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Haymart B, Kong X, Ali M, Schaefer JK, Froehlich JB, Ryan N, Stallings B, Barnes GD, Kaatz S. Prevalence of Guideline-Discordant Aspirin Use and Associated Adverse Events in Patients on Warfarin for Mechanical Valve Replacement. Am J Med 2024; 137:449-453. [PMID: 38280559 DOI: 10.1016/j.amjmed.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND For patients on warfarin for mechanical heart valve replacement, the 2020 American College of Cardiology and American Heart Association Guidelines recommend only adding aspirin in patients with a specific indication for antiplatelet therapy. This contrasts with prior guidelines, which recommended concomitant aspirin therapy. We sought to assess the prevalence of guideline-discordant aspirin use among patients on warfarin for mechanical heart valve replacement and to compare adverse event rates among patients with and without concomitant aspirin. METHODS Patients on warfarin for mechanical heart valve replacement were identified from the Michigan Anticoagulation Quality Improvement Initiative registry. Patients with myocardial infarction, percutaneous coronary intervention, or coronary artery bypass within the past 12 months were excluded. Patients were divided into 2 groups based on aspirin use. Patient characteristics and bleeding and thromboembolic outcomes were compared. RESULTS Four hundred forty-four patients met the inclusion criteria, with 341 (76.8%) on concomitant aspirin. The aspirin group was older (50.6 vs 46.3 years, P = .028) and had more hypertension (57.8% vs 46.6%, P = .046) but other patient characteristics were similar. The aspirin group had a higher rate of bleeding events (28.3 vs 13.3 per 100 patient-years, P < .001) and bleed-related emergency department visits (11.8 vs 2.9 per 100 patient-years, P = .001) compared with the non-aspirin group. There was no observed difference in rates of ischemic stroke (0.56 vs 0.48 per 100 patient-years, P = .89). CONCLUSIONS A significant proportion of patients on warfarin for mechanical heart valve replacement are on guideline-discordant aspirin. Aspirin deprescribing in select patients may safely reduce bleeding events.
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Affiliation(s)
- Brian Haymart
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor.
| | - Xiaowen Kong
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Mona Ali
- Department of Heart and Vascular Services, Corewell Health William Beaumont University Hospital, Royal Oak, Mich
| | - Jordan K Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - James B Froehlich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Noelle Ryan
- Ambulatory Anticoagulation Services, Henry Ford Health, Detroit, Mich
| | | | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Health, Detroit, Mich
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DeCamillo D, Herrel LA, Haymart B, Latfolla A, Barnes GD. Unexplained hematuria in direct oral anticoagulant use: a single-center retrospective case series. Res Pract Thromb Haemost 2024; 8:102404. [PMID: 38706780 PMCID: PMC11066542 DOI: 10.1016/j.rpth.2024.102404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/28/2024] [Accepted: 04/04/2024] [Indexed: 05/07/2024] Open
Affiliation(s)
- Deborah DeCamillo
- Division of Cardiovascular Medicine, Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsey A. Herrel
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Brian Haymart
- Division of Cardiovascular Medicine, Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Ahmaad Latfolla
- Division of Cardiovascular Medicine, Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Geoffrey D. Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
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Lee J, Kong X, Haymart B, Kline‐Rogers E, Kaatz S, Shah V, Ali MA, Kozlowski J, Froehlich J, Barnes GD. Outcomes in patients undergoing periprocedural interruption of warfarin or direct oral anticoagulants. J Thromb Haemost 2022; 20:2571-2578. [PMID: 35962753 PMCID: PMC9804988 DOI: 10.1111/jth.15850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 07/14/2022] [Accepted: 08/08/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Differences in clinical outcomes following a temporary interruption of warfarin or a direct oral anticoagulant (DOAC) for a surgical procedure are not well described. Differences in patient characteristics from practice-based cohorts have not typically been accounted for in prior analyses. AIM To describe risk-adjusted differences in postoperative outcomes following an interruption of warfarin vs DOACs. METHODS Patients receiving care at six anticoagulation clinics participating in the Michigan Anticoagulation Quality Improvement Initiative were included if they had at least one oral anticoagulant interruption for a procedure. Inverse probability of treatment weighting (IPTW) was used to balance baseline differences between the warfarin cohort and DOAC cohort. Bleeding and thromboembolic events within 30 days following the procedure were compared between the IPTW cohorts using the Poisson distribution test. RESULTS A total of 525 DOAC patients were matched with 1323 warfarin patients, of which 923 were nonbridged warfarin patients and 400 were bridged warfarin patients. The occurrence of postoperative minor bleeding (10.8% vs. 4.7%, p < .001), major bleeding (2.9% vs. 1.1%, p = .01) and clinically relevant nonmajor bleeding (CRNMB) (6.5% vs. 3.0%, p = .002) was greater in the DOAC cohort compared with the nonbridged warfarin cohort. The rates of postoperative bleeding outcomes were similar between the DOAC and the bridged warfarin cohorts. CONCLUSION Perioperative interruption of DOACs, compared with warfarin without bridging, is associated with a higher incidence of 30-day minor bleeds, major bleeds, and CRNMBs. Further research investigating the perioperative outcomes of these two classes of anticoagulants is warranted.
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Affiliation(s)
- Jeffrey Lee
- University of Michigan Department of Internal Medicine, Frankel Cardiovascular CenterRush Medical College, Rush University Medical CenterAnn ArborMichiganUSA
| | - Xiaowen Kong
- University of Michigan Department of Internal Medicine, Frankel Cardiovascular CenterAnn ArborMichiganUSA
| | - Brian Haymart
- University of Michigan Department of Internal Medicine, Frankel Cardiovascular CenterAnn ArborMichiganUSA
| | - Eva Kline‐Rogers
- University of Michigan Department of Internal Medicine, Frankel Cardiovascular CenterAnn ArborMichiganUSA
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford HospitalDetroitMichiganUSA
| | - Vinay Shah
- Division of Hospital Medicine, Henry Ford HospitalDetroitMichiganUSA
| | - Mona A. Ali
- Department of Heart and Vascular ServicesRoyal OakMichiganUSA
| | | | - James Froehlich
- University of Michigan Department of Internal Medicine, Frankel Cardiovascular CenterAnn ArborMichiganUSA
| | - Geoffrey D. Barnes
- University of Michigan Department of Internal Medicine, Frankel Cardiovascular CenterAnn ArborMichiganUSA
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Joyce E, Haymart B, Kong X, Ali MA, Carrigan M, Kaatz S, Shah V, Kline‐Rogers E, Kozlowski J, Froehlich JB, Barnes GD. Length of Anticoagulation in Provoked Venous Thromboembolism: A Multicenter Study of How Real‐World Practice Mirrors Guideline Recommendations. J Am Heart Assoc 2022; 11:e025471. [PMID: 36285782 PMCID: PMC9673630 DOI: 10.1161/jaha.122.025471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
For more than a decade, guidelines have recommended a limited 3 months of anticoagulation for the treatment of provoked venous thromboembolism (VTE). How closely real‐world practice follows guideline recommendations is not well described.
Methods and Results
In our multicenter, retrospective cohort study, we evaluated trends in anticoagulation duration for patients enrolled in the MAQI
2
(Michigan Anticoagulation Quality Improvement Initiative) registry who were receiving anticoagulation for a provoked VTE. The MAQI
2
registry comprises 6 centers in Michigan that manage patients' long‐term anticoagulation. We identified 474 patients on warfarin and 302 patients on direct oral anticoagulants who were receiving anticoagulation for a primary indication of provoked VTE between 2008 and 2020. Using a predefined threshold of 120 days (3 months plus a buffer period), predictors of extended anticoagulant use were identified using multivariable logistic regression. Most patients received >120 days of anticoagulation, regardless of which medication was used. The median (25th–75th percentile) length of treatment for patients taking warfarin was 142 (91–234) days and for direct oral anticoagulants was 180 (101–360) days. Recurrent VTE (odds ratio [OR], 2.75 [95% CI, 1.67–4.53]), history of myocardial infarction (OR, 3.92 [95% CI, 1.32–11.7]), and direct oral anticoagulant rather than warfarin use (OR, 2.22 [95% CI, 1.59–3.08]) were independently associated with prolonged anticoagulation.
