was 7303 per month, with an average of 1.3 visits per patient. Approximately 95% of the participants had a valvular indication to receive anticoagulation; of them, 55% underwent mitral valve replacement. Moreover, after the virtualization of the INR clinic, keeping INR levels within a therapeutic range was reported in 80% of patients. Regarding patient satisfaction, 90% of the total population was satisfied by the new experience.

CONCLUSION

Decentralization and virtualization of the INR clinic have similar TTR results if conducted properly.

Drive-up INR testing and phone-based consultations service during COVID-19 pandemic in a pharmacist-lead anticoagulation clinic in Qatar: Monitoring, clinical, resource utilization, and patient- oriented outcomes

Background

Coronavirus disease 2019 (COVID‐19) pandemic has resulted in unprecedented pressure on healthcare systems and led to widespread utilization of telemedicine or telehealth services. Combined with teleclinics, using drive‐up fingerstick International normalized ratio (INR) testing was recommended to decrease exposure risk of anticoagulation patients.

Objective

To evaluate the impact of transitioning from clinic‐based anticoagulation management services to drive‐up and phone‐based services during COVID‐19 pandemic in Qatar.

Methods

The study comprised of two components: a retrospective cohort study of all eligible patients who attended anticoagulation clinic over 1‐year period (6 months before and 6 months after service transition) and a cross‐sectional survey of eligible patients who agreed to provide data about their satisfaction with the new service. Monitoring parameters, clinical outcomes, and resource utilization related to warfarin therapy were compared before and after service transition. Patients' experience was explored through a structured survey.

Results

There was no statistically significant difference between clinic‐based and phone‐based anticoagulation services in mean time and number of visits within therapeutic range (P = .67; P = .06 respectively); mean number of extreme subtherapeutic and supratherapeutic INR values (P = .32 and P = .34, respectively); incidence of thromboembolic complications and warfarin related hospitalization. There was one reported bleeding and one emergency visit (0.9%) in the phone‐based group vs none in the clinic‐based group. Frequency of INR testing and compliance to attending clinics appointments declined significantly (P = .002; P = .001, respectively). Overall, patients were highly satisfied with the new service. The majority of patients found it better (51.6%) or just as good as the traditional service (44.5%). Patients who preferred the new service were significantly younger than their counterparts (P = .005).

Conclusion

The service of drive‐up INR testing and phone‐based consultations was shown to be comparable to traditional anticoagulation service, a finding that supports maintaining such services as part of the new normal after the pandemic is over.

Effectiveness of Telepharmacy Versus Face-to-Face Anticoagulation Services in the Ambulatory Care Setting: A Systematic Review and Meta-analysis

BACKGROUND

Effectiveness of anticoagulation services managed via telepharmacy (TP) has not been clearly demonstrated.

OBJECTIVE

This systematic review and meta-analysis compares the effectiveness of TP anticoagulation services to face-to-face (FTF) anticoagulation services in the ambulatory care setting.

METHODS

A literature search for studies assessing the effectiveness of TP services was conducted using PubMed, EMBASE, and Cochrane Central databases, from inception through November 18, 2020. Studies that compared TP with FTF anticoagulation services in the ambulatory care setting were included. Outcomes of interest included thromboembolic events, major bleeding, minor bleeding, any bleeding, warfarin international normalized ratio (INR) time in therapeutic range (TTR), frequency of extreme INR, anticoagulation-related emergency department visits, anticoagulation-related hospitalization, any hospitalization, and mortality. Relative risk (RR) and weighted mean difference were calculated using the DerSimonian and Laird random-effects model.

RESULTS

Overall, 11 studies involving 8395 patients were included in the systematic review, and 9 studies were included in the pooled meta-analysis. Compared with FTF service, TP was associated with a lower risk of any bleeding and any hospitalization, with RRs of 0.65 (95% CI = 0.47 to 0.90; P = 0.01) and 0.59 (95% CI = 0.39 to 0.87; P = 0.01), respectively. There was no statistically significant difference in TTR or the risk of extreme supratherapeutic INR, major bleeding, minor bleeding, or thromboembolic events between the 2 groups.

CONCLUSIONS

TP appears to be at least as effective as FTF anticoagulation services. Findings from this study support the utilization of TP practice models in ambulatory care anticoagulation management.

Comparative effects of telemedicine and face-to-face warfarin management: A systematic review and network meta-analysis

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.

