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Holbrook A, Troyan S, Telford V, Koubaesh Y, Vidug K, Yoo L, Deng J, Lohit S, Giilck S, Ahmed A, Talman M, Leonard B, Refaei M, Tarride JE, Schulman S, Douketis J, Thabane L, Hyland S, Ho JMW, Siegal D. Coordination of oral anticoagulant care at hospital discharge (COACHeD): pilot randomised controlled trial. BMJ Open 2024; 14:e079353. [PMID: 38692712 PMCID: PMC11086462 DOI: 10.1136/bmjopen-2023-079353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 04/05/2024] [Indexed: 05/03/2024] Open
Abstract
OBJECTIVES To evaluate whether a focused, expert medication management intervention is feasible and potentially effective in preventing anticoagulation-related adverse events for patients transitioning from hospital to home. DESIGN Randomised, parallel design. SETTING Medical wards at six hospital sites in southern Ontario, Canada. PARTICIPANTS Adults 18 years of age or older being discharged to home on an oral anticoagulant (OAC) to be taken for at least 4 weeks. INTERVENTIONS Clinical pharmacologist-led intervention, including a detailed discharge medication management plan, a circle of care handover and early postdischarge virtual check-up visits to 1 month with 3-month follow-up. The control group received the usual care. OUTCOMES MEASURES Primary outcomes were study feasibility outcomes (recruitment, retention and cost per patient). Secondary outcomes included adverse anticoagulant safety events composite, quality of transitional care, quality of life, anticoagulant knowledge, satisfaction with care, problems with medications and health resource utilisation. RESULTS Extensive periods of restriction of recruitment plus difficulties accessing patients at the time of discharge negatively impacted feasibility, especially cost per patient recruited. Of 845 patients screened, 167 were eligible and 56 were randomised. The mean age (±SD) was 71.2±12.5 years, 42.9% females, with two lost to follow-up. Intervention patients were more likely to rate their ability to manage their OAC as improved (17/27 (63.0%) vs 7/22 (31.8%), OR 3.6 (95% CI 1.1 to 12.0)) and their continuity of care as improved (21/27 (77.8%) vs 2/22 (9.1%), OR 35.0 (95% CI 6.3 to 194.2)). Fewer intervention patients were taking one or more inappropriate medications (7 (22.5%) vs 15 (60%), OR 0.19 (95% CI 0.06 to 0.62)). CONCLUSION This pilot randomised controlled trial suggests that a transitional care intervention at hospital discharge for older adults taking OACs was well received and potentially effective for some surrogate outcomes, but overly costly to proceed to a definitive large trial. TRIAL REGISTRATION NUMBER NCT02777047.
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Affiliation(s)
- Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Sue Troyan
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Victoria Telford
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Yousery Koubaesh
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Brantford General Hospital, Brantford, Ontario, Canada
| | - Kristina Vidug
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Lindsay Yoo
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Jiawen Deng
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Simran Lohit
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Stephen Giilck
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Grand River Hospital, Kitchener, Ontario, Canada
| | - Amna Ahmed
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Marianne Talman
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Blair Leonard
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Niagara Health System, St. Catharines, Ontario, Canada
| | - Mohammad Refaei
- Department of Medicine, Niagara Health System, St. Catharines, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Center for Health Economic and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
- Programs for Assessment of Technology in Health (PATH), Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James Douketis
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Biotatistics Unit, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Sylvia Hyland
- Institute for Safe Medication Practices Canada, North York, Ontario, Canada
| | - Joanne Man-Wai Ho
- Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Deborah Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Holbrook AM, Vidug K, Yoo L, Troyan S, Schulman S, Douketis J, Thabane L, Giilck S, Koubaesh Y, Hyland S, Keshavjee K, Ho J, Tarride JE, Ahmed A, Talman M, Leonard B, Ahmed K, Refaei M, Siegal DM. Coordination of Oral Anticoagulant Care at Hospital Discharge (COACHeD): protocol for a pilot randomised controlled trial. Pilot Feasibility Stud 2022; 8:166. [PMID: 35918731 PMCID: PMC9344454 DOI: 10.1186/s40814-022-01130-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022] Open
Abstract
Background Oral anticoagulants (OACs) are commonly prescribed, have well-documented benefits for important clinical outcomes but have serious harms as well. Rates of OAC-related adverse events including thromboembolic and hemorrhagic events are especially high shortly after hospital discharge. Expert OAC management involving virtual care is a research priority given its potential to reach remote communities in a more feasible, timely, and less costly way than in-person care. Our objective is to test whether a focused, expert medication management intervention using a mix of in-person consultation and virtual care follow-up, is feasible and effective in preventing anticoagulation-related adverse events, for patients transitioning from hospital to home. Methods and analysis A randomized, parallel, multicenter design enrolling consenting adult patients or the caregivers of cognitively impaired patients about to be discharged from medical wards with a discharge prescription for an OAC. The interdisciplinary multimodal intervention is led by a clinical pharmacologist and includes a detailed discharge medication reconciliation and management plan focused on oral anticoagulants at hospital discharge; a circle of care handover and coordination with patient, hospital team and community providers; and early post-discharge follow-up virtual medication check-up visits at 24 h, 1 week, and 1 month. The control group will receive usual care plus encouragement to use the Thrombosis Canada website. The primary feasibility outcomes include recruitment rate, participant retention rates, trial resources management, and the secondary clinical outcomes include adverse anticoagulant safety events composite (AASE), coordination and continuity of care, medication-related problems, quality of life, and healthcare resource utilization. Follow-up is 3 months. Discussion This pilot RCT tests whether there is sufficient feasibility and merit in coordinating oral anticoagulant care early post-hospital discharge to warrant a full sized RCT. Trial registration NCT02777047. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01130-z.