Conclusions
In our cohort of patients with provoked VTE, most patients received anticoagulation for longer than the guideline‐recommended 3 months. This demonstrates a potential opportunity to improve care delivery and reduce anticoagulant‐associated bleeding risk.
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Affiliation(s)
| | - Brian Haymart
- Michigan Medicine Frankel Cardiovascular Center Ann Arbor MI
| | - Xiaowen Kong
- Michigan Medicine Frankel Cardiovascular Center Ann Arbor MI
| | | | - Mara Carrigan
- Michigan Medicine Frankel Cardiovascular Center Ann Arbor MI
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Schaefer JK, Errickson J, Gu X, Alexandris-Souphis T, Ali MA, Haymart B, Kaatz S, Kline-Rogers E, Kozlowski JH, Krol GD, Shah V, Sood SL, Froehlich JB, Barnes GD. Assessment of an Intervention to Reduce Aspirin Prescribing for Patients Receiving Warfarin for Anticoagulation. JAMA Netw Open 2022; 5:e2231973. [PMID: 36121653 PMCID: PMC9486454 DOI: 10.1001/jamanetworkopen.2022.31973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE For some patients receiving warfarin, adding aspirin (acetylsalicylic acid) increases bleeding risk with unclear treatment benefit. Reducing excess aspirin use could be associated with improved clinical outcomes. OBJECTIVE To assess changes in aspirin use, bleeding, and thrombosis event rates among patients treated with warfarin. DESIGN, SETTING, AND PARTICIPANTS This pre-post observational quality improvement study was conducted from January 1, 2010, to December 31, 2019, at a 6-center quality improvement collaborative in Michigan among 6738 adults taking warfarin for atrial fibrillation and/or venous thromboembolism without an apparent indication for concomitant aspirin. Statistical analysis was conducted from November 26, 2020, to June 14, 2021. INTERVENTION Primary care professionals for patients taking aspirin were asked whether an ongoing combination aspirin and warfarin treatment was indicated. If not, then aspirin was discontinued with the approval of the managing clinician. MAIN OUTCOMES AND MEASURES Outcomes were assessed before and after intervention for the primary analysis and before and after 24 months before the intervention (when rates of aspirin use first began to decrease) for the secondary analysis. Outcomes included the rate of aspirin use, bleeding, and thrombotic outcomes. An interrupted time series analysis assessed cumulative monthly event rates over time. RESULTS A total of 6738 patients treated with warfarin (3160 men [46.9%]; mean [SD] age, 62.8 [16.2] years) were followed up for a median of 6.7 months (IQR, 3.2-19.3 months). Aspirin use decreased slightly from a baseline mean use of 29.4% (95% CI, 28.9%-29.9%) to 27.1% (95% CI, 26.1%-28.0%) during the 24 months before the intervention (P < .001 for slope before and after 24 months before the intervention) with an accelerated decrease after the intervention (mean aspirin use, 15.7%; 95% CI, 14.8%-16.8%; P = .001 for slope before and after intervention). In the primary analysis, the intervention was associated with a significant decrease in major bleeding events per month (preintervention, 0.31%; 95% CI, 0.27%-0.34%; postintervention, 0.21%; 95% CI, 0.14%-0.28%; P = .03 for difference in slope before and after intervention). No change was observed in mean percentage of patients having a thrombotic event from before to after the intervention (0.21% vs 0.24%; P = .34 for difference in slope). In the secondary analysis, reducing aspirin use (starting 24 months before the intervention) was associated with decreases in mean percentage of patients having any bleeding event (2.3% vs 1.5%; P = .02 for change in slope before and after 24 months before the intervention), mean percentage of patients having a major bleeding event (0.31% vs 0.25%; P = .001 for change in slope before and after 24 months before the intervention), and mean percentage of patients with an emergency department visit for bleeding (0.99% vs 0.67%; P = .04 for change in slope before and after 24 months before the intervention), with no change in mean percentage of patients with a thrombotic event (0.20% vs 0.23%; P = .36 for change in slope before and after 24 months before the intervention). CONCLUSIONS AND RELEVANCE This quality improvement intervention was associated with an acceleration of a preexisting decrease in aspirin use among patients taking warfarin for atrial fibrillation and/or venous thromboembolism without a clear indication for aspirin therapy. Reductions in aspirin use were associated with reduced bleeding. This study suggests that an anticoagulation clinic-based aspirin deimplementation intervention can improve guideline-concordant aspirin use.
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Affiliation(s)
- Jordan K. Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Josh Errickson
- Consulting for Statistics, Computing, & Analytics Research, University of Michigan, Ann Arbor
| | - Xiaokui Gu
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Tina Alexandris-Souphis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Mona A. Ali
- Department of Heart and Vascular Services, Beaumont Hospital, Royal Oak, Michigan
| | - Brian Haymart
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Eva Kline-Rogers
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | - Gregory D. Krol
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Vinay Shah
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Suman L. Sood
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - James B. Froehlich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Geoffrey D. Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
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6
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Haymart B, Barnes GD, Kong X, Ali M, Kline-Rogers E, DeCamillo D, Kaatz S. Comparison of Patient Outcomes Before and After Switching From Warfarin to a Direct Oral Anticoagulant Based on Time in Therapeutic Range Guideline Recommendations. JAMA Netw Open 2022; 5:e2222089. [PMID: 35834255 PMCID: PMC9284330 DOI: 10.1001/jamanetworkopen.2022.22089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cohort study evaluates stroke and major bleeding rates before and after switching from warfarin to a direct oral anticoagulant (DOAC) in patients grouped by pre-switch time-in-therapeutic range guideline thresholds.
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Affiliation(s)
- Brian Haymart
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Geoffrey D. Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Xiaowen Kong
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Mona Ali
- Department of Heart and Vascular Services, Beaumont Hospital, Royal Oak, Michigan
| | - Eva Kline-Rogers
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Deborah DeCamillo
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan
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7
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Song M, Haymart B, Kong X, Ali M, Kaatz S, Kozlowski J, Krol G, Schaefer J, Froehlich JB, Barnes GD. Association of adding antiplatelet therapy to warfarin for management of venous thromboembolism with bleeding and other adverse events. Vasc Med 2022; 27:382-384. [DOI: 10.1177/1358863x221089333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Melinda Song
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Brian Haymart
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Xiaowen Kong
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mona Ali
- Department of Heart and Vascular Services, Beaumont Hospital, Royal Oak, MI, USA
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Jay Kozlowski
- Department of Cardiovascular Medicine, DMC Huron Valley-Sinai Hospital, Commerce, MI, USA
| | - Gregory Krol
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Jordan Schaefer
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - James B Froehlich
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
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8
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Feldeisen T, Alexandris-Souphis C, Haymart B, Kong X, Kline-Rogers E, Handoo F, Scott K, Ali M, Kozlowski J, Shah V, Krol G, Froehlich JB, Barnes GD. Anticoagulation Changes Following Major and Clinically Relevant Nonmajor Bleeding Events in Non-valvular Atrial Fibrillation Patients. J Pharm Pract 2021; 36:542-547. [PMID: 34962835 DOI: 10.1177/08971900211064189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bleeding events are common complications of oral anticoagulant drugs, including both warfarin and the direct oral anticoagulants (DOACs). Some patients have their anticoagulant changed or discontinued after experiencing a bleeding event, while others continue the same treatment. Differences in anticoagulation management between warfarin- and DOAC-treated patients following a bleeding event are unknown. METHODS Patients with non-valvular atrial fibrillation from six anticoagulation clinics taking warfarin or DOAC therapy who experienced an International Society of Thrombosis and Haemostasis (ISTH)-defined major or clinically relevant non-major (CRNM) bleeding event were identified between 2016 and 2020. The primary outcome was management of the anticoagulant following bleeding (discontinuation, change in drug class, and restarting of same drug class). DOAC- and warfarin-treated patients were propensity matched based on the individual elements of the CHA2DS2-VASc and HAS-BLED scores as well as the severity of the bleeding event. RESULTS Of the 509 patients on warfarin therapy and 246 on DOAC therapy who experienced a major or CRNM bleeding event, the majority of patients continued anticoagulation therapy. The majority of warfarin (231, 62.6%) and DOAC patients (201, 81.7%) restarted their previous anticoagulation. CONCLUSION Following a bleeding event, most patients restarted anticoagulation therapy, most often with the same type of anticoagulant that they previously had been taking.
