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Villalba L, Cortés M, Garmendia C, Viruel M, Muñoz F, Suarez J, Costabel JP. HEALTH-RELATED QUALITY OF LIFE IN PATIENTS UNDER TREATMENT WITH APIXABAN IN LATIN AMERICA. Curr Probl Cardiol 2022; 47:101297. [PMID: 35753398 DOI: 10.1016/j.cpcardiol.2022.101297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 06/17/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) has a strong impact on the quality of life (QoL) of patients and anticoagulation has a lot to do with it. We evaluated the QoL of patients with nonvalvular AF who start treatment with apixaban in Latin America. METHODS QoL was analyzed through a questionnaire developed to evaluate anticoagulated patients, which was completed by them 3 months after starting treatment. RESULTS We included 521 patients from Uruguay, Bolivia, Ecuador, Paraguay, and Peru. A high index of general treatment satisfaction (5.34 ± 0.46) and self-efficacy (5.11 ± 0.68) were observed; the distress index was low (1.77 ± 0.88), as was the perception of daily hassles (1.35 ± 0.49) and strain social network related to medication (1.21 ± 0.34). CONCLUSIONS Patients with AF who started treatment with apixaban has good satisfaction and self-efficacy scores with low index of stress, few daily limitations and social disruptions.
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Affiliation(s)
- Lorena Villalba
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Marcia Cortés
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Cristian Garmendia
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Marcos Viruel
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Florencia Muñoz
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Jorge Suarez
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Juan Pablo Costabel
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina.
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Al-Jabi SW, Dalu AA, Koni AA, Khdour MR, Taha AA, Amer R, Zyoud SH. The relationship between self-efficacy and treatment satisfaction among patients with anticoagulant therapy: a cross-sectional study from a developing country. Thromb J 2022; 20:15. [PMID: 35379235 PMCID: PMC8978358 DOI: 10.1186/s12959-022-00374-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/23/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Thromboembolic events are a common complicated health problem. Although anticoagulants have several positive effects on these conditions, they also have several characteristics that strongly affect compliance and satisfaction. The purpose of this investigation is to explore the association between treatment satisfaction and self-efficacy in a sample of patients using anticoagulation therapy and determine the influence of sociodemographic and clinical factors on both aspects. METHODS This was a cross-sectional exploratory study carried out in Palestine. The Arabic version of the Anti-Coagulant Treatment Satisfaction Scale (ACTS) assessed treatment satisfaction. In addition, the Arabic version of the 6-Item Self-Efficacy for Managing Chronic Diseases (SES6C) was used to assess self-efficacy. RESULTS A total of 300 patients using anticoagulants (average age 51.95 and SD 17.98) were included. There is a modest correlation between treatment satisfaction and self-efficacy (r = 0.345; p < 0.001). The mean and median self-efficacy scores were 38.41 ± 9.88 and 39.00 (interquartile range: 33.00-46.00), respectively. Overall, patients reported a moderate burden and benefit score. The mean and median of the acting burden were 43.30 ± 10.45, and 43.30 (interquartile range: 36.00 to 51.00), respectively. The results showed that young age, higher education, employment, use of fewer medications, and having fewer diseases were significantly associated with higher self-efficacy behaviors. The results also showed that new oral anti-coagulants (NOACs) had a higher degree of self-efficacy and ACTS benefit scores (41.00 (33.75-47.00), p = 0.002; 13.00 (12.00-15.00), p < 0.001, respectively), than vitamin k antagonists (VKA). CONCLUSIONS The results demonstrated a significant relationship between treatment satisfaction and self-efficacy, and certain sociodemographic and clinical characteristics influence both. We found that there is a higher degree of self-efficacy and treatment satisfaction among patients who use NOACs than those who use UFH / VKA. Therefore, patients should be motivated to increase their knowledge about anticoagulant therapy. Healthcare providers should play an active role in educating patients, increasing their self-esteem, and awareness about anticoagulant drugs. Importantly, this study was an explanatory one, and it includes a low proportion of patients with venous thromboembolism. This encourages future research on a large scale of patients, considering the indications of anticoagulant therapy.
