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Kukafka R, Gupta A, Gilbert C, Huggins CE, Browning C, Chapman W, Haines T, Peeters A. Virtual Care Initiatives for Older Adults in Australia: Scoping Review. J Med Internet Res 2023; 25:e38081. [PMID: 36652291 PMCID: PMC9892987 DOI: 10.2196/38081] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/03/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND There has been a rapid shift toward the adoption of virtual health care services in Australia. It is unknown how widely virtual care has been implemented or evaluated for the care of older adults in Australia. OBJECTIVE We aimed to review the literature evaluating virtual care initiatives for older adults across a wide range of health conditions and modalities and identify key challenges and opportunities for wider adoption at both patient and system levels in Australia. METHODS A scoping review of the literature was conducted. We searched MEDLINE, Embase, PsycINFO, CINAHL, AgeLine, and gray literature (January 1, 2011, to March 8, 2021) to identify virtual care initiatives for older Australians (aged ≥65 years). The results were reported according to the World Health Organization's digital health evaluation framework. RESULTS Among the 6296 documents in the search results, we identified 94 that reported 80 unique virtual care initiatives. Most (69/80, 89%) were at the pilot stage and targeted community-dwelling older adults (64/79, 81%) with chronic diseases (52/80, 65%). The modes of delivery included videoconference, telephone, apps, device or monitoring systems, and web-based technologies. Most initiatives showed either similar or better health and behavioral outcomes compared with in-person care. The key barriers for wider adoption were physical, cognitive, or sensory impairment in older adults and staffing issues, legislative issues, and a lack of motivation among providers. CONCLUSIONS Virtual care is a viable model of care to address a wide range of health conditions among older adults in Australia. More embedded and integrative evaluations are needed to ensure that virtually enabled care can be used more widely by older Australians and health care providers.
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Affiliation(s)
| | - Adyya Gupta
- Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Cecily Gilbert
- Centre for Digital Transformation of Health, University of Melbourne, Melbourne, Australia
| | - Catherine E Huggins
- Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Colette Browning
- Health Innovation and Transformation Centre, Federation University, Ballarat, Australia.,Institute of Health and Wellbeing, Federation University, Ballarat, Australia
| | - Wendy Chapman
- Centre for Digital Transformation of Health, University of Melbourne, Melbourne, Australia
| | - Terry Haines
- National Centre for Healthy Ageing, Monash University, Frankston, Australia.,School of Primary and Allied Health Care, Monash University, Frankston, Australia
| | - Anna Peeters
- Institute for Health Transformation, Deakin University, Geelong, Australia
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Jiang S, Lv M, Wu T, Chen W, Zhang J. A smartphone application for remote adjustment of warfarin dose: Development and usability study. Appl Nurs Res 2022; 63:151521. [PMID: 35034699 DOI: 10.1016/j.apnr.2021.151521] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/17/2021] [Accepted: 10/30/2021] [Indexed: 10/19/2022]
Abstract
AIM The aim of this article is (a) to design and develop a smartphone app called Alfalfa that can provide remote dose adjustment (b) to evaluate its usability. BACKGROUND Patients taking warfarin need to spend substantial time, money, and energy frequently visiting the hospital in order to adjust its dose. Internet technology may be able to provide convenient dose adjustment services for these patients. METHODS We thought and discussed repeatedly about how to ensure the safety and effectiveness of remote administration of warfarin, and finally designed and developed the Alfalfa app. In addition, patients and medical practitioners were invited to participate in a system usability scale (SUS) to assess the usability of Alfalfa. RESULTS As of July 5, 2021, the number of Alfalfa accounts was 1736, including 1624 patients and 112 medical staff, and it provided a total of 12,968 remote dose adjustments. A total of 26 people participated in the questionnaire, including 15 patients and 11 medical staff. The results of SUS show that the usability score of patient terminal and medical terminal is 61.8 and 82.7, respectively. And age does not affect the usability of patient terminal. The usability of the Alfalfa app was rated similarly by younger and older adults (63.5 vs. 58.5, P = .535). CONCLUSIONS This study proves that the Alfalfa app can be used for remote management of warfarin. The usability of medical terminal is acceptable to medical practitioners, while the usability of patient terminal needs further improvement. TRIAL REGISTRATION ChiCTR1900021920.