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Affiliation(s)
- Thane Feldeisen
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
| | | | - Brian Haymart
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
| | - Xiaowen Kong
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
| | - Eva Kline-Rogers
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
| | - Faheem Handoo
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
| | | | - Mona Ali
- 21818William Beaumont Hospital, Royal Oak, MI, USA
| | - Jay Kozlowski
- 22945DMC Huron Valley-Sinai Hospital, Commerce Township, MI, USA
| | - Vinay Shah
- 2971Henry Ford Hospital, Detroit, MI, USA
| | | | - James B Froehlich
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
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9
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Hanigan S, Kong X, Haymart B, Kline-Rogers E, Kaatz S, Krol G, Shah V, Ali MA, Almany S, Kozlowski J, Froehlich J, Barnes G. Standard Versus Higher Intensity Anticoagulation for Patients With Mechanical Aortic Valve Replacement and Additional Risk Factors for Thromboembolism. Am J Cardiol 2021; 159:100-106. [PMID: 34656311 DOI: 10.1016/j.amjcard.2021.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 12/15/2022]
Abstract
Current guidelines recommend targeting an international normalized ratio (INR) of 2.5 to 3.5 for patients with mechanical aortic valve replacement (AVR) and additional risk factors for thromboembolic events. Available literature supporting the higher intensity (INR) goal is lacking. We aimed to evaluate the association of standard and higher intensity anticoagulation on outcomes in this patient population. The Michigan Anticoagulation Quality Improvement Initiative database was used to identify patients with mechanical AVR and at least one additional risk factor. Patients were classified into 2 groups based on INR goal: standard-intensity (INR goal 2.5) or higher-intensity (INR goal 3.0). Cox-proportional hazard model was used to calculate adjusted hazard ratios. One hundred and forty-six patients were identified of whom 110 (75.3%) received standard-intensity anticoagulation and 36 (24.7%) received higher intensity anticoagulation. Standard-intensity patients were older and more likely to be on aspirin. Atrial fibrillation was the most common additional risk factor for inclusion. The primary outcome of thromboembolic events, bleeding, or all-cause death was 13.9 and 19.5/100-person-years in the standard-intensity and higher intensity groups, respectively (adjusted HR 2.58, 95% confidence interval 1.28 to 5.18). Higher-intensity anticoagulation was significantly associated with any bleeding (adjusted HR 2.52, 95% confidence interval 1.27 to 5.00) and there were few thromboembolic events across both groups (5 events total). These results challenge current guideline recommendations for anticoagulation management of mechanical AVR in patients with additional risk factors.
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Affiliation(s)
- Sarah Hanigan
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan; Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan.
| | - Xiaowen Kong
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Brian Haymart
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Eva Kline-Rogers
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Gregory Krol
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Vinay Shah
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Mona A Ali
- Department of Heart and Vascular Services, Beaumont Hospital, Royal Oak, Michigan
| | - Steve Almany
- Department of Internal Medicine, Beaumont Health, Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Jay Kozlowski
- Department of Cardiovascular Medicine, Huron Valley Sinai Hospital, Commerce Township, Michigan
| | - James Froehlich
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Geoffrey Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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10
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Schaefer JK, Errickson J, Li Y, Kong X, Alexandris-Souphis T, Ali MA, Decamillo D, Haymart B, Kaatz S, Kline-Rogers E, Kozlowski JH, Krol GD, Shankar SR, Sood SL, Froehlich JB, Barnes GD. Adverse Events Associated With the Addition of Aspirin to Direct Oral Anticoagulant Therapy Without a Clear Indication. JAMA Intern Med 2021; 181:817-824. [PMID: 33871544 PMCID: PMC8056309 DOI: 10.1001/jamainternmed.2021.1197] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE It is unclear how many patients treated with a direct oral anticoagulant (DOAC) are using concomitant acetylsalicylic acid (ASA, or aspirin) and how this affects clinical outcomes. OBJECTIVE To evaluate the frequency and outcomes of prescription of concomitant ASA and DOAC therapy for patients with atrial fibrillation (AF) or venous thromboembolic disease (VTE). DESIGN, SETTING, AND PARTICIPANTS This registry-based cohort study took place at 4 anticoagulation clinics in Michigan from January 2015 to December 2019. Eligible participants were adults undergoing treatment with a DOAC for AF or VTE, without a recent myocardial infarction (MI) or history of heart valve replacement, with at least 3 months of follow-up. EXPOSURES Use of ASA concomitant with DOAC therapy. MAIN OUTCOMES AND MEASURES Rates of bleeding (any, nonmajor, major), rates of thrombosis (stroke, VTE, MI), emergency department visits, hospitalizations, and death. RESULTS Of the study cohort of 3280 patients (1673 [51.0%] men; mean [SD] age 68.2 [13.3] years), 1107 (33.8%) patients without a clear indication for ASA were being treated with DOACs and ASA. Two propensity score-matched cohorts, each with 1047 patients, were analyzed (DOAC plus ASA and DOAC only). Patients were followed up for a mean (SD) of 20.9 (19.0) months. Patients taking DOAC and ASA experienced more bleeding events compared with DOAC monotherapy (26.0 bleeds vs 31.6 bleeds per 100 patient years, P = .01). Specifically, patients undergoing combination therapy had significantly higher rates of nonmajor bleeding (26.1 bleeds vs 21.7 bleeds per 100 patient years, P = .02) compared with DOAC monotherapy. Major bleeding rates were similar between the 2 cohorts. Thrombotic event rates were also similar between the cohorts (2.5 events vs 2.3 events per 100 patient years for patients treated with DOAC and ASA compared with DOAC monotherapy, P = .80). Patients were more often hospitalized while undergoing combination therapy (9.1 vs 6.5 admissions per 100 patient years, P = .02). CONCLUSION AND RELEVANCE Nearly one-third of patients with AF and/or VTE who were treated with a DOAC received ASA without a clear indication. Compared with DOAC monotherapy, concurrent DOAC and ASA use was associated with increased bleeding and hospitalizations but similar observed thrombosis rate. Future research should identify and deprescribe ASA for patients when the risk exceeds the anticipated benefit.