Clinical Outcomes of Telephone Service for Patients on Warfarin: A Systematic Review and Meta-Analysis

Objective: To evaluate clinical outcomes of telephone-based service for patients on warfarin. Methods: Five bibliographic databases and gray literature were searched for articles that reported the effects of telephone interventions provided to patients using warfarin compared with those receiving usual clinic-based care. Mean difference (MD) and relative risk (RR) were used to calculate the effects of telephone intervention on time in therapeutic range (TTR) and visit in range (VIR), respectively. Adverse events (AEs) were pooled and reported as incidence rate ratios. Results: A total of 1,840 articles were examined. Eight articles involving 8,087 subjects were included in the quantitative synthesis. The pooled estimates from seven studies showed no difference on TTR between the telephone service group and the usual care group (MD 2.30; 95% confidence interval [CI] -3.56 to 8.16). In addition, VIR in the telephone service group was not different from the usual care group (RR 1.22, 95% CI 0.87-1.71). Moreover, patients in telephone service groups appeared to have a lower incidence of AEs compared with usual care groups. Discussion: Telephone-based service could be considered as an alternative anticoagulant management. However, owing to a lack of evidence from well-designed studies, further high-quality randomized control trials are warranted.

Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: a randomised controlled trial

OBJECTIVES

This study was designed to evaluate the impact of a pharmacist-led anticoagulation service on international normalised ratio (INR) control and other outcomes among patients receiving warfarin therapy at a tertiary hospital in Zhuhai, China.

METHODS

In this randomised controlled trial, adult patients who were newly initiated on warfarin with intended treatment duration of at least 3 months were recruited. Participants were randomly allocated to receive the pharmacist-led education and follow-up service (PEFS) or usual care (UC). Anticoagulation control was calculated as the proportions of time within the target INR range (TTR) and time within the expanded target range (TER).

KEY FINDINGS

A total of 152 participants (77 in the PEFS group and 75 in the UC group) were included. Within 180 days after hospital discharge, the PEFS group spent more TER than the UC group (54.4% versus 42.0%; P = 0.024), whereas the difference in TTR did not reach statistical significance (35.9% versus 29.5%; P = 0.203). No major bleeding events were observed, and the cumulative incidences of major thromboembolic events (6.5% versus 9.3%) and mortality (1.3% versus 1.3%) were similar between the two groups (P> 0.05). At 30 days postdischarge, the PEFS group had better warfarin knowledge by answering 57.5% of questions correctly, compared with the UC group (43.0%) (P = 0.003).

CONCLUSIONS

The PEFS markedly enhanced anticoagulation control and warfarin knowledge but there was room for improvement. The expansion of pharmacists' clinical role and the development of more effective education and follow-up strategies are warranted to optimise anticoagulation management services in China.

Patient-focused interventions to support vulnerable people using oral anticoagulants: a narrative review

The aim of this review was to identify patient-focused interventions that have been trialed to support vulnerable patient populations taking oral anticoagulants (warfarin and the direct-acting oral anticoagulants (DOACs)) such as older persons (65 years and over), those with limited health literacy, and those from culturally and linguistically diverse (CALD) backgrounds. This review also aimed to report on the effects of these interventions on outcomes relevant to the use of anticoagulant therapy. Original articles published between 1 January 1995 and 30 June 2017 were identified using several electronic databases such as Medline, Ovid, Embase, Scopus, Cochrane, and Google Scholar. The following terms were used for the three-tiered search: Tier 1, elderly, aged, older adult, geriatrics; Tier 2, health literacy, literacy, low health literacy, low English proficiency, patient literacy; and Tier 3, ethnicity, ethnic, ethnic groups, CALD, culturally and linguistically diverse, NESB, non-English speaking background, race, racial groups, religion, religious groups, and minority groups. The terms for each tier were combined with the following terms: anticoagulants, anticoagulation, warfarin, apixaban, dabigatran, rivaroxaban, DOACS, new oral anticoagulants, novel oral anticoagulants, patient care, patient knowledge, comprehension, patient education, patient participation, and communication. A total of 41 studies were identified. Most of the interventions identified included older persons taking warfarin who were monitored using the international normalized ratio (INR) and who received patient education. Many interventions reported a significant positive impact on patients' knowledge, reduction in the number of adverse events caused by hemorrhage, and better INR control. More research on patient-focused interventions is needed that includes patients with limited health literacy, those from CALD backgrounds, and family members and caregivers of patients taking oral anticoagulants.