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Affiliation(s)
- Samah W. Al-Jabi
- grid.11942.3f0000 0004 0631 5695Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
| | - Amal Abu Dalu
- grid.11942.3f0000 0004 0631 5695Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
| | - Amer A. Koni
- grid.11942.3f0000 0004 0631 5695Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Division of Clinical Pharmacy, Department of Hematology and Oncology, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Maher R. Khdour
- grid.16662.350000 0001 2298 706XFaculty of Pharmacy, Al-Quds University, Abu Deis, Jerusalem, 51000 Palestine
| | - Adham Abu Taha
- grid.11942.3f0000 0004 0631 5695Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Department of Pathology, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Riad Amer
- grid.11942.3f0000 0004 0631 5695Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Department of Hematology and Oncology, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Sa’ed H. Zyoud
- grid.11942.3f0000 0004 0631 5695Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Poison Control and Drug Information Center (PCDIC), College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Clinical Research Center, An-Najah National University Hospital, Nablus, 44839 Palestine
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Price EL, Ansell J. Virtual Education for Patient Self-Testing for Warfarin Therapy Is Effective During the COVID-19 Pandemic. Jt Comm J Qual Patient Saf 2022; 48:214-221. [PMID: 35131178 PMCID: PMC8763408 DOI: 10.1016/j.jcjq.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/20/2021] [Accepted: 01/03/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Prior to the COVID-19 pandemic, warfarin users were required to complete in-person training in order to participate in approved international normalized ratio (INR) patient self-testing (PST) programs. To minimize in-person contact during the pandemic, a federal waiver of the in-person training requirement allowed new patients to begin PST after completing virtual training. However, it was uncertain whether such patients achieved comparable levels of INR control to patients receiving in-person training. METHODS INR results for patients receiving virtual training upon PST commencement between April 1, 2020, and December 31, 2020, were compared to those of patients initiating PST with in-person training between April 1, 2019, and December 31, 2019. The primary outcome was the difference in warfarin time in therapeutic range (TTR) between the groups, with secondary outcomes including differences in the percentages of INR values within individually prescribed INR range and of critical INR values. RESULTS The records of 33,683 patients were included in the analysis (13,568 in the "In-Person" sample; 20,115 in the "Virtual" sample). Patients in the Virtual sample achieved a TTR of 66.78%, compared to the In-Person sample (64.19%; absolute difference 2.59; 95% confidence interval [CI] = 2.50-2.68, p < 0.001). The TTR values were also statistically significantly higher in all subgroups evaluated across categories of patient age, gender, geography, and indication. Similarly favorable results were achieved for INR values in range and critical values. CONCLUSION Virtual education for PST for warfarin therapy is effective and should continue to be an option for patients and providers throughout the pandemic, and possibly beyond.
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Lorenzoni V, Pirri S, Turchetti G. Cost-Effectiveness of Direct Non-Vitamin K Oral Anticoagulants Versus Vitamin K Antagonists for the Management of Patients with Non-Valvular Atrial Fibrillation Based on Available "Real-World" Evidence: The Italian National Health System Perspective. Clin Drug Investig 2021; 41:255-267. [PMID: 33587284 PMCID: PMC7946694 DOI: 10.1007/s40261-021-01002-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND OBJECTIVE The increasing availability of real-world evidence (RWE) about safety and effectiveness of direct non-vitamin K oral anticoagulants (DOACs) for the management of atrial fibrillation (AF) offers the opportunity to better understand the clinical and economic implications of DOACs versus vitamin K antagonists (VKAs). The objective of this study was to compare the economic implications of DOACs and VKAs using data from real-world evidence in patients with AF. METHODS A Markov model simulating the lifetime course of patients diagnosed with non-valvular AF was used to evaluate the cost-effectiveness of DOACs (i.e., rivaroxaban, dabigatran and apixaban) versus VKAs from the Italian National Health System (INHS) perspective. The model was made up of data from the literature and a meta-analysis of RWE on the incidence of stroke/systemic embolism (SE), major bleeding (MB), intracranial haemorrhage (ICH) and all-cause mortality (ACM); direct costs included drug costs, costs for drug monitoring, and management of events from official national lists. One-way and probabilistic sensitivity analyses (PSA) were used to assess the robustness of the results. RESULTS Results from the meta-analysis showed that apixaban had a high probability of being the most effective for stroke/SE, MB and ACM. Despite their higher acquisition costs, the cost-effectiveness analysis showed all DOACs involved a saving when compared with VKAs, with per-patient savings ranging between €4647 (rivaroxaban) to €6086 (apixaban). Moreover, all DOACs indicated a gain both in quality-adjusted life-years and life-years. According to PSA, findings related to apixaban were consistent, while for dabigatran and rivaroxaban PSA revealed a higher degree of uncertainty. CONCLUSIONS The beneficial effect of DOACs on containing events showed in RWE had the potential to offset drug-related costs, thus improving the sustainability of treatment for non-valvular AF in daily clinical practice.