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Affiliation(s)
- Jordan K Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Josh Errickson
- Consulting for Statistics, Computing, & Analytics Research, University of Michigan, Ann Arbor
| | - Yun Li
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Xiaowen Kong
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Tina Alexandris-Souphis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Mona A Ali
- Department of Heart and Vascular Services, Beaumont Hospital, Royal Oak, Michigan
| | - Deborah Decamillo
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Brian Haymart
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Eva Kline-Rogers
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jay H Kozlowski
- Department of Cardiovascular Medicine, Huron Valley Sinai Hospital, Commerce Township, Michigan
| | - Gregory D Krol
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Sahana R Shankar
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Suman L Sood
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - James B Froehlich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
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Sheikh MA, Kong X, Haymart B, Kaatz S, Krol G, Kozlowski J, Dahu M, Ali M, Almany S, Alexandris-Souphis T, Kline-Rogers E, Froehlich JB, Barnes GD. Comparison of temporary interruption with continuation of direct oral anticoagulants for low bleeding risk procedures. Thromb Res 2021; 203:27-32. [PMID: 33906063 DOI: 10.1016/j.thromres.2021.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/11/2021] [Accepted: 04/12/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Limited data is available on the rates of bleeding and thromboembolic events for patients undergoing low bleeding risk procedures while taking direct oral anticoagulants (DOAC). METHODS Adults taking DOAC in the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) database who underwent a low bleeding risk procedure between May 2015 and Sep 2019 were included. Thirty-day bleeding (of any severity), thromboembolic events, and death were compared between DOAC temporarily interrupted and continued uninterrupted groups. Adverse event rates were compared using an inverse probability weighting propensity score. RESULTS There were 820 patients who underwent 1412 low risk procedures. DOAC therapy was temporarily interrupted in 371 (45.2%) patients (601 [42.6%] procedures) and continued uninterrupted in 449 (54.8%) patients (811 [57.4%] procedures). DOAC patients with temporary interruptions were more likely to have diabetes, prior stroke or TIA, prior bleeding, higher CHA2DS2-VASc, and higher modified HAS-BLED scores. DOAC interruption was common for gastrointestinal endoscopy, electrophysiology device implantation, and cardiac catheterization while it was less common for cardioversion, dermatologic procedures, and subcutaneous injection. After propensity score adjustment, bleeding risk was lower in the DOAC temporary interruption group (OR 0.62, 95% CI 0.41-0.95) as compared to the group with continuous DOAC use. Rates of thromboembolic events and death did not differ significantly between the two groups. CONCLUSIONS DOAC-treated patients undergoing low bleeding risk procedures may experience lower rates of bleeding when DOAC is temporarily interrupted. Prospective studies focused on low bleeding risk procedures are needed to identify the safety DOAC management strategy.
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Affiliation(s)
- Muhammad Adil Sheikh
- Division of Hospital Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Xiaowen Kong
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States of America
| | - Brian Haymart
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States of America
| | - Scott Kaatz
- Henry Ford Hospital, Detroit, MI, United States of America
| | - Gregory Krol
- Henry Ford Hospital, Detroit, MI, United States of America
| | - Jay Kozlowski
- Cardiology and Vascular Associates, Huron Valley-Sinai Hospital, Commerce Township, MI, United States of America
| | - Musa Dahu
- Spectrum Health System, Grand Rapids, MI, United States of America
| | - Mona Ali
- Beaumont Hospital, Royal Oak, MI, United States of America
| | - Steven Almany
- Beaumont Hospital, Royal Oak, MI, United States of America
| | - Tina Alexandris-Souphis
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States of America
| | - Eva Kline-Rogers
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States of America
| | - James B Froehlich
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States of America
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States of America.
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12
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Neshewat J, Wasserman A, Alexandris-Souphis C, Haymart B, Feldeisen D, Kong X, Harvey RS, Pynnonen M, Froehlich JB, Kline-Rogers E, Barnes GD. Reduction in epistaxis and emergency department visits in patients taking warfarin after implementation of an education program. Thromb Res 2021; 199:119-122. [PMID: 33486320 DOI: 10.1016/j.thromres.2021.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Anticoagulated patients are often seen unnecessarily in the emergency department (ED) for epistaxis, leading to increased healthcare costs. Patients are often unaware of preventative and management techniques for handling epistaxis in the home. METHODS In 2016, the Michigan Anticoagulation Quality Improvement Initiative (MAQI2), a Blue Cross Blue Shield of Michigan-sponsored consortium of 6 anticoagulation clinics in Michigan, implemented an epistaxis-management educational program for warfarin-treated patients with the goal of reducing unnecessary ED visits. A pre-implementation cohort (2014-2015) consisted of patients who did not receive epistaxis-related educational materials. A post-implementation cohort (2017-2018) received epistaxis educational materials covering home treatment and prevention strategies. Patient characteristics and outcomes (rates of epistaxis and epistaxis ED visits) were compared using Chi-square, Poisson regression, and t-tests. RESULTS Of the 4473 patients included, 2634 (58.9%) initiated warfarin in the pre-implementation phase and 1839 (41.1%) initiated warfarin in the post-implementation phase. The post-implementation cohort had a lower overall epistaxis rate (13.4 vs 10.4 per 100 patient-year, pre- vs. post-implementation; p = 0.029), a lower epistaxis-related ED visit rate (5.6 vs. 3.1 per 100 patient-year; p = 0.003), and a lower proportion of nosebleeds that led to an ED visit (42% vs. 30%; p = 0.032). After controlling for antiplatelet use, renal disease, and time in therapeutic range, both cohorts were equally likely to have nosebleeds (RR 0.77, 95% CI: 0.58-1.02); however, the post-implementation cohort was less likely to visit the ED for epistaxis (RR 0.52, 95% CI: 0.32-0.84). CONCLUSION An epistaxis education program was associated with a reduction in epistaxis-related ED visits among warfarin-treated patients.
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13
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Dawson T, DeCamillo D, Kong X, Shensky B, Kaatz S, Krol GD, Ali M, Haymart B, Froehlich JB, Barnes GD. Correcting Inappropriate Prescribing of Direct Oral Anticoagulants: A Population Health Approach. J Am Heart Assoc 2020; 9:e016949. [PMID: 33150804 PMCID: PMC7763734 DOI: 10.1161/jaha.120.016949] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Taylor Dawson
- Division of Cardiovascular Medicine Department of Internal Medicine Michigan Medicine Ann Arbor MI.,Michigan Clinical Outcomes Research and Reporting Program Michigan Medicine Ann Arbor MI
| | - Deborah DeCamillo
- Michigan Clinical Outcomes Research and Reporting Program Michigan Medicine Ann Arbor MI
| | - Xiaowen Kong
- Michigan Clinical Outcomes Research and Reporting Program Michigan Medicine Ann Arbor MI
| | - Brian Shensky
- Michigan Clinical Outcomes Research and Reporting Program Michigan Medicine Ann Arbor MI
| | - Scott Kaatz
- Division of Hospital Medicine Henry Ford Hospital Detroit MI
| | - Gregory D Krol
- Department of General Internal Medicine Henry Ford Hospital Detroit MI
| | - Mona Ali
- Department of Pharmacy Beaumont Hospital, Royal Oak MI
| | - Brian Haymart
- Division of Cardiovascular Medicine Department of Internal Medicine Michigan Medicine Ann Arbor MI.,Michigan Clinical Outcomes Research and Reporting Program Michigan Medicine Ann Arbor MI
| | - James B Froehlich
- Division of Cardiovascular Medicine Department of Internal Medicine Michigan Medicine Ann Arbor MI.,Michigan Clinical Outcomes Research and Reporting Program Michigan Medicine Ann Arbor MI
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine Department of Internal Medicine Michigan Medicine Ann Arbor MI.,Michigan Clinical Outcomes Research and Reporting Program Michigan Medicine Ann Arbor MI
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14
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Barnes GD, Li Y, Gu X, Haymart B, Kline-Rogers E, Ali MA, Kozlowski J, Krol G, Froehlich JB, Kaatz S. Periprocedural bridging anticoagulation in patients with venous thromboembolism: A registry-based cohort study. J Thromb Haemost 2020; 18:2025-2030. [PMID: 32428998 PMCID: PMC7415673 DOI: 10.1111/jth.14903] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Use of bridging anticoagulation increases a patient's bleeding risk without clear evidence of thrombotic prevention among warfarin-treated patients with atrial fibrillation. Contemporary use of bridging anticoagulation among warfarin-treated patients with venous thromboembolism (VTE) has not been studied. METHODS We identified warfarin-treated patients with VTE who temporarily stopped warfarin for a surgical procedure between 2010 and 2018 at six health systems. Using the 2012 American College of Chest Physicians guideline, we assessed use of periprocedural bridging anticoagulation based on recurrent VTE risk. Recurrent VTE risk and 30-day outcomes (bleeding, thromboembolism, emergency department visit) were each assessed using logistic regression adjusted for multiple procedures per patient. RESULTS During the study period, 789 warfarin-treated patients with VTE underwent 1529 procedures (median, 2; interquartile range, 1-4). Unadjusted use of bridging anticoagulation was more common in patients at high risk for VTE recurrence (99/171, 57.9%) than for patients at moderate (515/1078, 47.8%) or low risk of recurrence (134/280, 47.86%). Bridging anticoagulation use was higher in high-risk patients compared with low- or moderate-risk patients in both unadjusted (P = .013) and patient-level cluster-adjusted analyses (P = .031). Adherence to American College of Chest Physicians guidelines in high- and low-risk patients did not change during the study period (odds ratio, 0.98 per year; 95% confidence interval, 0.91-1.05). Adverse events were rare and not statistically different between the two treatment groups. CONCLUSIONS Bridging anticoagulation was commonly overused among low-risk patients and underused among high-risk patients treated with warfarin for VTE. Adverse events were rare and not different between the two treatment groups.