The effect of online versus hospital warfarin management on patient outcomes: a systematic review and meta-analysis

Background Patients using oral anticoagulants are prone both to thrombus from insufficient anticoagulant therapy and to bleeding by overmedication, so there is a need for further exploring. Aim of the review To assess the effect of online management (using electronic communication such as smartphone), and hospital management on the outcome of patients on long-term anticoagulant therapy, and to explore an appropriate anticoagulation management model. Method Studies published in English prior to July 2017 were retrieved from PubMed, EMBASE, Web of Science, and the Cochrane Library. Two researchers screened the literature independently, extracted the data and evaluated the methodological quality of the included studies. Meta-analysis was conducted using RevMan 5.3 software. The publication bias analysis was evaluated. Results A total of ten studies met the inclusion criteria, covering 16,915 patients. Of these, 8260 cases formed the online anticoagulation management group, and the other 8655 cases the hospital anticoagulant management group. There were no significant differences between the management models for time in therapeutic range, incidence of major or minor bleeding events, thromboembolic events, or warfarin-related emergency department visits. However, online management was associated with fewer warfarin-related hospital admissions than hospital management (odds ratio: 0.47, 95% confidence interval [0.30, 0.73]; P = 0.0009). Conclusion The online management of anticoagulant therapy was not inferior to hospital management, and may provide more convenient, higher quality anticoagulant therapy services for patients.

INR Control of Patients with Mechanical Heart Valve on Long-Term Warfarin Therapy

BACKGROUND

Warfarin is an anticoagulant indicated for patients who had undergone mechanical heart valve(s) replacement (MHVR). In these patients, time in therapeutic range (TTR) is important in predicting the bleeding and thrombotic risks.

OBJECTIVE

This study aimed to describe the anticoagulation control of warfarin using TTR in patients with MHVR in a tertiary health care referral Center.

METHODS

Data were collected retrospectively by reviewing clinical notes of outpatients who attended international normalized ratio (INR) clinics in November 2015. Patients who had MHVR and who took warfarin were included. The data collected were demographics, relevant laboratory investigations, and patients' prior medical history. TTR was calculated using Rosendaal and traditional methods.

RESULTS

A total of 103 patients with MHVR were recruited. The mean age was 51.72 ± 13.97 years and 46.6% were male. A total of 54.4% had mitral valve replacement (MVR), whereas 26.2% had aortic valve replacement (AVR). The mean TTR calculated using the Rosendaal method was 57.1%. There was no significant difference among patients with AVR, MVR, and both valves (AMVR) in terms of TTR (AVR vs. MVR vs. AMVR, 62.94 ± 23.08, 54.12 ± 21.62, 57.63 ± 17.47; p = 0.213). The average dose of warfarin for all groups was approximately 3 mg/day. Moreover, MVR, AVR, and AMVR patients who had TTR (Rosendaal method) ≤60% were 58.9%, 37.0%, and 45.0%, respectively. Only 4.8% had minor bleeding, whereas none had stroke in the period of TTR determination.

CONCLUSIONS

Despite a majority of patients having <60% TTR, there were low incidences of bleeding and stroke events in this center. There were no factors found to be associated with INR control in this study.

Do telehealth interventions improve oral anticoagulation management? A systematic review and meta-analysis

The benefits and harms of telehealth interventions compared to usual care for oral anticoagulation management are unclear. A systematic review and meta-analysis was conducted to assess their impact on clinically important outcomes. A search was conducted through MEDLINE, EMBASE and CENTRAL databases, and the retrieved citations were independently screened and extracted by two review authors. Cochrane Collaboration-recommended tools were used to assess for risk of bias. Co-primary outcomes were major bleeding and major thromboembolic events. Of 2145 retrieved citations, 7 were included for qualitative synthesis (1 randomized controlled trial, 1 prospective cohort and 5 retrospective cohorts). None addressed direct oral anticoagulants. Telehealth interventions were mainly consisted of telephone visits by clinicians, pharmacists and specialists. Meta-analysis of 3 studies (n = 6955) showed significant improvements in the telehealth group for major thromboembolic events (RR 0.43, 95% CI 0.25-0.74, p = 0.002), but no significant difference for major bleeding events (RR 0.83, 95% CI 0.52-1.33, p = 0.44). There was no significant difference in any of the secondary outcomes. The overall GRADE quality of evidence was rated very low due to high risk of bias and low precision. Based on very low quality evidence, telehealth interventions may lower the risk of major thromboembolic events, but not other clinically important outcomes. A high quality study is likely to strongly influence these results. High quality randomized trials are recommended to better assess the benefits and harms of telehealth interventions for anticoagulation management.

