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Poggio S, Roy S, Bégué T, Dumenil AS, Henry C. [Targeting anticoagulated patients for medication reconciliation at discharge in orthopaedic surgery]. ANNALES PHARMACEUTIQUES FRANÇAISES 2023; 81:173-181. [PMID: 35792149 DOI: 10.1016/j.pharma.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/09/2022] [Accepted: 06/29/2022] [Indexed: 01/07/2023]
Abstract
In orthopedic surgery, the well-known iatrogenic risk of oral anticoagulants is particularly increased due to surgical management (suspension and resumption of treatment). In order to prevent avoidable iatrogenic events linked to incomplete discharge documents, targeted medical reconciliation (MR) has been deployed. This is a single-center prospective study conducted in orthopaedic surgery for six months including any patient treated upon admission with an oral anticoagulant. The analysis of the compliance of discharge documents (hospitalization report and prescriptions) was carried out before and after pharmaceutical interventions. The criteria analysed included the mention of the oral treatment, its dosage as well as the supervision of the switch from heparin therapy to the usual oral treatment. The documents were compliant if the mention of oral anticoagulant treatment and the date of the shift were correctly documented. Thirty-seven patients were included. The compliance rate of discharge documents was significantly improved by MR, going from 13.5 % to 78.4 % (P <0.05). The non-compliances before the intervention concerned the absence of mention of: the usual treatment (64.9 %), its dosage (81.1 %) or the switch's securing (75.7 %). Discharge from surgery of the patient on anticoagulants is a stage presenting a real risk which can be managed by the intervention of pharmacists. Improving the compliance of discharge documents is a first step towards better securing drug management.
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Affiliation(s)
- S Poggio
- Service de pharmacie, Hôpital Antoine Béclère - AP-HP, 157, rue de la porte de Trivaux, 92140 Clamart, France
| | - S Roy
- Service de pharmacie, Hôpital Antoine Béclère - AP-HP, 157, rue de la porte de Trivaux, 92140 Clamart, France
| | - T Bégué
- Service de chirurgie, Hôpital Antoine Béclère- AP-HP, 157, rue de la porte de Trivaux, 92140 Clamart, France
| | - A-S Dumenil
- Service d'anesthésie, Hôpital Antoine Béclère - AP-HP, 157, rue de la porte de Trivaux, 92140 Clamart, France
| | - C Henry
- Service de pharmacie, Hôpital Antoine Béclère - AP-HP, 157, rue de la porte de Trivaux, 92140 Clamart, France.
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Cost-Effectiveness of Bridging Anticoagulation. J Gen Intern Med 2021; 36:226. [PMID: 31602562 PMCID: PMC7858997 DOI: 10.1007/s11606-019-05322-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/26/2019] [Indexed: 10/25/2022]
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Kulkarni SA, Fang MC. Bridging Anticoagulation Therapy: A Teachable Moment. JAMA Intern Med 2020; 180:311-312. [PMID: 31764945 DOI: 10.1001/jamainternmed.2019.5934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Shradha A Kulkarni
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
| | - Margaret C Fang
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
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van der Pol S, Jacobs MS, Meijer K, Piersma-Wichers MG, Tieleman RG, Postma MJ, van Hulst M. Perioperative bridging of vitamin K antagonist treatment in patients with atrial fibrillation: only a very small group of patients benefits. Europace 2019; 21:716-723. [PMID: 30649301 DOI: 10.1093/europace/euy308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 12/03/2018] [Indexed: 01/19/2023] Open
Abstract
AIMS Bridging anticoagulation in atrial fibrillation (AF) patients who need to interrupt vitamin K antagonists for procedures is a clinical dilemma. Currently, guidelines recommend clinicians to take the stroke and bleeding risk into consideration, but no clear thresholds are advised. To aid clinical decision making, we aimed to develop a model in which periprocedural bridging therapy is compared with withholding anticoagulation in AF patients, for several bleeding and stroke risk groups. METHODS AND RESULTS A model was developed to simulate both a bridge and a non-bridge cohort, using simulated international normalized ratio (INR) values for patients on warfarin, acenocoumarol, and phenprocoumon. For both clinical strategies, stroke and bleeding risks were included and outcomes were stratified by CHA2DS2-VASc or CHADS2 and HAS-BLED groups. Quality-adjusted life expectancy was the main outcome considered. Our analyses show bridging to only be beneficial for patients with HAS-BLED scores equal or lower to 2 and with CHA2DS2-VASc scores of 6 or higher. For patients using acenocoumarol bridging may be beneficial starting at a CHA2DS2-VASc score of 7. Post-procedural time to therapeutic INR has a significant influence on the results: no significant benefit of bridging was found for patients reaching therapeutic INR values within 5 days. CONCLUSION When deciding whether to bridge anticoagulation, clinicians should consider the patient's individual stroke and bleeding risk, while also considering the patient's post-procedural INR management. In practice, only a small subset of patients is expected to benefit from bridging anticoagulation treatment.