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Affiliation(s)
- Geoffrey D Barnes
- – Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | - Yun Li
- – School of Public Health, University of Michigan, Ann Arbor, MI
| | - Xiaokui Gu
- – Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | - Brian Haymart
- – Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | - Eva Kline-Rogers
- – Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | - Mona A Ali
- – Department of Pharmacy, Beaumont Hospital, Royal Oak, MI
| | - Jay Kozlowski
- – Department of Internal Medicine, Huron Valley Sinai Hospital, Commerce Township, MI
| | - Gregory Krol
- – Department of Internal Medicine, Henry Ford Health System, Detroit, MI
| | - James B Froehlich
- – Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | - Scott Kaatz
- – Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI
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15
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Schaefer JK, Li Y, Gu X, Souphis NM, Haymart B, Kline-Rogers E, Almany SL, Kaatz S, Kozlowski JH, Krol GD, Sood SL, Froehlich JB, Barnes GD. Association of Adding Aspirin to Warfarin Therapy Without an Apparent Indication With Bleeding and Other Adverse Events. JAMA Intern Med 2019; 179:533-541. [PMID: 30830172 PMCID: PMC6450296 DOI: 10.1001/jamainternmed.2018.7816] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
IMPORTANCE It is not clear how often patients receive aspirin (acetylsalicylic acid) while receiving oral anticoagulation with warfarin sodium without a clear therapeutic indication for aspirin, such as a mechanical heart valve replacement, recent percutaneous coronary intervention, or acute coronary syndrome. The clinical outcomes of such patients treated with warfarin and aspirin therapy compared with warfarin monotherapy are not well defined to date. OBJECTIVE To evaluate the frequency and outcomes of adding aspirin to warfarin for patients without a clear therapeutic indication for combination therapy. DESIGN, SETTING, AND PARTICIPANTS A registry-based cohort study of adults enrolled at 6 anticoagulation clinics in Michigan (January 1, 2010, to December 31, 2017) who were receiving warfarin therapy for atrial fibrillation or venous thromboembolism without documentation of a recent myocardial infarction or history of valve replacement. EXPOSURE Aspirin use without therapeutic indication. MAIN OUTCOMES AND MEASURES Rates of any bleeding, major bleeding events, emergency department visits, hospitalizations, and thrombotic events at 1, 2, and 3 years. RESULTS Of the study cohort of 6539 patients (3326 men [50.9%]; mean [SD] age, 66.1 [15.5] years), 2453 patients (37.5%) without a clear therapeutic indication for aspirin were receiving combination warfarin and aspirin therapy. Data from 2 propensity score-matched cohorts of 1844 patients were analyzed (warfarin and aspirin vs warfarin only). At 1 year, patients receiving combination warfarin and aspirin compared with those receiving warfarin only had higher rates of overall bleeding (cumulative incidence, 26.0%; 95% CI, 23.8%-28.3% vs 20.3%; 95% CI, 18.3%-22.3%; P < .001), major bleeding (5.7%; 95% CI, 4.6%-7.1% vs 3.3%; 95% CI, 2.4%-4.3%; P < .001), emergency department visits for bleeding (13.3%; 95% CI, 11.6%-15.1% vs 9.8%; 95% CI, 8.4%-11.4%; P = .001), and hospitalizations for bleeding (8.1%; 6.8%-9.6% vs 5.2%; 4.1%-6.4%; P = .001). Rates of thrombosis were similar, with a 1-year cumulative incidence of 2.3% (95% CI, 1.6%-3.1%) for those receiving combination warfarin and aspirin therapy compared with 2.7% (95% CI, 2.0%-3.6%) for those receiving warfarin alone (P = .40). Similar findings persisted during 3 years of follow-up as well as in sensitivity analyses. CONCLUSIONS AND RELEVANCE Compared with warfarin monotherapy, receipt of combination warfarin and aspirin therapy was associated with increased bleeding and similar observed rates of thrombosis. Further research is needed to better stratify which patients may benefit from aspirin while anticoagulated with warfarin for atrial fibrillation or venous thromboembolism; clinicians should be judicious in selecting patients for combination therapy.
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Affiliation(s)
- Jordan K Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Yun Li
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Xiaokui Gu
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Nicole M Souphis
- College Student, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Brian Haymart
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Eva Kline-Rogers
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Steven L Almany
- Department of Internal Medicine, Beaumont Health, Oakland University School of Medicine, Royal Oak, Michigan
| | - Scott Kaatz
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jay H Kozlowski
- Department of Cardiovascular Medicine, Huron Valley Sinai Hospital, Commerce Township, Michigan
| | - Gregory D Krol
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Suman L Sood
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - James B Froehlich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
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16
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Kurlander JE, Gu X, Scheiman JM, Haymart B, Kline-Rogers E, Saini SD, Kaatz S, Froehlich JB, Richardson CR, Barnes GD. Missed opportunities to prevent upper GI hemorrhage: The experience of the Michigan Anticoagulation Quality Improvement Initiative. Vasc Med 2019; 24:153-155. [PMID: 30813868 DOI: 10.1177/1358863x18815971] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jacob E Kurlander
- 1 Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,2 Veterans Affairs (VA) Ann Arbor Health Care System, Ann Arbor, MI, USA.,3 Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Xiaokui Gu
- 4 Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - James M Scheiman
- 1 Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,5 Department of Medicine, University of Virginia, Charlottesville, VA
| | - Brian Haymart
- 4 Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Eva Kline-Rogers
- 4 Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sameer D Saini
- 1 Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,2 Veterans Affairs (VA) Ann Arbor Health Care System, Ann Arbor, MI, USA.,3 Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,6 VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - James B Froehlich
- 1 Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,4 Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Caroline R Richardson
- 3 Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,8 Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- 1 Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,3 Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,4 Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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17
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Barnes GD, Li Y, Gu X, Haymart B, Kline-Rogers E, Almany S, Kozlowski J, Krol G, McNamara M, Froehlich JB, Kaatz S. Periprocedural Bridging Anticoagulation: Measuring the Impact of a Clinical Trial on Care Delivery. Am J Med 2019; 132:109.e1-109.e7. [PMID: 30076828 DOI: 10.1016/j.amjmed.2018.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/16/2018] [Indexed: 11/29/2022]
Abstract
Use of bridging anticoagulation has been shown to be harmful and without benefit in warfarin-treated patients with atrial fibrillation. We performed a quasi-experimental interrupted time series analysis between 2010 and 2017 in the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) collaborative before and after the BRIDGE trial publication (July 2015). Predicted use of bridging at the end of the study period was calculated with and without the effect of the BRIDGE trial after adjustment for patient-level clustering. Predictors of bridging anticoagulation use in the post-BRIDGE trial period were analyzed. In adjusted analyses, the use of bridging anticoagulation declined from a predicted 27.8% (95% confidence interval, 20.5%-35.1%) to 13.6% (95% confidence interval, 9.0%-18.2%) at the end of 2017 (P = .001) in response to the BRIDGE trial. Use of bridging anticoagulation declined similarly among atrial fibrillation patients at low risk for stroke (29.0% to 14.4%) and intermediate or high risk for stroke (38.0%-20.3%). Younger age and a prior history of stroke were independent predictors of bridging anticoagulation use following the BRIDGE trial publication. The BRIDGE trial publication is associated with a rapid and significant decline in the use of periprocedural bridging anticoagulation.
