Effect of Study Setting on Anticoagulation Control

Walraven, Carl van; Jennings, Alison; Oake, Natalie; Fergusson, Dean; Forster, Alan J.

doi:10.1378/chest.129.5.1155

Cited by 445 publications

(371 citation statements)

References 84 publications

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“…Comparable results were found only in the study of Sarawate et al (27) where the average TTR was 28.6 months. Differently from the present study, most prior observational studies reporting higher TTR were conducted in patients in hospital setting, under supervision of hospital-based physicians or by anticoagulation clinics (28). What is evident in this real world study performed in a community setting covering a long period of time, is a persisting difficulty for general practitioners of managing especially elderly patients (aged 75 or older) affected by several comorbidities.…”

Section: Resultsmentioning

confidence: 64%

Real-practice thromboprophylaxis in atrial fibrillation

et al. 2017

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This retrospective observational study was based on databases of the Local Health Authority of Treviso, Italy. It evaluated the prevalence and the effectiveness of oral anticoagulation treatment (OAT) for the management of nonvalvular atrial fibrillation (NVAF) in everyday clinical practice. Out of 6,138 NVAF patients, only 3,024 received vitamin K antagonist (VKA). Potential barriers decreasing the probability of being treated with VKA were female sex, older age, antiplatelet treatment and history of bleeding. In addition, VKA-treatment was not in line with current ESC and AIAC guidelines, since the patients at high or low risk of stroke were under-or over-treated, resp. Among VKAtreated patients, 73 % of subjects were not at target with anticoagulation. OAT resulted to be effective in reducing stroke risk. However, stroke events were significantly influenced also by previous stroke or transient ischemic attack (hazard ratio, HR = 2.99, p < 0.001) and by previous bleeding events (HR = 1.60, p < 0.001).

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Section: Resultsmentioning

confidence: 64%

Real-practice thromboprophylaxis in atrial fibrillation

et al. 2017

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“…The cost analyses are specific to the practice at two hospitals in BC and other hospitals across Canada that have similar ED programs in place; they may not apply to outpatient anticoagulation clinics, which have different workflow and cost models. 16 In addition, costs are specific to the practice setting, city, and province of this study; although comparable to other jurisdictions, costs will obviously differ between settings.…”

Section: Limitationsmentioning

confidence: 94%

A pharmacoeconomic study of traditional anticoagulation versus direct oral anticoagulation for the treatment of venous thromboembolism in the emergency department

Law

Ghag

Grafstein

et al. 2016

CJEM

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Objectives: Patients with venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [PE]) are commonly treated as outpatients. Traditionally, patients are anticoagulated with low-molecular-weight heparin (LMWH) and warfarin, resulting in return visits to the ED. The direct oral anticoagulant (DOAC) medications do not require therapeutic monitoring or repeat visits; however, they are more expensive. This study compared health costs, from the hospital and patient perspectives, between traditional versus DOAC therapy. Methods: A chart review of VTE cases at two tertiary, urban hospitals from January 1, 2010 to December 31, 2012 was performed to capture historical practice in VTE management, using LMWH/warfarin. This historical data were compared against data derived from clinical trials, where a DOAC was used. Cost minimization analyses comparing the two modes of anticoagulation were completed from hospital and patient perspectives. Results: Of the 207 cases in the cohort, only 130 (63.2%) were therapeutically anticoagulated (international normalized ratio 2.0-3.0) at emergency department (ED) discharge; patients returned for a mean of 7.18 (range: 1-21) visits. Twenty-one (10%) were admitted to the hospital; 4 (1.9%) were related to VTE or anticoagulation complications. From a hospital perspective, a DOAC (in this case, rivaroxaban) had a total cost avoidance of $1,488.04 per VTE event, per patient. From a patient perspective, it would cost an additional $204.10 to $349.04 over 6 months, assuming no reimbursement. Conclusions: VTE management in the ED has opportunities for improvement. A DOAC is a viable and cost-effective strategy for VTE treatment from a hospital perspective and, depending on patient characteristics and values, may also be an appropriate and cost-effective option from a patient perspective. RÉSUMÉObjectif: Les patients souffrant d'une thromboembolie veineuse (TEV) (thrombose veineuse profonde [TVP] ou embolie pulmonaire [EP]) sont souvent traités en consultation externe. L'anticoagulation se réalise habituellement par l'héparine de faible masse moléculaire (HFMM) et par la warfarine, ce qui nécessite des consultations ultérieures au service des urgences (SU). Il existe aussi l'anticoagulation orale directe (AOD), qui ne nécessite pas de surveillance thérapeutique ou de consultations rapprochées, mais son coût est plus élevé que celui du traitement classique. L'étude décrite ici visait donc à comparer les coûts, liés aux soins de santé, de l'anticoagulation classique avec ceux de l'AOD, et ce, tant pour les hôpitaux que pour les patients. Méthode: Les auteurs ont procédé à un examen des dossiers des cas de TEV traités dans deux hôpitaux urbains, de soins tertiaires, pour la période du 1 er janvier 2010 au 31 décembre 2012, afin de recueillir des données sur la pratique historique du traitement de la TEV par l'HFMM et la warfarine. Il y a eu par la suite comparaison des données historiques avec celles provenant d'essais cliniques d'anticoagulants oraux directs. Enfin...

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“…Several studies indicate a clear association between a low time in therapeutic range (TTR) and an increased risk of vascular events and major hemorrhage in patients on Warfarin [89][90][91]. A meta-regression analysis of recently published studies reported a mean TTR in all studies of 64% [92], although a wide variation was seen, occasionally with TTRs as low as 29%. A marked benefit against stroke and total vascular events for patients on warfarin treated at centers with mean TTRs above 65% has been documented; [91] no apparent benefit was found for patients treated at centers achieving mean TTRs below 65%.…”

Section: Pitfalls Of Warfarin: Is It Worth the Trouble?mentioning

confidence: 99%

Untreated atrial fibrillation in the United Kingdom: Understanding the barriers and treatment options

Barra

Fynn

2015

Journal of the Saudi Heart Association

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Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a major preventable cause of stroke and hospitalization. Its prevalence is on the rise worldwide and experts believe it will continue to rise for the foreseeable future, due to the ageing population and increased survival from conditions associated with AF. Despite the fact that oral anticoagulation is effective in preventing strokes due to AF, there is extensive evidence suggesting this therapy remains underused. Barriers to the prescription of anticoagulation include patients' age per se, comorbidities, inadequate risk stratification, perceived risk of falls and bleeding, and the difficulty in achieving a stable international normalized ratio (INR) on warfarin. Also, asymptomatic patients with AF may not be identified and therefore not be candidates for anticoagulation. Physicians need continued better education on the identification of patients at risk of stroke and management of oral anticoagulation. This article reviews the barriers to anticoagulation in patients with AF in the United Kingdom and considers how those barriers may be overcome.

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Effect of Study Setting on Anticoagulation Control

Cited by 445 publications

References 84 publications

Real-practice thromboprophylaxis in atrial fibrillation

Real-practice thromboprophylaxis in atrial fibrillation

A pharmacoeconomic study of traditional anticoagulation versus direct oral anticoagulation for the treatment of venous thromboembolism in the emergency department

Untreated atrial fibrillation in the United Kingdom: Understanding the barriers and treatment options

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