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Affiliation(s)
- Anne M Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada. .,Clinical Pharmacology Research, Research Institute of St Joes Hamilton, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada. .,Division of General Internal Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada. .,Department of Medicine, Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Kristina Vidug
- Clinical Pharmacology Research, Research Institute of St Joes Hamilton, Hamilton, ON, Canada
| | - Lindsay Yoo
- Clinical Pharmacology Research, Research Institute of St Joes Hamilton, Hamilton, ON, Canada
| | - Sue Troyan
- Clinical Pharmacology Research, Research Institute of St Joes Hamilton, Hamilton, ON, Canada
| | - Sam Schulman
- Divsion of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - James Douketis
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Division of General Internal Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Divsion of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Clinical Pharmacology Research, Research Institute of St Joes Hamilton, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Stephen Giilck
- Division of General Internal Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Grand River Hospital, Kitchener, ON, Canada
| | - Yousery Koubaesh
- Division of General Internal Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Brantford General Hospital, Brantford, ON, Canada
| | - Sylvia Hyland
- Institute for Safe Medication Practices Canada, North York, ON, Canada
| | - Karim Keshavjee
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Joanne Ho
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Research Institute for Aging, Schlegel-University of Waterloo, Waterloo, ON, Canada.,Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Center for Health Economic and Policy Analysis (CHEPA), McMaster University, Hamilton, ON, Canada.,Programs for Assessment of Technology in Health (PATH), Research Institute of St. Joe's Hamilton, Hamilton, ON, Canada
| | - Amna Ahmed
- Division of General Internal Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Marianne Talman
- Division of General Internal Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Blair Leonard
- Department of Medicine, Niagara Health System, Regional Municipality of Niagara, Canada
| | - Khursheed Ahmed
- Clinical Pharmacology Research, Research Institute of St Joes Hamilton, Hamilton, ON, Canada
| | - Mohammad Refaei
- Department of Medicine, Niagara Health System, Regional Municipality of Niagara, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Poénou G, Tolédano E, Helfer H, Plaisance L, Happe F, Versini E, Diab N, Djennaoui S, Mahé I. In Search of the Appropriate Anticoagulant-Associated Bleeding Risk Assessment Model for Cancer-Associated Thrombosis Patients. Cancers (Basel) 2022; 14:cancers14081937. [PMID: 35454844 PMCID: PMC9029420 DOI: 10.3390/cancers14081937] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Patients with venous thromboembolism events in the context of cancer should receive anticoagulants as long as the cancer is active. Therefore, a tailor-made anticoagulation strategy should rely on an individualized assessment of the risks of recurrent venous thromboembolism and anticoagulant-associated bleeding. No existing risk assessment model for anticoagulant-associated bleeding risk has been validated for cancer-associated thrombosis. To obtain a better risk assessment model to assess anticoagulant-associated bleeding risk in cancer-associated thrombosis patients, we deemed it necessary to answer questions related to how and when to assess anticoagulant-associated bleeding risk as well as what factors to assess for which patients. Abstract Patients with venous thromboembolism events (VTE) in the context of cancer should receive anticoagulants as long as the cancer is active. Therefore, a tailor-made anticoagulation strategy should rely on an individualized risk assessment model (RAM) of recurrent VTE and anticoagulant-associated bleeding. The aim of this review is to investigate the applicability of the currently available RAMs for anticoagulant-associated bleeding after VTE in the CAT population and to provide new insights on how we can succeed in developing a new anticoagulant-associated bleeding RAM for the current medical care of CAT patients. A systematic search for peer-reviewed publications was performed in PubMed. Studies, including systematic reviews, were eligible if they comprised patients with VTE and used a design for developing a prediction model, score, or other prognostic tools for anticoagulant-associated bleeding during anticoagulant treatment. Out of 15 RAMs, just the CAT-BLEED was developed for CAT patients and none of the presented RAMs developed for the VTE general population were externally validated in a population of CAT patients. The current review illustrates the limitations of the available RAMs for anticoagulant-associated bleeding in CAT patients. The development of a RAM for bleeding risk assessment in patients with CAT is warranted.