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Affiliation(s)
- Simon van der Pol
- Department of Health Sciences, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Maartje S Jacobs
- Department of Clinical Pharmacy and Toxicology, Martini Hospital, RM Groningen, The Netherlands.,University of Groningen, Groningen Research Institute of Pharmacy, Groningen, The Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Margriet G Piersma-Wichers
- Department of Haematology, University Medical Center, University of Groningen, Groningen, The Netherlands.,Certe Thrombosis Service Groningen, Groningen, The Netherlands
| | - Robert G Tieleman
- Department of Cardiology, Martini Hospital, Groningen, The Netherlands.,Department of Cardiology, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Maarten J Postma
- Department of Health Sciences, University of Groningen, University Medical Center, Groningen, The Netherlands.,University of Groningen, Groningen Research Institute of Pharmacy, Groningen, The Netherlands.,Institute of Science in Healthy Aging and Healthcare (SHARE), University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Marinus van Hulst
- Department of Health Sciences, University of Groningen, University Medical Center, Groningen, The Netherlands.,Department of Clinical Pharmacy and Toxicology, Martini Hospital, RM Groningen, The Netherlands
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Cost-Effectiveness of Bridging Anticoagulation Among Patients with Nonvalvular Atrial Fibrillation. J Gen Intern Med 2019; 34:583-590. [PMID: 30623388 PMCID: PMC6445930 DOI: 10.1007/s11606-018-4796-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 06/14/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Bridging anticoagulation is commonly prescribed to patients with atrial fibrillation during initiation and interruption of warfarin. Guidelines recommend bridging patients at high risk of stroke, while a recent randomized trial demonstrated overall harm in a population at comparatively low risk of ischemic stroke. Theory suggests that patients at high risk of stroke and low risk of hemorrhage may benefit from bridging, but data informing patient selection are scant. OBJECTIVE To estimate the utility and cost-effectiveness of bridging anticoagulation among patients with nonvalvular atrial fibrillation, stratified by thromboembolic and hemorrhagic risk DESIGN: Cost-effectiveness analysis with lifelong time horizon, from the perspective of a third-party payer MAIN MEASURES: Quality-adjusted life years (QALYs) per bridged patient; US dollars per QALY gained KEY RESULTS: Unselected patients with nonvalvular atrial fibrillation may be harmed by bridging anticoagulation. Hospital admission for bridging is almost never cost-effective, and generally harmful. Among patients carefully selected by both thromboembolic and hemorrhagic risks, outpatient bridging can be beneficial and cost-effective. Results were sensitive to how effectively heparin products reduce stroke risk. CONCLUSIONS Outpatient bridging anticoagulation can be beneficial and cost-effective for a subset of patients with nonvalvular atrial fibrillation during interruption or initiation of warfarin. Admission for bridging should be avoided.
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