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Affiliation(s)
| | - Yun Li
- School of Public Health, University of Michigan, Ann Arbor
| | | | | | | | - Steven Almany
- Beaumont Health/Oakland University School of Medicine, Royal Oak, Mich
| | - Jay Kozlowski
- Huron Valley Sinai Hospital, Commerce Township, Mich
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18
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Kurlander JE, Barnes GD, Anderson MA, Haymart B, Kline-Rogers E, Kaatz S, Saini SD, Krein SL, Richardson CR, Froehlich JB. Mind the gap: results of a multispecialty survey on coordination of care for peri-procedural anticoagulation. J Thromb Thrombolysis 2018; 45:403-409. [PMID: 29423559 DOI: 10.1007/s11239-018-1625-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
To understand how physicians from various specialties perceive coordination of care when managing peri-procedural anticoagulation. Cross-sectional survey of cardiologists, gastroenterologists, and primary care physicians (PCPs) in an integrated health system (N = 251). The survey began with a vignette of a patient with atrial fibrillation co-managed by his PCP, cardiologist, and an anticoagulation clinic who must hold warfarin for a colonoscopy. Respondents' experiences and opinions around responsibilities and institutional support for managing peri-procedural anticoagulation were elicited using multiple choice questions. We examined differences in responses across specialties using Chi square analysis. The response rate was 51% (n = 127). 52% were PCPs, 28% cardiologists, and 21% gastroenterologists. Nearly half (47.2%) of respondents believed that the cardiologist should be primarily responsible for managing peri-procedural anticoagulation, while fewer identified the PCP (25.2%), anticoagulation clinic (21.3%), or gastroenterologist (6.3%; p = 0.09). Respondents across specialties had significantly different approaches to deciding how to manage the clinical case presented (p < 0.001). Most cardiologists (60.0%) would decide whether to offer bridging without consulting with other providers or clinical resources, while most PCPs would decide after consulting clinical resources (57.6%). Gastroenterologists would most often (46.2%) defer the decision to another provider. A majority of all three specialties agreed that their institution could do more to help manage peri-procedural anticoagulation, and there was broad support (88.1%) for anticoagulation clinics' managing all aspects of peri-procedural anticoagulation. Providers across specialties agree that their institution could do more to help manage peri-procedural anticoagulation, and overwhelmingly support anticoagulation clinics' taking responsibility.
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Affiliation(s)
- Jacob E Kurlander
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA. .,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA. .,3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA.
| | - Geoffrey D Barnes
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michelle A Anderson
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brian Haymart
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Eva Kline-Rogers
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Sameer D Saini
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health Services Research & Development Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health Services Research & Development Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Caroline R Richardson
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - James B Froehlich
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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19
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Barnes GD, Kong X, Cole D, Haymart B, Kline-Rogers E, Almany S, Dahu M, Ekola M, Kaatz S, Kozlowski J, Froehlich JB. Extended International Normalized Ratio testing intervals for warfarin-treated patients. J Thromb Haemost 2018; 16:1307-1312. [PMID: 29763979 DOI: 10.1111/jth.14150] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Indexed: 12/22/2022]
Abstract
Essentials Warfarin typically requires International Normalized Ratio (INR) testing at least every 4 weeks. We implemented extended INR testing for stable warfarin patients in six anticoagulation clinics. Use of extended INR testing increased from 41.8% to 69.3% over the 3 year study. Use of extended INR testing appeared safe and effective. SUMMARY Background A previous single-center randomized trial suggested that patients with stable International Normalized Ratio (INR) values could safely receive INR testing as infrequently as every 12 weeks. Objective To test the success of implementation of an extended INR testing interval for stable warfarin patients in a practice-based, multicenter collaborative of anticoagulation clinics. Methods At six anticoagulation clinics, patients were identified as being eligible for extended INR testing on the basis of prior INR value stability and minimal warfarin dose changes between 2014 and 2016. We assessed the frequency with which anticoagulation clinic providers recommended an extended INR testing interval (> 5 weeks) to eligible patients. We also explored safety outcomes for eligible patients, including next INR values, bleeding events, and emergency department visits. Results At least one eligible period for extended INR testing was identified in 890 of 3362 (26.5%) warfarin-treated patients. Overall, the use of extended INR testing in eligible patients increased from 41.8% in the first quarter of 2014 to 69.3% in the fourth quarter of 2016. The number of subsequent out-of-range next INR values were similar between eligible patients who did and did not have an extended INR testing interval (27.3% versus 28.4%, respectively). The numbers of major bleeding events were not different between the two groups, but rates of clinically relevant non-major bleeding (0.02 per 100 patient-years versus 0.09 per 100 patient-years) and emergency department visits (0.07 per 100 patient-years versus 0.19 per 100 patient-years) were lower for eligible patients with extended INR testing intervals than for those with non-extended INR testing intervals. Conclusions Extended INR testing for stable warfarin patients can be successfully and safely implemented in diverse, practice-based anticoagulation clinic settings.