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Affiliation(s)
- Shaojun Jiang
- Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou 350001, Fujian, China
| | - Meina Lv
- Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou 350001, Fujian, China
| | - Tingting Wu
- Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou 350001, Fujian, China
| | - Wenjun Chen
- Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou 350001, Fujian, China
| | - Jinhua Zhang
- Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou 350001, Fujian, China.
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Zhu Z, Li C, Shen J, Wu K, Li Y, Liu K, Zhang F, Zhang Z, Li Y, Han J, Qin Y, Yang Y, Fan G, Zhang H, Ding Z, Xu D, Chen Y, Zheng Y, Zheng Z, Meng X, Zhang H. New Internet-Based Warfarin Anticoagulation Management Approach After Mechanical Heart Valve Replacement: Prospective, Multicenter, Randomized Controlled Trial. J Med Internet Res 2021; 23:e29529. [PMID: 34397393 PMCID: PMC8398748 DOI: 10.2196/29529] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/13/2021] [Accepted: 07/05/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Mechanical heart valve replacement (MHVR) is an effective method for the treatment of severe heart valve disease; however, it subjects patient to lifelong warfarin therapy after MHVR with the attendant risk of bleeding and thrombosis. Whether internet-based warfarin management reduces complications and improves patient quality of life remains unknown. OBJECTIVE This study aimed to compare the effects of internet-based warfarin management and the conventional approach in patients who received MHVR in order to provide evidence regarding alternative strategies for long-term anticoagulation. METHODS This was a prospective, multicenter, randomized, open-label, controlled clinical trial with a 1-year follow-up. Patients who needed long-term warfarin anticoagulation after MHVR were enrolled and then randomly divided into conventional and internet-based management groups. The percentage of time in the therapeutic range (TTR) was used as the primary outcome, while bleeding, thrombosis, and other events were the secondary outcomes. RESULTS A total of 721 patients were enrolled. The baseline characteristics did not reach statistical differences between the 2 groups, suggesting the random assignment was successful. As a result, the internet-based group showed a significantly higher TTR (mean 0.53, SD 0.24 vs mean 0.46, SD 0.21; P<.001) and fraction of time in the therapeutic range (mean 0.48, SD 0.22 vs mean 0.42, SD 0.19; P<.001) than did those in the conventional group. Furthermore, as expected, the anticoagulation complications, including the bleeding and embolic events had a lower frequency in the internet-based group than in the conventional group (6.94% vs 12.74%; P=.01). Logistic regression showed that internet-based management increased the TTR by 7% (odds ratio [OR] 1.07, 95% CI 1.05-1.09; P<.001) and reduced the bleeding and embolic risk by 6% (OR 0.94, 95% CI 0.92-0.96; P=.01). Moreover, low TTR was found to be a risk factor for bleeding and embolic events (OR 0.87, 95% CI 0.83-0.91; P=.005). CONCLUSIONS The internet-based warfarin management is superior to the conventional method, as it can reduce the anticoagulation complications in patients who receive long-term warfarin anticoagulation after MHVR. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR1800016204; http://www.chictr.org.cn/showproj.aspx?proj=27518. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1136/bmjopen-2019-032949.