Clinical Outcomes of Telemonitoring for Patients on Warfarin after Discharge from Hospital

OBJECTIVE

To evaluate the impact of telephone follow-up service on clinical outcomes in patients on warfarin when discharged from hospital.

METHODS

This randomized controlled trial was conducted at a general hospital in Thailand. Patients aged ≥20 years who were prescribed warfarin when discharged were eligible to participate in this study. They were randomly allocated, using a computer generated random number, to receive either telephone follow-up intervention or usual care. Participants in the intervention group received telephone follow-up by hospital pharmacists for three months. During each telephone call, pharmacists performed medicine use reviews and addressed any problems identified.

KEY FINDINGS

A total of 50 patients participated in this study. The proportion of international normalized ratio (INR) values in the target range for the telephone follow-up group (36/79, 45.6%) was higher than that in the usual care group (19/79, 24.1%), p=0.005. The mean time in the therapeutic range (TTR) in the telephone follow-up group was also higher than that in the usual care group (49.8±34.3 versus 28.0±27.5, p=0.017). All patients in the usual care group experienced one or more out-of-range INR values (25/25, 100%) compared to 21 out of 25 (84%) in the telephone follow-up group, p=0.037. There was no difference between the two groups in the incidence of complications or adverse events associated with warfarin.

CONCLUSIONS

The telephone follow-up service in recently discharged patients helps them achieve and maintain their INR target. This anticoagulant supportive service should be promoted to patients receiving warfarin therapy after discharge. This trial is registered with TCTR20180614006 (Thai Clinical Trials Registry).

Outcomes of warfarin therapy managed by pharmacists via hospital anticoagulation clinic versus online anticoagulation clinic

Background In response to the recognized difficulty in the management of patients on anticoagulation therapy, anticoagulation management services were developed in both hospital anticoagulation clinics (HACs) and an online anticoagulation clinic (OAC) by a pharmacist. Objective To compare monitoring outcomes and complications of warfarin therapy managed by pharmacists via hospital or on-line. Setting The anticoagulation clinic of Fujian Medical University Union Hospital, China. Method A retrospective, observational cohort study was used to compare patients managed via hospital  to those managed o-line between December 2015 and 2016. The primary outcome was the percentage of time in the therapeutic range (TTR). The secondary outcomes were the incidence rates of hemorrhagic events, thrombotic events and extreme international normalized ratio (INR) values. Results A total of 152 patients were evaluated; 70 patients managed in a HAC were compared to 82 patients managed via an OAC. There were no significant differences in the TTR (78.9 vs. 74.0%, P = 0.393) and adverse events [major bleeding events (0 vs. 1.2%, P = 1.000), minor bleeding events (10.0 vs. 9.8%, P = 0.960), thromboembolic events (0 vs. 0%, P = 1.000), warfarin-related emergency visits (2.9 vs. 3.7%, P = 1.000)], warfarin-related hospital admissions (0 vs. 1.2%, P = 1.000), and the incidence of subtherapeutic (3.0 vs. 3.8%, P = 0.148), and extreme total (8.4 vs. 5.8%, P = 0.135), between the groups managed via HAC and OAC. Patients managed in the HAC were more stable on warfarin, with a higher percentage of INR values within the target therapeutic range (80.2 vs. 71.9%, P = 0.005) and a lower incidence of supratherapeutic INR values (8.4 vs. 18.5%, P = 0.001) compared to patients managed via OAC. Conclusion The management of oral anticoagulation therapy on-line yielded similar clinical outcomes compared to that achieved by management via the hospital, although the incidence of supra-therapeutic INR values was increased.

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.

Clinical and Financial Outcomes Evaluation of Multimodal Pharmacist Warfarin Management of a Statewide Urban and Rural Population

PURPOSE

To evaluate the efficacy, safety, and indirect financial outcomes of pharmacist face-to-face warfarin management with telephone-based distance management utilizing local laboratories or patient self-testing (PST).