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Affiliation(s)
- G D Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - X Kong
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - D Cole
- Wayne State University School of Medicine, Detroit, MI, USA
| | - B Haymart
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - E Kline-Rogers
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - S Almany
- William Beaumont Hospital, Royal Oak, MI, USA
| | - M Dahu
- Spectrum Health System, Grand Rapids, MI, USA
| | - M Ekola
- Memorial Health System, Owosso, MI, USA
| | - S Kaatz
- Henry Ford Hospital, Detroit, MI, USA
| | - J Kozlowski
- Detroit Medical Center, Commerce Township, MI, USA
| | - J B Froehlich
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
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Hughey AB, Gu X, Haymart B, Kline-Rogers E, Almany S, Kozlowski J, Besley D, Krol GD, Ahsan S, Kaatz S, Froehlich JB, Barnes GD. Warfarin for prevention of thromboembolism in atrial fibrillation: comparison of patient characteristics and outcomes of the “Real-World” Michigan Anticoagulation Quality Improvement Initiative (MAQI2) registry to the RE-LY, ROCKET-AF, and ARISTOTLE trials. J Thromb Thrombolysis 2018; 46:316-324. [DOI: 10.1007/s11239-018-1698-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Barnes GD, Misirliyan S, Kaatz S, Jackson EA, Haymart B, Kline-Rogers E, Kozlowski J, Krol G, Froehlich JB, Sales A. Barriers and facilitators to reducing frequent laboratory testing for patients who are stable on warfarin: a mixed methods study of de-implementation in five anticoagulation clinics. Implement Sci 2017; 12:87. [PMID: 28709455 PMCID: PMC5513354 DOI: 10.1186/s13012-017-0620-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/05/2017] [Indexed: 01/28/2023] Open
Abstract
Background Patients on chronic warfarin therapy require regular laboratory monitoring to safely manage warfarin. Recent studies have challenged the need for routine monthly blood draws in the most stable warfarin-treated patients, suggesting the safety of less frequent laboratory testing (up to every 12 weeks). De-implementation efforts aim to reduce the use of low-value clinical practices. To explore barriers and facilitators of a de-implementation effort to reduce the use of frequent laboratory tests for patients with stable warfarin management in nurse/pharmacist-run anticoagulation clinics, we performed a mixed-methods study conducted within a state-wide collaborative quality improvement collaborative. Methods Using a mixed-methods approach, we conducted post-implementation semi-structured interviews with a total of eight anticoagulation nurse or pharmacist staff members at five participating clinic sites to assess barriers and facilitators to de-implementing frequent international normalized ratio (INR) laboratory testing among patients with stable warfarin control. Interview guides were based on the Tailored Implementation for Chronic Disease (TICD) framework. Informed by interview themes, a survey was developed and administered to all anticoagulation clinical staff (n = 62) about their self-reported utilization of less frequent INR testing and specific barriers to de-implementing the standard (more frequent) INR testing practice. Results From the interviews, four themes emerged congruent with TICD domains: (1) staff overestimating their actual use of less frequent INR testing (individual health professional factors), (2) barriers to appropriate patient engagement (incentives and resources), (3) broad support for an electronic medical record flag to identify potentially eligible patients (incentives and resources), and (4) the importance of personalized nurse/pharmacist feedback (individual health professional factors). In the survey (65% response rate), staff report offering less frequent INR testing to 56% (46–66%) of eligible patients. Most survey responders (n = 24; 60%) agreed that an eligibility flag in the electronic medical record would be very helpful. Twenty-four (60%) respondents agreed that periodic, personalized feedback on use of less frequent INR testing would also be helpful. Conclusions Leveraging information system notifications, reducing additional work load burden for participating patients and providers, and providing personalized feedback are strategies that may improve adoption and utilization new policies in anticoagulation clinics that focus on de-implementation. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0620-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, 2800 Plymouth Rd, B14 G101, Ann Arbor, MI, 48109-2800, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Sevan Misirliyan
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, 2800 Plymouth Rd, B14 G101, Ann Arbor, MI, 48109-2800, USA
| | - Scott Kaatz
- Division of Hospital Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Elizabeth A Jackson
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, 2800 Plymouth Rd, B14 G101, Ann Arbor, MI, 48109-2800, USA.,Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brian Haymart
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, 2800 Plymouth Rd, B14 G101, Ann Arbor, MI, 48109-2800, USA
| | - Eva Kline-Rogers
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, 2800 Plymouth Rd, B14 G101, Ann Arbor, MI, 48109-2800, USA
| | - Jay Kozlowski
- Cardiovascular Associates, Huron-Valley Sinai Hospital, Commerce Township, MI, USA
| | - Gregory Krol
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - James B Froehlich
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, 2800 Plymouth Rd, B14 G101, Ann Arbor, MI, 48109-2800, USA.,Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anne Sales
- Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
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Graves CM, Haymart B, Kline-Rogers E, Barnes GD, Perry LK, Pluhatsch D, Gearhart N, Gikas H, Ryan N, Kurtz B. Root Cause Analysis of Adverse Events in an Outpatient Anticoagulation Management Consortium. Jt Comm J Qual Patient Saf 2017; 43:299-307. [PMID: 28528624 DOI: 10.1016/j.jcjq.2017.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A number of factors can lead to adverse events (AEs) in patients taking warfarin. Performing a root cause analysis (RCA) of serious AEs is one systematic way of determining the causes of these events. METHODS Multidisciplinary teams were formed at Michigan Anticoagulation Quality Improvement Initiative (MAQI2) sites with organized anticoagulation management services (AMS). Medical records from patients who suffered serious AEs (major bleed, embolic stroke, venous thromboembolism) were reviewed, and AMS staff were interviewed to determine the root cause using the "5 Whys" technique. More than 600 patients had an AE and underwent screening by trained RNs. Of these, 79 required full review by a multidisciplinary panel. All potential contributing factors (comorbidities, concurrent medications, current protocols) were assessed to determine the main factor that caused the AE. RESULTS Full RCA was completed in 79 cases. The main contributing factor was identified in 69/79 (87%) cases. Most identified AEs, 55/69 (80%), were due to patient-specific factors such as comorbidities. Patient-to-provider and provider-to-provider communication accounted for 16/69 (23%) of events and was the second most common cause. Other causes included protocol non-adherence and technology/equipment issues. After each detailed review, the multidisciplinary panel recommended system changes that addressed the primary cause. CONCLUSION The majority of severe AEs for patients taking warfarin were related to nonmodifiable patient-related issues. The remaining AEs were primarily due to patient-to-provider and provider-to-provider communication issues. Methods for improving communication need to be addressed, and methods for more effective patient education should be investigated.
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Hale ZD, Kong X, Haymart B, Gu X, Kline-Rogers E, Almany S, Kozlowski J, Krol GD, Kaatz S, Froehlich JB, Barnes GD. Prescribing trends of atrial fibrillation patients who switched from warfarin to a direct oral anticoagulant. J Thromb Thrombolysis 2017; 43:283-288. [PMID: 27837309 DOI: 10.1007/s11239-016-1452-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Direct oral anticoagulant (DOAC) agents offer several lifestyle and therapeutic advantages for patients relative to warfarin in the treatment of atrial fibrillation (AF). These alternative agents are increasingly used in the treatment of AF, however the adoption practices, patient profiles, and reasons for switching to a DOAC from warfarin have not been well studied. Through the Michigan Anticoagulation Quality Improvement Initiative, abstracted data from 3873 AF patients, enrolled between 2010 and 2015, were collected on demographics and comorbid conditions, stroke and bleeding risk scores, and reasons for anticoagulant switching. Over the study period, patients who switched from warfarin to a DOAC had similar baseline characteristics, risk scores, and insurance status but differed in baseline CrCl. The most common reasons for switching were patient related ease of use concerns (37.5%) as opposed to clinical reasons (16.5% of patients). Only 13% of patients that switched to a DOAC switched back to warfarin by the end of the study period.
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Affiliation(s)
- Zachary D Hale
- Texas Heart Institute, CHI-Baylor St. Luke's Medical Center, 6720 Bertner Ave. MC-1-133, Houston, TX, 77030, USA.
| | - Xiowen Kong
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Brian Haymart
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Xiaokui Gu
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Eva Kline-Rogers
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Steve Almany
- William Beaumont Hospital, 4600 Investment Drive Suite 200, Troy, MI, 48098, USA
| | - Jay Kozlowski
- Huron Valley Sinai Hospital, 1 William Carls Drive, Commerce, MI, 48382, USA
| | - Gregory D Krol
- Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI, 48202, USA
| | - Scott Kaatz
- Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI, 48202, USA
| | - James B Froehlich
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Geoffrey D Barnes
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
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Stahlbaum K, Kline-Rogers E, Kong X, Barnes GD, Haymart B, Kozlowski JH, Almany SL, Kaatz S, Krol GD, Shah V, McNamara MW, Froehlich JB. Abstract 096: Association of Body Mass Index With Bleeding in Patients Taking Warfarin for Atrial Fibrillation or Venous Thromboembolism. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/circoutcomes.10.suppl_3.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Most patients taking warfarin for atrial fibrillation (AF) and venous thromboembolism (VTE) have a target International Normalized Ratio (INR) between 2-3 to reduce risk of bleeding and thromboembolic events. Body Mass Index (BMI) is not included in traditional bleed risk scores, but may be an indicator of bleeding risk in warfarin patients.