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Affiliation(s)
- Valentina Lorenzoni
- Institute of Management, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127, Pisa, Italy.
| | - Salvatore Pirri
- Institute of Management, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127, Pisa, Italy
| | - Giuseppe Turchetti
- Institute of Management, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127, Pisa, Italy
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Iqbal MS, Kassab YW, Al-Saikhan FI, Almalki ZS, Haseeb A, Iqbal MZ, Ali M. Assessing quality of life using WHOQOL-BREF: A cross-sectional insight among patients on warfarin in Malaysia. Saudi Pharm J 2020; 28:936-942. [PMID: 32792838 PMCID: PMC7414056 DOI: 10.1016/j.jsps.2020.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/20/2020] [Indexed: 11/03/2022] Open
Abstract
Background and aim The effect of anticoagulation control on overall Health-Related Quality of Life (HRQoL) in patients taking warfarin in Malaysia has not been explored yet. Therefore, this study aimed to evaluate HRQoL among patients on warfarin in Malaysia. Methods HRQoL among patients on warfarin was measured using WHOQOL-BREF (World Health Organization Quality of life Assessment: Brief Version). Descriptive and inferential statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 22. Results Out of 319 patients, more female patients were observed than the males (n = 221, 69.3%, and n = 98, 30.7% respectively). Mean scores for the physical (61.14 ± 15.96), psychological (68.58 ± 16.11), social (63.55 ± 27.06) and environmental domains (62.78 ± 17.58) were observed. Statistically, a significant association was found between the comorbidities other than CVDs with health satisfaction (p = 0.002), physical (p = 0.001), psychological (p < 0.001), social (p = 0.003) and environmental domains of the WHOQOL-BREF. A weak positive correlation between overall health satisfaction and the social domain (r = 0.153) and a moderate positive correlation between the physical and environmental domains (r = 0.628) of the WHOQOL-BREF were observed. Conclusion Patients had overall better perceived HRQoL scores in the psychological domain as compared with the rest of the domains of the WHOQOL-BREF. Age, gender, employment status, education level, the indication of use and duration of warfarin therapy associated with overall perceived HRQoL.
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Affiliation(s)
- Muhammad Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam bin Abdulaziz University, Al-kharj 11942, Saudi Arabia
| | - Yaman Walid Kassab
- Department of Hospital and Clinical Pharmacy, Faculty of Pharmacy, Cyberjaya University College of Medical Sciences, 63000 Selangor, Malaysia
| | - Fahad I Al-Saikhan
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam bin Abdulaziz University, Al-kharj 11942, Saudi Arabia
| | - Ziyad S Almalki
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam bin Abdulaziz University, Al-kharj 11942, Saudi Arabia
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Al-Abdia Campus, Taif Road, PO Box 13574, Makkah, 21955, Saudi Arabia
| | - Muhammad Zahid Iqbal
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, AIMST University, 08100 Bedong, Kedah Darul Aman, Malaysia
| | - Majid Ali
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Al-Abdia Campus, Taif Road, PO Box 13574, Makkah, 21955, Saudi Arabia
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Determinants of health-related quality of life among warfarin patients in Pakistan. PLoS One 2020; 15:e0234734. [PMID: 32555595 PMCID: PMC7299364 DOI: 10.1371/journal.pone.0234734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 06/01/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The effect of anticoagulation control on overall Health-Related Quality of Life (HRQoL) in patients taking warfarin in Pakistan has not been explored yet. Therefore, this study aimed to evaluate HRQoL among warfarin patients in Pakistan. METHODS This cross-sectional study was conducted among patients on warfarin in Pakistan. By purposive sampling, data were collected using demographic data collection form and the World Health Organization Quality of Life: Brief Version (WHOQOL-BREF). The WHOQOL-BREF is comprised of four domains; physical, psychological, social relationships, and environment. Descriptive and inferential statistical analysis was done using SPSS version 22. RESULTS Out of 295 warfarin patients, more females than males (<0.001) were observed (n = 184, 62.4%, and n = 111, 37.6% respectively). One hundred and eighteen (40.0%) patients were less than 30-years of age, whereas one hundred and seventy-seven (60.0%) patients were above 30-years of age. Mean scores for the physical (62.44±15.36), psychological (67.84±15.54), social (64.27±26.28) and environment domains (63.45±17.66) were observed. CONCLUSION Patients had overall lower to moderate but satisfactory HRQoL scores in all four domains. Age, gender, employment status, education level, the indication of use and duration of warfarin therapy was associated with one or more domains of HRQoL among warfarin patients. The findings of this study would serve as a primary database for future studies. This study highlights how non-clinical factors could impact HRQoL in studied patients.
