Delivery of Optimized Anticoagulant Therapy: Consensus Statement from the Anticoagulation Forum

Quality improvement in an anticoagulation clinic: development of a new treatment protocol

We sought to improve patient outcomes and efficiency in our anticoagulation clinic through development of a new protocol for managing heart valve patients with subtherapeutic international normalized ratio (INR) tests. The new protocol standardized use of 1 anticoagulation agent while warfarin was retitrated, timelines for INR retesting, and target INR levels depending on the type of valve implanted. The new protocol provided significant improvements in patient care; however, outcomes for clinic operating efficiency were mixed.

Vitamin K antagonists--current concepts and challenges

Vitamin K antagtonists (VKAs) have, for decades, been the corner-stone of anticoagulation in the outpatient setting. While the long half life makes once daily administration practical, close monitoring of VKA effect is necessary because these medicines have a narrow therapeutic index. Despite inter-individual variations in response to VKA doses, the increasing availability of specialized anticoagulation monitoring systems, along with a better understanding of potential drug and dietary interactions, has made the use of VKAs safer and less burdensome. In the future, newer classes of oral anticoagulants and genomic-based dosing strategies may further expand or improve the management options for many patients at risk for thromboembolism.

Challenges and benefits of an inpatient anticoagulation service: one hospital's experience

While outpatient anticoagulation services (AMS) have existed extensively for a number of years, inpatient AMS have only recently begun to be implemented on a widespread basis. This is in direct response to anticoagulation regulations set forth by entities such as the Joint Commission (TJC) and the Centers for Medicare and Medicaid services (CMS). Hospitals not complying with these regulations are at risk for either financial or accreditation punition. Inpatient AMS have reported positive impacts on patient outcomes in the literature, which gives hospitals an additional impetus to provide this type of service. Inpatient AMS pose many challenges, including identification of resources for development and implementation of the service, means to make changes to the service as it evolves and effectively tracking performance of the service. Using a well-planned, methodical approach for implementation has helped our institution capitalize on the numerous potential benefits of an inpatient AMS, including improved inpatient anticoagulation therapy, improved transitions of care and enhanced interdisciplinary practices.

Management of atrial fibrillation: translating clinical trial data into clinical practice

Atrial fibrillation is a supraventricular tachyarrhythmia with significant consequences in terms of morbidity and mortality. In light of the limitations of available pharmacologic treatment options (suboptimal efficacy plus safety and tolerability issues), atrial fibrillation management should be individualized based on patient characteristics and comorbidities that could influence response to specific management approaches. The importance of adequate anticoagulation should not be overlooked. This review provides a practical guide for primary care physicians, internists, and cardiologists on current management strategies for atrial fibrillation, based on recent guidelines and current clinical data.

Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

This guideline provides an overview of the evidence on established and emerging risk factors for stroke to provide evidence-based recommendations for the reduction of risk of a first stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council Scientific Statement Oversight Committee and the AHA Manuscript Oversight Committee. The writing group used systematic literature reviews (covering the time since the last review was published in 2006 up to April 2009), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations using standard AHA criteria (Tables 1 and 2). All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive peer review by the Stroke Council leadership and the AHA scientific statements oversight committees before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic predisposition. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, excessive alcohol consumption, drug abuse, use of oral contraceptives, sleep-disordered breathing, migraine, hyperhomocysteinemia, elevated lipoprotein(a), hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed.

CONCLUSIONS

Extensive evidence identifies a variety of specific factors that increase the risk of a first stroke and that provide strategies for reducing that risk.

A formal risk-benefit framework for genomic tests: facilitating the appropriate translation of genomics into clinical practice

PURPOSE

Evaluation of genomic tests is often challenging because of the lack of direct evidence of clinical benefit compared with usual care and unclear evidence requirements. To address these issues, this study presents a risk-benefit framework for assessing the health-related utility of genomic tests.

METHODS

We incorporated approaches from a variety of established fields including decision science, outcomes research, and health technology assessment to develop the framework. Additionally, we considered genomic test stakeholder perspectives and case studies.

RESULTS

We developed a three-tiered framework: first, we use decision-analytic modeling techniques to synthesize data, project incidence of clinical events, and assess uncertainty. Second, we defined the health-related utility of genomic tests as improvement in health outcomes as measured by clinical event rates, life expectancy, and quality-adjusted life-years. Finally, we displayed results using a risk-benefit policy matrix to facilitate the interpretation and implementation of findings from these analyses.

CONCLUSION

A formal risk-benefit framework may accelerate the utilization and practice-based evidence development of genomic tests that pose low risk and offer plausible clinical benefit, while discouraging premature use of tests that provide little benefit or pose significant health risks compared with usual care.

Optimizing use of current anticoagulants

Although warfarin has been the mainstay of oral anticoagulation therapy for decades, evidence-based methods for improving the quality of warfarin therapy remain underused. The arrival of new anticoagulants that do not require routine laboratory monitoring and lack the significant dietary and drug interaction potential that are seen with warfarin is an important evolutionary step in the management of thromboembolic disease. However, it will be years before the efficacy and long-term safety of these new agents are defined. Newer oral anticoagulants will be more expensive than generic warfarin. This article examines various approaches to optimize the clinical use of warfarin. For patients able to achieve stable anticoagulation control, warfarin remains an important therapeutic option, delivering similar clinical outcomes at a fraction of the cost to the health care system.

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

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

Comparative effectiveness research and personalized medicine: catalyzing or colliding?