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Affiliation(s)
- Zhihui Zhu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Ludwig Maximilian University of Munich, Munich, Germany
| | - Chenyu Li
- Renal Division, Department of Medicine IV, Ludwig Maximilian University of Munich, Munich, Germany
| | - Jinglun Shen
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kaisheng Wu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuehuan Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kun Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fan Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhenhua Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Department of Cardiovascular Surgery, Beijing Luhe Hospital,, Capital Medical University, Beijing, China
| | - Yan Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jie Han
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ying Qin
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yu Yang
- Department of Cardiovascular Surgery, Beijing Xuanwu Hospital, Beijing, China
| | - Guangpu Fan
- Department of Cardiovascular Surgery, Peking University People's Hospital, Beijing, China
| | - Huajun Zhang
- Department of Cardiovascular Surgery, PLA General Hospital, Beijing, China
| | - Zheng Ding
- Department of Pharmacy, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Xu
- Department of Cardiovascular Surgery, Beijing Xuanwu Hospital, Beijing, China
| | - Yu Chen
- Department of Cardiovascular Surgery, Peking University People's Hospital, Beijing, China
| | - Yingli Zheng
- Department of Pharmacy, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhe Zheng
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu Meng
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haibo Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Fontil V, Kazi D, Cherian R, Lee SY, Sarkar U. Evaluation of a Health Information Technology-Enabled Panel Management Platform to Improve Anticoagulation Control in a Low-Income Patient Population: Protocol for a Quasi-Experimental Design. JMIR Res Protoc 2020; 9:e13835. [PMID: 31929105 PMCID: PMC6996764 DOI: 10.2196/13835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/29/2019] [Accepted: 09/04/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Warfarin is one of the most commonly prescribed medications in the United States, and it causes a significant proportion of adverse drug events. Patients taking warfarin fall outside of the recommended therapeutic range 30% of the time, largely because of inadequate laboratory monitoring and dose adjustment. This leads to an increased risk of blood clots or bleeding events. We propose a comparative effectiveness study to examine whether a technology-enabled anticoagulation management program can improve long-term clinical outcomes compared with usual care. OBJECTIVE Our proposed intervention is the implementation of an electronic dashboard (integrated into a preexisting electronic health record) and standardized workflow to track patients' laboratory results, identify patients requiring follow-up, and facilitate the use of a validated nomogram for dose adjustment. The primary outcome of this study is the time in therapeutic range (TTR) at 6 months post intervention (a validated metric of anticoagulation quality among patients receiving warfarin). METHODS We will employ a pre-post quasi-experimental design with a nonequivalent usual-care comparison site and a difference-in-differences approach to compare the effectiveness of a technology-enabled anticoagulation management program compared with usual care at a large university-affiliated safety-net clinic. RESULTS We used a commercially available health information technology (HIT) platform to host a registry of patients on warfarin therapy and create the electronic dashboard for panel management. We developed the intervention with, and for, frontline clinician users, using principles of human-centered design. This study is funded until September 2020 and is approved by the University of California, San Francisco Institutional Review Board until June 22, 2020. We completed data collection in September 2019 and expect to complete our proposed analyses by February 2020. CONCLUSIONS We anticipate that the intervention will increase TTR among patients taking warfarin and that the use of this HIT platform will facilitate tracking and monitoring of patients on warfarin, which could enable outreach to those overdue for visits or laboratory monitoring. We will use these findings to iteratively improve the platform in preparation for a larger, multiple-site, pragmatic clinical trial. If successful, our study will demonstrate the integration of HIT platforms into existing electronic health records to improve patient care in real-world clinical settings. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/13835.