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Magon A, Arrigoni C, Moia M, Mancini M, Dellafiore F, Manara DF, Caruso R. Determinants of health-related quality of life: a cross-sectional investigation in physician-managed anticoagulated patients using vitamin K antagonists. Health Qual Life Outcomes 2020; 18:73. [PMID: 32178684 PMCID: PMC7077005 DOI: 10.1186/s12955-020-01326-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Literature has paid little attention in describing the specific contribution of each modifiable and non-modifiable characteristics on health-related quality of life (HRQoL) in physician-managed anticoagulated patients using vitamin K antagonists (VKAs). To describe how patients' treatment-specific knowledge, health literacy, treatment beliefs, clinical, and socio-demographic characteristics influence HRQoL in Italian physician-managed anticoagulated patients using VKAs. METHODS Cross-sectional multicentre study with a consecutive sampling strategy, enrolling 164 long-term anticoagulated patients. Clinical and socio-demographic characteristics were collected from electronic medical records. Valid and reliable questionnaires were used to collect patients' treatment-specific knowledge, health literacy, beliefs about VKAs, physical and health perceptions. RESULTS Obtaining and understanding health information (i.e., communicative health literacy) positively predicts both adequate mental (ORadjusted = 10.9; 95%CI = 1.99-19.10) and physical (ORadjusted = 11.54; 95%CI = 1.99-34.45) health perceptions. Conversely, the ability to perform proper health decision making (i.e., critical health literacy) was associated with lower rates of adequate mental health perception (ORadjusted = 0.13; 95%CI = 0.03-0.63). Further, age negatively predicted physical health perception (ORadjusted = 0.87; 95%CI = 0.81-0.93). CONCLUSIONS Health literacy plays an interesting role in predicting HRQoL. The relationship between critical health literacy and mental health perception could be influenced by some psychological variables, such as distress and frustration, which could be present in patients with higher levels of critical health literacy, as they could be more inclined for self-monitoring. For this reason, future research are needed to identify the most suitable patients' profile for each OAC-management model, by longitudinally describing the predictive performance of each modifiable and non-modifiable determinant of HRQoL.
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Affiliation(s)
- Arianna Magon
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier, 1 - 00133, Rome, Italy.
| | - Cristina Arrigoni
- Department of Public Health, Experimental and Forensic Medicine, Section of Hygiene, University of Pavia, Pavia, Italy
| | - Marco Moia
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Michela Mancini
- Nursing Office, ASST Melegnano e della Martesana, Melzo, Italy
| | - Federica Dellafiore
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Duilio F Manara
- School of Nursing, Vita-Salute San Raffaele University, Milan, Italy
| | - Rosario Caruso
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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Comparative efficacy and safety of warfarin care bundles and novel oral anticoagulants in patients with atrial fibrillation: a systematic review and network meta-analysis. Sci Rep 2020; 10:662. [PMID: 31959803 PMCID: PMC6971267 DOI: 10.1038/s41598-019-57370-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/18/2019] [Indexed: 01/04/2023] Open
Abstract
Warfarin care bundles (e.g. genotype-guided warfarin dosing, patient’s self-testing [PST] or patient’s self-management [PSM] and left atrial appendage closure) are based on the concept of combining several interventions to improve anticoagulation care. NOACs are also introduced for stroke prevention in atrial fibrillation (SPAF). However, these interventions have not been compared in head-to-head trials yet. We did a network meta-analysis based on a systematic review of randomized controlled trials comparing anticoagulant interventions for SPAF. Studies comparing these interventions in adults, whether administered alone or as care bundles were included in the analyses. The primary efficacy outcome was stroke and the primary safety outcome was major bleeding. Thirty-seven studies, involving 100,142 patients were assessed. Compared to usual care, PSM significantly reduced the risk of stroke (risk ratio [RR] 0.24, 95% CI 0.08–0.68). For major bleeding, edoxaban 60 mg (0.80, 0.71–0.90), edoxaban 30 mg (0.48, 0.42–0.56), and dabigatran 110 mg (0.81, 0.71–0.94) significantly reduced the risk of major bleeding compared with usual warfarin care. Cluster rank plot incorporating stroke and major bleeding outcomes indicates that some warfarin care bundles perform as well as NOACs. Both interventions are therefore viable options to be considered for SPAF. Additional studies including head-to-head trials and cost-effectiveness evaluation are still warranted.