Comparative effectiveness research (CER) is generating intense attention as interest grows in finding new and better drug technology assessment processes. The federal government is supporting the expansion of CER through funding made available in the American Recovery and Reinvestment Act of 2009 (ARRA) and by establishing the Patient-Centered Outcomes Research Institute through the Patient Protection and Affordable Care Act of 2010. At the same time, personalized medicine is generating debate about its place in clinical medicine, and so, naturally, how CER can or cannot play a role in personalized medicine is part of these debates. At the heart of the debate around the role of CER in personalized medicine is the nature of personalized medicine and how it fits within contemporary clinical research concepts. We maintain in this article that CER can serve to catalyze personalized medicine, but we recognize that, for this to happen, researchers will need to embrace new data sources and new analytic approaches. We also recognize that drug technology assessment processes will have to undergo necessary adaptations to accommodate CER as configured for personalized medicine, and that clinicians will need to be educated appropriately and provided access to decision-support systems through health information technology to use the information coming from this research. To illustrate our argument, we describe two ongoing CER studies funded and managed in the private sector evaluating personalized medicine interventions that have important clinical and financial implications. One of the studies investigates the clinical and financial effects of pharmacogenomic testing for warfarin as prescribed in conditions of typical practice settings. The other study is also set in community practice settings and compares cardiovascular outcomes of patients receiving clopidogrel who are extensive metabolizer phenotypes for the cytochrome P450 2C19 hepatic isoenzyme with all patients receiving prasugrel.

10 years of oral anticoagulant pharmacogenomics: what difference will it make? A critical appraisal

Since the first report on warfarin pharmacogenetics in 1999, genetic variants have emerged as an important predictor of warfarin maintenance doses before therapy is initiated, raising expectations of greatly improved clinical outcomes. However, much of the information on warfarin sensitivity conveyed by genetic variants is captured by early international normalized ratio values traditionally used to guide dose titration. Thus, inclusion of early international normalized ratios in prediction models reduces the contribution of genetics. Moreover, in large population cohorts, genetics explained only 20–30% of variance in warfarin doses. Finally, even pharmacogenetic prediction models did not predict doses reliably in the majority of at-risk patients with warfarin requirements at the low or high end of the dose range. Currently, the clinical utility and cost–effectiveness of pharmacogenetic-based dosing are being assessed in large prospective trials in various settings. In the interim, enthusiasm for warfarin pharmacogenetics should not supersede strict adherence to traditional measures used to optimize coumarin anticoagulation.

How I treat the antiphospholipid syndrome

This article discusses how we approach medical decision making in the treatment of the various facets of the antiphospholipid syndrome (APS), including secondary prophylaxis in the setting of venous and arterial thrombosis, as well as treatment for the prevention of recurrent miscarriages and fetal death. The role of primary thromboprophylaxis is also discussed in depth. Great emphasis is given to incorporating the most up-to-date and relevant evidence base both from the APS literature, and from large, recent, randomized controlled trials (RCTs) of primary and secondary thrombotic prophylaxis in the general population setting (ie, the population that has not been specifically investigated for APS).

Potentially avoidable inpatient nights among warfarin receiving patients; an audit of a single university teaching hospital

BACKGROUND

Warfarin is an oral anticoagulant (OAT) that needs active management to ensure therapeutic range. Initial management is often carried out as an inpatient, though not requiring inpatient facilities. This mismatch results in financial costs which could be directed more efficaciously. The extent of this has previously been unknown. Here we aim to calculate the potential number of bed nights which may be saved among those being dose optimized as inpatients and examine associated factors.

METHODS

A 6 week prospective audit of inpatients receiving OAT, at Cork University Hospital, was carried out. The study period was from 11th June 2007 to 20th July 2007. Data was collected from patient's medications prescription charts, medical record files, and computerised haematology laboratory records. The indications for OAT, the patient laboratory coagulation results and therapeutic intervals along with patient demographics were analysed. The level of potentially avoidable inpatient nights in those receiving OAT in hospital was calculated and the potential cost savings quantified. Potential avoidable bed nights were defined as patients remaining in hospital for the purpose of optimizing OAT dosage, while receiving subtherapeutic or therapeutic OAT (being titred up to therapeutic levels) and co-administered covering low molecular weight heparin, and requiring no other active care. The average cost of euro638 was taken as the per night hospital stay cost for a non-Intensive Care bed. Ethical approval was granted from the Ethical Committee of the Cork Teaching Hospitals, Cork, Ireland.

RESULTS

A total of 158 patients were included in the audit. There was 94 men (59.4%) and 64 women (40.6%). The mean age was 67.8 years, with a median age of 70 years.Atrial Fibrillation (43%, n = 70), followed by aortic valve replacement (15%, n = 23) and pulmonary emboli (11%, n = 18) were the commonest reasons for prescribing OAT. 54% had previously been prescribed OAT prior to current admission.It was confirmed that, there are potentially avoidable nights in patients receiving OAT. The majority of this group were those being commenced on OAT for the first time (p = 0.00002), in the specialities of Cardiology, Cardiothoracic surgery and Care of the Elderly. The potential number of bed nights to be saved is 13 per week for the hospital or 1.1 bed nights per 10,000 general hospital admissions. These were predominantly weekday nights. The estimated cost of avoidable inpatient OAT dose optimization was approximately euro8300 per week.

CONCLUSION

With rising costs and the increasing demands for acute hospital beds, alterations to inpatient management for this group of patients should be considered. Alternatives include increasing the size of current anticoagulation clinics, introduction of POCT (point of care testing) devices and increased GP management. POCT can be justified based upon the publication by Gardiner et al, who showed that 87% of patients find self testing straightforward, 87% were confident in the result they obtained using the devices and 77% preferred self testing.