METHODS

A retrospective analysis of a clinic population of 336 patients on established warfarin therapy distributed statewide in rural and urban settings over a 6-month period was conducted. Participants were stratified into face-to-face management, telephone-based management utilizing local laboratory testing, and telephone-based management utilizing PST.

RESULTS

The primary outcome of international normalized ratio (INR) time in therapeutic range (TTR) for face-to-face management was significantly greater than distance management utilizing local laboratory testing (69.0% vs 60.5%, P = .0032). No difference was observed between face-to-face management and PST (69.0% vs 68.0%, P = .25). No significant difference in bleeding or thromboses was observed. Although increased clinician time was utilized during face-to-face encounters compared to telephone encounters (8.7-minute face-to-face, 5.5-minute local laboratory, and 5.4-minute PST), face-to-face encounters tended to be billable at lower levels, whereas telephone-based encounters were billable at higher levels.

CONCLUSION

A multimodal approach to pharmacist warfarin management of a patient population distributed statewide in rural and urban locations is effective despite TTR differences associated with INR testing used in distance management. PST may improve warfarin treatment outcomes and adherence in distance management, particularly when the use of alternative oral anticoagulants is inappropriate. Although time and billing differences between face-to-face and distance management exist, clinical and safety outcomes remain acceptable despite encounter complexity and support reimbursement of pharmacist anticoagulation management in all settings.

Transition of stable patients from traditional anticoagulation clinic services to telephonic management

Background Outpatient warfarin dosing and monitoring with telephonic anticoagulation management (TAM) could be an effective alternative to other more labor intensive management models. Objectives To evaluate the time in therapeutic range (TTR) and number of extreme INR values (<1.5 or >4.5) of a telephonic system of warfarin management for stable patients who currently utilized traditional anticoagulation management services (AMSs). Method A retrospective, observational cohort with three groups (1) patients transitioned from an office-based anticoagulation clinic to TAM, (2) patients continuously enrolled in office-based AMS, (3) patients continuously managed by usual physician care without specialized anticoagulation services (UPC). Data was collected for six months before and six months after transition. Results All groups demonstrated decreased TTR from baseline to active phase, with the TAM and AMS groups showing similar magnitude of reduction (-10.61 and -12.66% respectively) but UPC group producing a greater drop (-20.08%). The TAM and AMS groups had similar rates of extreme INR levels; UPC had higher numbers of extreme INRs in three of the four measurements. Conclusion Stable patients transitioned from office-based anticoagulation clinic to a telephonic model of management performed equally as well as those who continued traditional enrollment.

Evaluation of Time in Therapeutic Range on Warfarin Therapy Between Face-to-Face and Telephone Follow-Up in a VA Medical Center

Background: Few studies have evaluated percent time in therapeutic range (TTR) for warfarin managed via face-to-face (FF) to telephone (TELE) visits-all finding no difference between groups. Objective: Compare and evaluate TTR for warfarin in patients who received pharmacist-managed care via FF or TELE. Methods: Single-center, retrospective study. Eligible participants were ≥18 years old, on indefinite warfarin therapy, followed by clinical pharmacists via FF or TELE from 2010 to 2012. Primary outcome (TTR) calculated via Rosendaal method. Event data included rates of any bleeding, significant bleeding, deep vein thrombosis, pulmonary embolism, cerebrovascular accident, hospitalizations, and death. Clinics were also compared by location. Results: Two hundred subjects (90 FF and 110 TELE) were included. Mean TTR was 68.17% and 69.57% in FF and TELE groups, respectively. The FF group had statistically significant higher rates of any bleeding (48.9% vs 30.9%). Rates of significant bleeding in FF versus TELE were not significantly different (6.67% vs 2.73%). The majority followed FF with significant bleeding were at a higher bleeding risk than those followed via TELE. There were low rates of venous thromboembolism (1.1% and 1.8%). Conclusions: TTR was ≥65% for most subjects with minimal variability in TTR between clinics. Mean TTR results for each group were greater and above the threshold that has been commonly described in the literature as quality control, suggesting a progression in implementation of telephone-based anticoagulation management.

Anticoagulation clinic versus a traditional warfarin management model

Warfarin is the most commonly prescribed oral anticoagulant. The management of warfarin is challenging, and current guidelines fail to include a model to assist practitioners in optimizing therapeutic dosing. The traditional model and the anticoagulation clinic (AC) model of warfarin management were compared and results found the AC model optimum.