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Moloney E, Craig D, Holdsworth N, Smithson J. Optimising clinical effectiveness and quality along the atrial fibrillation anticoagulation pathway: an economic analysis. BMC Health Serv Res 2019; 19:1007. [PMID: 31883510 PMCID: PMC6935474 DOI: 10.1186/s12913-019-4841-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 12/16/2019] [Indexed: 01/04/2023] Open
Abstract
Background Atrial fibrillation (AF) represents the most common sustained cardiac arrhythmia. A service evaluation was carried out at an anticoagulation clinic in Newcastle upon-Tyne to explore the efficacy of introducing self-testing of anticoagulation status for AF patients on warfarin. The analysis presented aims to assess the potential cost savings and clinical outcomes associated with introducing self-testing at a clinic in the Northeast of England, and to determine the cost-effectiveness of a redesigned treatment pathway including genetic testing and self-testing components. Methods Questionnaires were administered to individuals participating in the service evaluation to understand the patient costs associated with clinical monitoring (139 patients), and quality-of-life before and after the introduction of self-testing (varying numbers). Additionally, data on time in therapeutic range (TTR) were captured at multiple time points to identify any change in outcome. Finally, an economic model was developed to assess the cost-effectiveness of introducing a redesigned treatment pathway, including genetic testing and self-testing, for AF patients. Results The average cost per patient of attending the anticoagulation clinic was £16.24 per visit (including carer costs). Costs were higher amongst patients tested at the hospital clinic than those tested at the community clinic. Improvements in quality-of-life across all psychological topics, and improved TTR, were seen following the introduction of self-testing. Results of the cost-effectiveness analysis showed that the redesigned treatment pathway was less costly and more effective than current practice. Conclusions Allowing AF patients on warfarin to self-test, rather than attend clinic to have their anticoagulation status assessed, has the potential to reduce patient costs. Additionally, self-testing may result in improved quality-of-life and TTR. Introducing genetic testing to guide patient treatment based on sensitivity to warfarin, and applying this in combination with self-testing, may also result in improved patient outcomes and reduced costs to the health service in the long-term.
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Affiliation(s)
- Eoin Moloney
- Health Economics Group, Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Newcastle, NE2 4AX, UK.
| | - Dawn Craig
- Health Economics Group, Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Newcastle, NE2 4AX, UK
| | - Nikki Holdsworth
- Academic Health Science Network North East and North Cumbria, Newcastle, UK
| | - Joanne Smithson
- Academic Health Science Network North East and North Cumbria, Newcastle, UK
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Runev N, Potpara T, Naydenov S, Vladimirova A, Georgieva G, Manov E. Physicians' Perceptions of Their Patients' Attitude and Knowledge of Long-Term Oral Anticoagulant Therapy in Bulgaria. ACTA ACUST UNITED AC 2019; 55:medicina55070313. [PMID: 31248007 PMCID: PMC6681397 DOI: 10.3390/medicina55070313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/17/2019] [Accepted: 06/21/2019] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Oral anticoagulation (OAC) is widely used in daily clinical practice worldwide for various indications. We aimed to explore the perception of Bulgarian clinicians about their patients' attitude and knowledge of long-term OAC, prescribed for atrial fibrillation (AF) and/or known deep venous thrombosis (DVT)/pulmonary embolism (PE). Materials and Methods: We performed a cross-sectional study that involved 226 specialists: 187 (82.7%) cardiologists, 23 (10.2%) neurologists, and 16 (7.1%) vascular surgeons. They filled in a questionnaire, specially designed for our study, answering various questions regarding OAC treatment in their daily clinical practice. Results: The mean prescription rate of OACs in AF patients was 80.3% and in DVT/PE-88.6%. One hundred and eighty-seven (82.7%) of the participants stated they see their patients on OAC at least once per month. According to more than one-third of the inquired clinicians, the patients did not understand well enough the provided information concerning net clinical benefit of OAC treatment. About 68% of the clinicians declared that their patients would prefer a "mutual" approach, discussing with the physician the OAC options and taking together the final decision, whereas according to 43 (19.0%), the patients preferred the physician to take a decision for them. Patients' OAC treatment had been interrupted at least once within the last year due to a physician's decision by 178 (78.8%) of the participants and the most common reason was elective surgery. The most influential factors for a patient's choice of OAC were the need of a specific diet to be kept, intake frequency, and possible adverse reactions. Conclusions: Our results suggest that a clinician's continuous medical education, shared decision-making, and appropriate local strategies for improved awareness of AF/DVT/PE patients are key factors for improvement of OAC management.