Methods:
Using data from the multi-site Michigan Anticoagulation Quality Improvement Initiative (MAQI
2
) Registry, we identified all AF/VTE patients , separated them into three cohorts: BMI < 20 (underweight), BMI 20-25 (normal weight) and BMI >25 (overweight). Bleeding events in these cohorts were identified and stratified into severity according to International Society of Thrombosis and Hemostasis criteria.
Results:
Of 6,054 patients, 4,766 (78.7%) had a BMI of > 25. These patients were generally younger, with higher prevalence of hypertension. The HAS-BLED scores were slightly lower in overweight AF patients (2.6 vs 2.8; p=0.04); otherwise no difference between groups. The overall minor, major, and life threatening bleeding rates were 22.8/27.7; 4.3/3.7; and 1.2/0.7 (per 100 patient years) in AF and VTE patients, respectively. A higher proportion of females were underweight for both indications, and AF patients were older. More underweight and normal weight AF and VTE patients had a bleeding history compared to overweight patients. Bleeding outcomes are listed in Table. Comparisons were made with Poisson regression analysis.
Conclusion:
In a large, unselected cohort of warfarin treated patient from a multi-site registry, minor bleeding was more common in underweight and normal weight AF patients; major and life-threatening bleeding was more common in underweight and normal weight VTE patients. Since the majority of patients were overweight, further studies are needed to determine if reasons for bleeding differ between patients based on BMI in order to guide quality improvement efforts.
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Kataruka A, Kong X, Haymart B, Kline-Rogers E, Almany S, Kozlowski J, Krol GD, Kaatz S, McNamara MW, Froehlich JB, Barnes GD. SAMe-TT 2R 2 predicts quality of anticoagulation in patients with acute venous thromboembolism: The MAQI 2 experience. Vasc Med 2017; 22:197-203. [PMID: 28145152 DOI: 10.1177/1358863x16682863] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A high SAMe-TT2R2 score predicted poor warfarin control and adverse events among atrial fibrillation patients. However, the SAMe-TT2R2 score has not been well validated in venous thromboembolism (VTE) patients. A cohort of 1943 warfarin-treated patients with acute VTE was analyzed to correlate the SAMe-TT2R2 score with time in therapeutic range (TTR) and clinical adverse events. A TTR <60% was more frequent among patients with a high (>2) versus low (0-1) SAMe-TT2R2 score (63.4% vs 52.3%, p<0.0001). A high SAMe-TT2R2 score (>2) correlated with increased overall adverse events (7.9 vs 4.5 overall adverse events/100 patient years, p=0.002), driven primarily by increased recurrent VTE rates (4.2 vs 1.5 recurrent VTE/100 patient years, p=0.0003). The SAMe-TT2R2 score had a modest predictive ability for international normalized ratio (INR) quality and adverse clinical events among warfarin-treated VTE patients. The utility of the SAMe-TT2R2 score to guide clinical decision-making remains to be investigated.
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Affiliation(s)
- Akash Kataruka
- 1 Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Xiaowen Kong
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Brian Haymart
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Eva Kline-Rogers
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Steve Almany
- 3 Department of Cardiology, William Beaumont Hospital, Royal Oak, MI, USA
| | | | | | - Scott Kaatz
- 5 Henry Ford Health System, Detroit, MI, USA
| | | | - James B Froehlich
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- 2 Department of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA
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Barnes GD, Kurlander J, Haymart B, Kaatz S, Saini S, Froehlich JB. Bridging Anticoagulation Before Colonoscopy: Results of a Multispecialty Clinician Survey. JAMA Cardiol 2016; 1:1076-1077. [PMID: 27627046 DOI: 10.1001/jamacardio.2016.2409] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Jacob Kurlander
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor3Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor4VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan
| | - Brian Haymart
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Scott Kaatz
- Department of Internal Medicine, Henry Ford Hospital, Ann Arbor, Michigan
| | - Sameer Saini
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor3Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor4VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan
| | - James B Froehlich
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Putnam A, Gu X, Haymart B, Kline-Rogers E, Almany S, Kozlowski J, Krol GD, Kaatz S, Froehlich JB, Barnes GD. The changing characteristics of atrial fibrillation patients treated with warfarin. J Thromb Thrombolysis 2016; 40:488-93. [PMID: 26130229 DOI: 10.1007/s11239-015-1244-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
It has been suggested that direct oral anticoagulants are being preferentially used in low risk atrial fibrillation (AF) patients. Understanding the changing risk profile of new AF patients treated with warfarin is important for interpreting the quality of warfarin delivery through an anticoagulation clinic. Six anticoagulation clinics participating in the Michigan Anticoagulation Quality Improvement Initiative enrolled 1293 AF patients between 2010 and 2014 as an inception cohort. Abstracted data included demographics, comorbidities, medication use and all INR values. Risk scores including CHADS2, CHA2DS2-VASc, HAS-BLED, SAMe-TT2R2, and Charlson comorbidity index (CCI) were calculated for each patient at the time of warfarin initiation. The quality of anticoagulation was assessed using the Rosendaal time in the therapeutic range (TTR) during the first 6 months of treatment. Between 2010 and 2014, patients initiating warfarin therapy for AF had an increasing mean CHADS2 (2.0 ± 1.1 to 2.2 ± 1.4, p = 0.02) and CCI (4.7 ± 1.8 to 5.1 ± 2.0, p = 0.03), and a trend towards increasing mean CHA2DS2-VASc, HAS-BLED, and SAMe-TT2R2 scores. The actual TTR remained unchanged over the study period (62.6 ± 18.2 to 62.7 ± 17.0, p = 0.98), and the number of INR checks did not change (18.9 ± 5.2 to 18.5 ± 5.1, p = 0.06). Between 2010 and 2014, AF patients newly starting warfarin had mild increases in risk for stroke and death with sustained quality of warfarin therapy.
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Affiliation(s)
- Andrew Putnam
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA.
| | - Xiaokui Gu
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Brian Haymart
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Eva Kline-Rogers
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Steve Almany
- William Beaumont Hospital, 4600 Investment Dr., Suite 200, Troy, MI, 48098, USA
| | - Jay Kozlowski
- Huron Valley Sinai Hospital, 1 William Carls Dr., Commerce, MI, 48382, USA
| | - Gregory D Krol
- Henry Ford Health System, 2799 W. Grand Blvd., Detroit, MI, 48202, USA
| | - Scott Kaatz
- Hurley Medical Center, 1 Hurley Plaza, Flint, MI, 48503, USA
| | - James B Froehlich
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
| | - Geoffrey D Barnes
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr., Lobby A Rm 3201, Ann Arbor, MI, 48106, USA
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Barnes GD, Gu X, Haymart B, Kline-Rogers E, Almany S, Kozlowski J, Besley D, Krol GD, Froehlich JB, Kaatz S. The Predictive Ability of the CHADS2 and CHA2DS2-VASc Scores for Bleeding Risk in Atrial Fibrillation: The MAQI2 Experience. Thromb Res 2014; 134:294-9. [DOI: 10.1016/j.thromres.2014.05.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 04/22/2014] [Accepted: 05/20/2014] [Indexed: 10/25/2022]
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Barnes GD, Kaatz S, Winfield J, Gu X, Haymart B, Kline-Rogers E, Kozlowski J, Beasley D, Almany S, Leyden T, Froehlich JB. Warfarin use in atrial fibrillation patients at low risk for stroke: analysis of the Michigan Anticoagulation Quality Improvement Initiative (MAQI2). J Thromb Thrombolysis 2013; 37:171-6. [DOI: 10.1007/s11239-013-0934-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Winfield J, Barnes GD, Kaatz S, Gu X, Kline-Rogers E, Kozlowski J, Hickman L, Leyden T, Besley D, Haymart B, Leidal A, Theurer A, Froehlich JB. USE OF WARFARIN THERAPY AND RISK STRATIFICATION TOOLS FOR ATRIAL FIBRILLATION PATIENTS. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)61245-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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