Educational protocol for patients on oral anticoagulant therapy: construction and validation

This is a report of experience on the construction and validation of an educational protocol for patients on oral anticoagulation therapy. Based on Bandura's Social Cognitive Theory, three phases were identified to construct the educational protocol. The literature review on oral anticoagulants was used to prepare the content of each phase of the protocol. As a result, verbal and written orientation in the phases of attention and retention were developed. In the reproduction and motivation phase, support through contact by telephone was provided. And finally, an improvement in the evaluation of the outcomes related to oral anticoagulant is expected in the performance phase. Once the educational protocol was defined, we proceeded with the face and content validity process, which allowed adaptations to the final version of the educational protocol constructed.

Telephone-based anticoagulation management in the homebound setting: a retrospective observational study

Background

Anticoagulation management is currently performed through anticoagulation clinics or self-managed with or without the help of medical services. Homebound patients are a unique population that cannot utilize anticoagulation clinics or self-testing. Telephone-based anticoagulation management could be an alternative to the traditional methods of monitoring warfarin in this subgroup. The objective of this retrospective, observational study is to investigate the feasibility of warfarin management in homebound patients.

Methods

This study was performed through the use of telephone-based adjustments of warfarin dose based on an international normalized ratio (INR) result. Four hundred forty-eight homebound patients referred to the anticoagulation clinic at Staten Island University Hospital were visited at home by a phlebotomist; a blood sample was drawn for initial laboratory testing. A nurse practitioner then called the patient or designated person to relay the INR result and to direct dosage adjustment. INR results and dosage changes were entered into an electronic medical record and analyzed statistically.

Results

The mean percentage of INR values in range was 58.39%. The mean time when the INR was in the therapeutic range was 62.75%. The percent of patients who were therapeutically controlled decreased as the number of medications increased. The complication rate was 4% per patient year, with an equal distribution between bleeding and clotting. These values compared favorably to other studies in which monitoring was performed through anticoagulation clinics or self-monitoring. The cost per visit at our anticoagulation clinic was found to be approximately $300 compared with $82 when utilizing our homebound service.

Conclusion

Telephone-based management of warfarin therapy in the homebound setting is feasible. It can lower the cost of health care expenditures compared to other modalities of anticoagulation management.

Adherence and outcomes of patients treated with dabigatran: pharmacist-managed anticoagulation clinic versus usual care

PURPOSE

The results of a study to determine whether pharmacist monitoring in the crucial first months of dabigatran therapy in patients with atrial fibrillation or flutter can help optimize adherence and stroke-prevention outcomes are presented.

METHODS

A retrospective preimplementation-postimplementation study was conducted at a Veterans Affairs (VA) hospital to evaluate dabigatran adherence and treatment outcomes in a group of patients whose therapy was monitored by anticoagulation clinic (ACC) pharmacists (n = 20) and a historical comparison group (n = 48) that received usual care (UC). The primary endpoint was the medication possession ratio (MPR) averaged across each group over three months (acceptable adherence was defined as an MPR of ≥80%); three secondary endpoints (dabigatran-related bleeding and incident stroke and venous thromboembolism) were evaluated.

RESULTS

Relative to the UC group, ACC-monitored patients were significantly more likely to have undergone recommended baseline laboratory tests before dabigatran initiation (p = 0.02). ACC patients were also more likely to have MPR values of ≥80% at the end of the three-month follow-up period (25% of patients versus 10% of patients), although the difference was not statistically significant; the mean MPR values in the ACC-monitored and UC groups were 93.1% and 88.3%, respectively. Aside from one episode of major gastrointestinal bleeding, none of the evaluated adverse outcomes occurred in either group.

CONCLUSION

VA patients treated with dabigatran for nonvalvular atrial fibrillation or flutter and followed by a pharmacist-managed ACC did not differ significantly from similar patients receiving UC in the proportion adherent with dabigatran therapy or in the frequency of minor or major bleeding episodes. Thromboembolic events and strokes were absent in both groups.