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Affiliation(s)
- Géraldine Poénou
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
- Correspondence:
| | - Emmanuel Tolédano
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
- Université de Paris Cité, 75006 Paris, France
| | - Hélène Helfer
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
| | - Ludovic Plaisance
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
| | - Florent Happe
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
| | - Edouard Versini
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
- Université de Paris Cité, 75006 Paris, France
| | - Nevine Diab
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
- Université de Paris Cité, 75006 Paris, France
| | - Sadji Djennaoui
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
| | - Isabelle Mahé
- Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, 92700 Colombes, France; (E.T.); (H.H.); (L.P.); (F.H.); (E.V.); (N.D.); (S.D.); (I.M.)
- Université de Paris Cité, 75006 Paris, France
- Unité Inserm UMR-S1140 Innovation Thérapeutique en Hémostase, 75006 Paris, France
- INNOVTE-FCRIN, CEDEX 2, 42055 Saint-Etienne, France
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Benipal H, Holbrook A, Paterson JM, Douketis J, Foster G, Ma J, Thabane L. Derivation and validation of predictors of oral anticoagulant-related adverse events in seniors transitioning from hospital to home. Thromb Res 2021; 206:18-28. [PMID: 34391064 DOI: 10.1016/j.thromres.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/20/2021] [Accepted: 07/29/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Oral anticoagulant (OAC)-related adverse events are high post-hospitalization. We planned to develop and validate a prediction model for OAC-related harm within 30 days of hospitalization. METHODS We undertook a population-based study of adults aged ≥66 years who were discharged from hospital on an OAC from September 2010 to March 2015 in Ontario, Canada. The primary outcome was a composite of time to first hospitalization or emergency department visit for a hemorrhagic or thromboembolic event, or mortality within 30 days of hospital discharge. Cox proportional hazards regression was used to build the model. RESULTS We included 120,721 patients of which 5423 experienced the outcome. Most patients were aged ≥75 years (59.5%) and were female (55.6%). Sixty percent of the cohort had a follow-up visit with a healthcare provider within 7 days of discharge. Patients discharged on a direct acting OAC versus warfarin (apixaban: Hazard Ratio [HR] 0.82, 95% confidence interval [CI] 0.71-0.94; dabigatran: HR 0.73, 95% CI 0.63-0.84; rivaroxaban: HR 0.79, 95% CI 0.71-0.88), were prevalent users of the dispensed OAC versus incident users (HR 0.82, 95% CI 0.69-0.96), had a joint replacement in the past 35 days (HR 0.40, 95% CI 0.33-0.50) or major surgery during index hospital stay (HR 0.69, 95% CI 0.60-0.80) had a lower risk for the outcome. The Cox model was stable with acceptable discrimination but poor goodness-of-fit. CONCLUSIONS A model for OAC-related harm in the early post-discharge period was developed. External validation studies are required to understand the model's poor calibration.
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Affiliation(s)
- Harsukh Benipal
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, 2C Area, Hamilton, Ontario L8S 4K1, Canada.
| | - Anne Holbrook
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, 2C Area, Hamilton, Ontario L8S 4K1, Canada; Division of Clinical Pharmacology & Toxicology, Department of Medicine, McMaster University, SJHH G623, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.
| | - J Michael Paterson
- ICES, G1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario M5T 3M6, Canada.
| | - James Douketis
- Division of Hematology and Thromboembolism, Department of Medicine, HSC-3V50, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada; Thrombosis and Atherosclerosis Research Institute, David Braley Research Institute C5-121, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.
| | - Gary Foster
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, 2C Area, Hamilton, Ontario L8S 4K1, Canada; Biostatistics Unit, St Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.
| | - Jinhui Ma
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, 2C Area, Hamilton, Ontario L8S 4K1, Canada.
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, 2C Area, Hamilton, Ontario L8S 4K1, Canada; Biostatistics Unit, St Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.
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