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Affiliation(s)
- Valy Fontil
- Center for Vulnerable Populations, University of California, San Francisco, CA, United States
| | - Dhruv Kazi
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, United States
| | - Roy Cherian
- Center for Vulnerable Populations, University of California, San Francisco, CA, United States
| | - Shin-Yu Lee
- Outpatient Pharmacy, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Urmimala Sarkar
- Center for Vulnerable Populations, University of California, San Francisco, CA, United States
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Zhu Z, Li Y, Meng X, Han J, Li Y, Liu K, Shen J, Qin Y, Zhang H. New warfarin anticoagulation management model after heart valve surgery: rationale and design of a prospective, multicentre, randomised trial to compare an internet-based warfarin anticoagulation management model with the traditional warfarin management model. BMJ Open 2019; 9:e032949. [PMID: 31811010 PMCID: PMC6924837 DOI: 10.1136/bmjopen-2019-032949] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Warfarin is an effective anticoagulant and the only oral anticoagulant available for patients with mechanical heart valves. The prothrombin time and the associated international normalised ratio (INR) are routinely tested to monitor the response to anticoagulation therapy in patients. Patients who undergo mechanical heart valve replacement need lifelong anticoagulation therapy, and their INR is regularly measured to adjust the anticoagulation strength and the dose of anticoagulation drugs. Appropriate warfarin anticoagulation management can reduce patient complications, such as bleeding and thrombosis, and improve the long-term survival rate. We propose modern internet technology as a platform to build a warfarin anticoagulation follow-up system after valve replacement surgery. This system will provide doctors and patients with more standardised and safer follow-up methods as well as a method to further reduce the risk of warfarin anticoagulation-related complications and improve its therapeutic effects. METHODS AND ANALYSIS A prospective, multicentre, randomised, controlled trial will be conducted. A total of 700 patients who require long-term warfarin anticoagulation monitoring after heart valve replacement will be enrolled and randomly divided at a 1:1 ratio into a traditional outpatient anticoagulation management group and a group undergoing a new method of management based on the internet technology with follow-up for 1 year. Differences in the percentage of time in the therapeutic range (TTR), drug dose adjustments, bleeding/thrombosis and other related complications will be observed. The primary endpoint is the difference in the TTR between the two groups. The purpose of this study is to explore a safer and more effective mode of doctor-patient interaction and communication in the internet era. As of 13 July 2019, 534 patients had been enrolled. ETHICS AND DISSEMINATION This study protocol was approved by the Ethics Committee of Beijing Anzhen Hospital, Capital Medical University. The results will be published in a peer-reviewed medical journal. TRIAL REGISTRATION NUMBER ChiCTR1800016204.
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Affiliation(s)
- Zhihui Zhu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuehuan Li
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xu Meng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jie Han
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yan Li
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kun Liu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jinglun Shen
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ying Qin
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haibo Zhang
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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6
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Naderi Haji M, Moghaddasi H, Sharif-Kashani B, Kazemi A, Rahimi F. Characteristics of software used in self-management of vitamin K antagonist therapy: A systematic review. Eur J Cardiovasc Nurs 2019; 18:358-365. [PMID: 30966777 DOI: 10.1177/1474515119843739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND GOAL Currently, 1-2% of the population in developed countries are under treatment with oral anticoagulants. An appropriate strategy to deal with this increase in demand of treatment with oral anticoagulants and to manage the costs is the transfer of part or all of the responsibility for managing treatment to the patients. The use of information technology, particularly electronic health software, can be an appropriate method to improve the quality of self-management of treatment with these drugs. Therefore, this systematic review investigated studies that discuss the characteristics of electronic health software in self-management of oral anticoagulation therapy. METHOD A systematic review based on PRISMA protocol was conducted. In this study, articles were investigated that were in English. Articles existing in Cochrane, EMBASE and PubMed databases were searched up to 14 May 2017. Then, articles searched through Google Scholar were added to this study. FINDINGS The common characteristics used in most software included 'encryption in exchanging information', having an 'instruction module' and 'being Android-based'. In terms of functionality, 'communication between the patient and healthcare team' existed in most of the software. CONCLUSION The results of the study showed that the accuracy of administration of the dose of the drug using computer to reach a target international normalized ratio level was not less than those administered with experienced medical staff. In addition, the results indicated that important characteristics of the software include encryption in exchanging information, instruction module and Android-based instruction module. The most important characteristic was the interaction between the patient and the healthcare team.