Penny-wise, pound-foolish? Highmark Medicare Services' proposal for anticoagulation clinic reimbursement

Warfarin is prescribed to millions of Americans for the management of thromboembolism and is a common cause of adverse events. Optimizing warfarin therapy has been the focus of national quality improvement initiatives. Anticoagulation clinics have been demonstrated to result in better outcomes than usual care. Nevertheless, Highmark Medicare Services recently issued a provider bulletin on anticoagulation clinic visit reimbursement that we believe will adversely affect the care for patients on anticoagulation. In this commentary, we review the potential unintended consequences of this proposal and offer alternatives that we believe will increase the efficiency and quality of anticoagulation management.

Evaluation of a Pharmacist-Managed Telephone Lipid Clinic at a Veterans Affairs Medical Center

BACKGROUND

Heart disease is one of the leading causes of death and disability in the US, with dyslipidemia being a significant risk factor. Pharmacist-managed lipid clinics have been shown to be effective in lowering low-density lipoprotein cholesterol (LDL-C) values in the veteran population. In addition, telephone-managed clinics are known to be an effective method to manage anticoagulation therapy. This type of appointment is very convenient; it reduces travel and waiting times, costs, and potential no-show rates.

OBJECTIVE

To assess changes in LDL-C levels from baseline to follow-up and number of patients attaining LDL-C goals during enrollment in the pharmacist-managed telephone lipid clinic (PMTLC).

METHODS

A retrospective chart review was conducted on all patients enrolled in the clinic who had follow-up laboratory data available. Baseline LDL-C values were compared with values obtained at follow-up. Patients' total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and triglyceride (TG) values were also collected and analyzed for improvement. The agents used, number of antidyslipidemic medications, and the incidence of adverse drug reactions prior to and during clinic enrollment were also collected.

RESULTS

Patients in the PMTLC had a mean ± SD reduction in LDL-C of 44.3 ± 45.2 mg/dL (p < 0.001). In addition, 10 (28%) patients achieved the LDL-C goal (p = 0.002). Mean reductions in TC and TG levels were 44 mg/dL (18%) and 14.6 mg/dL (8%), respectively. There was no significant change in HDL-C levels.

CONCLUSIONS

The PMTLC at the Erie, PA, Veterans Affairs Medical Center demonstrated statistically significant reduction in patients' LDL-C levels and increase in the number of patients attaining LDL-C goal.

Adherence to a new oral anticoagulant treatment prescription: dabigatran etexilate

The recent development of new oral anticoagulants, of which dabigatran etexilate is currently at the most advanced stage of development, is the greatest advance in the provision of convenient anticoagulation therapy for many years. A new oral anticoagulation treatment, dabigatran etexilate, is already on the market in Europe. The main interest probably will be to improve the prescription and the adherence to an effective thromboprophylaxis in medical conditions such as atrial fibrillation without bleeding side effects, without the need for monitoring coagulation, and without drug and food interactions such as vitamin K anticoagulant (VKA) treatment. Dabigatran is particularly interesting for extended thromboprophylaxis after major orthopedic surgery in order to avoid daily injection for a month. However, oral long-term treatments such as VKA are not systematically associated with a higher compliance level than injected treatments such as low-molecular-weight heparins. Indeed, adherence to an oral treatment, instead of the usual daily injection in major orthopedic surgery, is complex, and based not only on the frequency of dosing but also on patient motivation, understanding, and socio-economic status. New oral anticoagulants may be useful in this way but education and detection of risk factors of nonadherence to treatment are still essential.

Evaluation of a telemedicine-based service for the follow-up and monitoring of patients treated with oral anticoagulant therapy

The authors have designed and developed a telemedicine-based service for the follow-up and monitoring of patients on oral anticoagulant therapy (OAT) that consists of two phases; the first involving self-testing and the second involving guided self-management. To evaluate the first phase of the protocol, a project was conducted with 108 patients, with a mean age of 72.7 years and a mean treatment time at the start of the study of 55.2 months, divided into two groups: telemedicine and control (conventional procedure). The degree of anticoagulation control was similar in the two groups: individual in-range international normalized ratios (59.2% vs 61.1%; p = 0.55) and individual time within target range (65.7% vs 66.4%; p = 0.85) showed no significant differences. The incidence of adverse events--death (5.5% vs 5.5%; p = 1.0), major hemorrhagic complications (0% vs 1.8%; p = 1.0), minor hemorrhagic complications (7.4% vs 3.7%; p = 0.67), and thromboembolism (1.8% vs 3.7%; p = 1.0)--was also similar, with no significant differences. Acceptability of the change, measured in terms of quality of life (SF-12 and Sawicki questionnaires) and anxiety (state-trait anxiety inventory questionnaire) at the beginning and end of the study period was higher in the telemedicine group, with statistically significant improvements in mental component summary (3.6 vs -6.2; p = 0.02), dissatisfaction (-0.8 vs 0.2; p = 0.001), stress (-0.3 vs 0.05; p = 0.03), limitations (-0.2 vs 0.3; p = 0.005), social problems (-0.1 vs 0.3; p = 0.03), and state anxiety (-2.5 vs 2.3; p = 0.04). Parameters related to costs, such as the mean number per patient of office visits due to OAT (1.7 vs 13.8; p << 0.001) and other office visits (10.1 vs 11.5; p = 0.028), were also more favorable in the telemedicine group, as were additional parameters that enabled an exhaustive evaluation of the service. The positive results obtained indicate that the second phase of the trial can be initiated.