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Affiliation(s)
- Mohammadreza Naderi Haji
- 1 Department of Health Information Technology & Management, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Moghaddasi
- 1 Department of Health Information Technology & Management, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Babak Sharif-Kashani
- 2 Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Disease, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Kazemi
- 1 Department of Health Information Technology & Management, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Forugh Rahimi
- 3 Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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8
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Brieger D, Amerena J, Attia J, Bajorek B, Chan KH, Connell C, Freedman B, Ferguson C, Hall T, Haqqani H, Hendriks J, Hespe C, Hung J, Kalman JM, Sanders P, Worthington J, Yan TD, Zwar N. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018. Heart Lung Circ 2019; 27:1209-1266. [PMID: 30077228 DOI: 10.1016/j.hlc.2018.06.1043] [Citation(s) in RCA: 205] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - David Brieger
- Department of Cardiology, Concord Hospital, Sydney, Australia; University of Sydney, Sydney, Australia.
| | - John Amerena
- Geelong Cardiology Research Unit, University Hospital Geelong, Geelong, Australia
| | - John Attia
- University of Newcastle, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Beata Bajorek
- Graduate School of Health, University of Technology Sydney & Department of Pharmacy, Royal North Shore Hospital, Australia
| | - Kim H Chan
- Royal Prince Alfred Hospital, Sydney, Australia; Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Cia Connell
- The National Heart Foundation of Australia, Melbourne, Australia
| | - Ben Freedman
- Sydney Medical School, The University of Sydney, Sydney, Australia; Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Caleb Ferguson
- Western Sydney University, Western Sydney Local Health District, Blacktown Clinical and Research School, Blacktown Hospital, Sydney, Australia
| | | | - Haris Haqqani
- University of Queensland, Department of Cardiology, Prince Charles Hospital, Brisbane, Australia
| | - Jeroen Hendriks
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia; Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Charlotte Hespe
- General Practice and Primary Care Research, School of Medicine, The University of Notre Dame Australia, Sydney, Australia
| | - Joseph Hung
- Medical School, Sir Charles Gairdner Hospital Unit, University of Western Australia, Perth, Australia
| | - Jonathan M Kalman
- University of Melbourne, Director of Heart Rhythm Services, Royal Melbourne Hospital, Melbourne, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - John Worthington
- RPA Comprehensive Stroke Service, Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Nicholas Zwar
- Graduate Medicine, University of Wollongong, Wollongong, Australia
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9
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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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10
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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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11
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Clarkesmith DE, Pattison HM, Khaing PH, Lane DA. Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation. Cochrane Database Syst Rev 2017; 4:CD008600. [PMID: 28378924 PMCID: PMC6478129 DOI: 10.1002/14651858.cd008600.pub3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Current guidelines recommend oral anticoagulation therapy for patients with atrial fibrillation (AF) with one or more risk factors for stroke; however, anticoagulation control (time in therapeutic range (TTR)) with vitamin K antagonists (VKAs) is dependent on many factors. Educational and behavioural interventions may impact patients' ability to maintain their international normalised ratio (INR) control. This is an updated version of the original review first published in 2013. OBJECTIVES To evaluate the effects of educational and behavioural interventions for oral anticoagulation therapy (OAT) on TTR in patients with AF. SEARCH METHODS We updated searches from the previous review by searching the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library (January 2016, Issue 1), MEDLINE Ovid (1949 to February week 1 2016), EMBASE Classic + EMBASE Ovid (1980 to Week 7 2016), PsycINFO Ovid (1806 to Week 1 February 2016) and CINAHL Plus with Full Text EBSCO (1937 to 16/02/2016). We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials evaluating the effect of any educational and behavioural intervention compared with usual care, no intervention, or intervention in combination with other self-management techniques among adults with AF who were eligible for, or currently receiving, OAT. DATA COLLECTION AND ANALYSIS Two of the review authors independently selected studies and extracted data. Risk of bias was assessed using the Cochrane 'Risk of bias' tool. We included outcome data on TTR, decision conflict (patient's uncertainty in making health-related decisions), percentage of INRs in the therapeutic range, major bleeding, stroke and thromboembolic events, patient knowledge, patient satisfaction, quality of life (QoL), beliefs about medication, illness perceptions, and anxiety and depression. We pooled data for three outcomes - TTR, anxiety and depression, and decision conflict - and reported mean differences (MD). Where insufficient data were present to conduct a meta-analysis, we reported effect sizes and confidence intervals (CI) from the included studies. We evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. MAIN RESULTS Eleven trials with a total of 2246 AF patients (ranging from 14 to 712 by study) were included within the review. Studies included education, decision aids, and self-monitoring plus education interventions. The effect of self-monitoring plus education on TTR was uncertain compared with usual care (MD 6.31, 95% CI -5.63 to 18.25, I2 = 0%, 2 trials, 69 participants, very low-quality evidence). We found small but positive effects of education on anxiety (MD -0.62, 95% CI -1.21 to -0.04, I2 = 0%, 2 trials, 587 participants, low-quality evidence) and depression (MD -0.74, 95% CI -1.34 to -0.14, I2 = 0%, 2 trials, 587 participants, low-quality evidence) compared with usual care. The effect of decision aids on decision conflict favoured usual care (MD -0.1, 95% CI -0.17 to -0.02, I2 = 0%, 2 trials, 721 participants, low-quality evidence). AUTHORS' CONCLUSIONS This review demonstrates that there is insufficient evidence to draw definitive conclusions regarding the impact of educational or behavioural interventions on TTR in AF patients receiving OAT. Thus, more trials are needed to examine the impact of interventions on anticoagulation control in AF patients and the mechanisms by which they are successful. It is also important to explore the psychological implications for patients suffering from this long-term chronic condition.
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Affiliation(s)
- Danielle E Clarkesmith
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS TrustDudley RoadBirminghamUKB18 7QH
| | - Helen M Pattison
- Aston UniversitySchool of Life and Health SciencesAston TriangleBirminghamUKB4 7ET
| | - Phyo H Khaing
- University of BirminghamCollege of Medical and Dental Sciences8 Minnesota DriveGreat SankeyBirminghamCheshireUKWA5 3SY
| | - Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS TrustDudley RoadBirminghamUKB18 7QH
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Abstract
This article provides an overview of the current use of point-of-care testing (POCT) and its utility for patients’ self-management of chronic disease states. Pharmacists utilize POCT to provide rapid laboratory diagnostic results as a monitoring tool in the management of their patients and in order to improve medication outcomes. Considerations for the transition to use of POCT in the home to further improve disease management and improve health care cost-effectiveness are discussed. Devices available for home use include those suitable for management of diabetes mellitus, hypertension, congestive heart failure, and anticoagulation. Many of these devices include software capabilities enabling patients to share important health information with health care providers using a computer. Limitations and challenges surrounding implementation of home POCT for patients include reliability of instrumentation, ability to coordinate data collection, necessary training requirements, and cost-effectiveness. Looking forward, the successful integration of POCT into the homes of patients is contingent on a concerted effort made by all members of the health care team.
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Affiliation(s)
- Joseph A. Goble
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Patrick T. Rocafort
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
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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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You JHS. Universal versus genotype-guided use of direct oral anticoagulants in atrial fibrillation patients: a decision analysis. Pharmacogenomics 2015; 16:1089-100. [PMID: 26230572 DOI: 10.2217/pgs.15.64] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM This study aims to compare clinical and economic outcomes of CYP2C9 and VKORC1 genotype-guided (PG-DOAC) versus universal use of direct oral anticoagulant (DOAC) for stroke prevention in patients with atrial fibrillation (AF). METHODS Outcomes of oral anticoagulation therapy were simulated using life-long Markov modeling. In PG-DOAC, patients with genotype of high or low warfarin sensitivity were treated with DOAC, and patients with normal warfarin sensitivity genotype received warfarin. RESULTS Expected quality-adjusted life-years (QALYs) and cost of DOAC were higher than PG-DOAC. Incremental cost per QALY (ICER) of DOAC versus PG-DOAC was 314,129 USD/QALY, exceeding willingness-to-pay threshold (50,000 USD/QALY). CONCLUSION Using individual genotype to guide the use of DOAC versus warfarin appears to be the preferred strategy.
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Affiliation(s)
- Joyce H S You
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China SAR
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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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