Evaluation of INR Monitoring Frequency and Time in Therapeutic Range

Background:

Although anticoagulant therapy has been used for more than 50 years, the optimal interval between international normalized ratio (INR) measurements in patients who demonstrate a stable dose response remains unsettled. Based on the results of observational studies, the American College of Chest Physicians currently recommends that patients receiving a stable dose of warfarin undergo INR testing at least once every 4 weeks.1

Objective:

To determine whether an increased frequency of INR monitoring impacts time in therapeutic range (TTR) among patients receiving maintenance warfarin therapy managed by an anticoagulation clinic.

Methods:

A total of 2,222 INR results belonging to more than 700 adults who were followed by the anticoagulation service at the University of Pittsburgh Medical Center and who were receiving maintenance warfarin therapy between April 1, 2006, and September 30, 2006, were retrospectively reviewed. INR measurements were categorized as having been determined fewer than 21 days or 21 or more days after the previous measurement, and the percentage of INRs within the therapeutic range was calculated for each interval.

Results:

During the evaluation period, INRs measured within 21 days of the preceding test were within the therapeutic range 75.1% of the time, whereas INRs obtained at least 21 days after the antecedent INR test were within the therapeutic range 79.9% of the time (p < 0.001). Additionally, the proportion of INRs below 1.5 or above 5.0 was not significantly different between the 2 groups, representing only 0.04% of all results at either interval (p > 0.05).

Conclusions:

Our evaluation suggests that more frequent INR monitoring among patients receiving maintenance warfarin does not impact TTR to a clinically meaningful extent. Moreover, these findings support the reevaluation of the anticoagulation service management algorithm to reduce the frequency of INR measurements among patients within the maintenance phase of therapy.

Laboratory clinical effectiveness: pathologists improving clinical outcomes

This article calls on pathologists to take a larger role in improving the performance of the American health care system. To improve outcomes for populations and individuals require that pathologists increase their activities outside of the traditional laboratory in interdisciplinary collaborations, outcomes research, health care systems development, and clinical care.

Effect of electrical stimulus parameters on the development and propagation of action potentials in short excitable fibres

Intracellular action potentials (IAPs) produced by short fibres in response to their electrical stimulation were analysed. IAPs were calculated on the basis of the Hodgkin-Huxley (1952) model by the method described by Joyner et al. (1978). Principal differences were found in processes of activation of short (semilength L less than 5 lambda) and long fibres under near-threshold stimulation. The shorter the fibre, the lower was the threshold value (Ithr). Dependence of the latency on the stimulus strength (Ist) was substantially non-linear and was affected by the fibre length. Both fibre length and stimulus strength influenced the IAP amplitude, the instantaneous propagation velocity (IPV) and the site of the first origin of the IAP (and, consequently, excitability of the short fibre membrane). With L less than or equal to 2 lambda and Ithr less than or equal to Ist less than or equal to 1.1Ithr, IPV could reach either very high values (so that all the fibre membrane fired practically simultaneously) or even negative values. The latter corresponded to the first origin of the propagated IAP, not at the site of stimulation but at the fibre termination or at a midpoint. The characters of all the above dependencies were unchanged irrespective of the manner of approaching threshold (variation of stimulus duration or its strength). Reasons for differences in processes of activation of short and long fibres are discussed in terms of electrical load and latency. Applications of the results to explain an increased jitter, velocity recovery function and velocity-diameter relationship are also discussed.