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Affiliation(s)
- Nikolay Runev
- Department of Internal Diseases, Medical University of Sofia, 1431 Sofia, Bulgaria.
| | - Tatjana Potpara
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia.
| | - Stefan Naydenov
- Department of Internal Diseases, Medical University of Sofia, 1431 Sofia, Bulgaria.
| | - Anita Vladimirova
- Boehringer Ingelheim RCV GmbH & Co KG Bulgarian Branch, 1505 Sofia, Bulgaria.
| | - Gergana Georgieva
- Boehringer Ingelheim RCV GmbH & Co KG Bulgarian Branch, 1505 Sofia, Bulgaria.
| | - Emil Manov
- Department of Internal Diseases, Medical University of Sofia, 1431 Sofia, Bulgaria.
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Treatment Expectations, Convenience, and Satisfaction with Anticoagulant Treatment: Perceptions of Patients in South-East Queensland, Australia. J Clin Med 2019; 8:jcm8060863. [PMID: 31212944 PMCID: PMC6617501 DOI: 10.3390/jcm8060863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/03/2019] [Accepted: 06/14/2019] [Indexed: 12/21/2022] Open
Abstract
Background: Warfarin has long been the only oral anticoagulant (OAC) available, but options now include non-vitamin K antagonists. Prescribing an OAC may be influenced by patient factors and preferences influenced by dosing, monitoring, and adverse effects, which may ultimately impact patient satisfaction and convenience. The aim of this study was to explore the perception of OAC treatment by Australian patients in terms of treatment expectations, convenience, and satisfaction. Methods: The Perception of Anticoagulant Treatment Questionnaire was distributed to patients dispensed OAC medication from three pharmacies in South-East Queensland. Responses to questions using a five-point Likert scale were collated and mean results utilised to assess expectations, convenience, and satisfaction, including an analysis across demographic groups. Results: A total of 56 (26.8%) surveys were returned, with the majority of respondent’s male (58.2%). Highest mean scores for treatment expectation were for an OAC that was easy to take (4.85 ± 0.79) and that could be taken care of by the respondents themselves (4.11 ± 1.14). The mean overall score for convenience was 68.90 ± 11.44% and for satisfaction 69.43 ± 16.58%. Significantly higher mean convenience scores were found in females and patients with atrial fibrillation. Conclusions: Patients’ highest expectations were for an OAC that would be easy to take, and overall satisfaction and convenience was around 69%. Factors including demographics can influence perceptions of therapy, and addressing individual preferences for OAC therapy may increase ratings of satisfaction and convenience.
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Cabbar F, Cabbar AT, Coşansu K, Çekirdekçi Eİ. Effects of Direct Oral Anticoagulants on Quality of Life During Periprocedural Management for Dental Extractions. J Oral Maxillofac Surg 2019; 77:904-911. [DOI: 10.1016/j.joms.2018.11.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/09/2018] [Accepted: 11/28/2018] [Indexed: 11/27/2022]
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Ng DLC, Gan GG, Chai CS, Chee KH, Tan KL, Tan SB, Bee PC. Comparing quality of life and treatment satisfaction between patients on warfarin and direct oral anticoagulants: a cross-sectional study. Patient Prefer Adherence 2019; 13:1363-1373. [PMID: 31616136 PMCID: PMC6698611 DOI: 10.2147/ppa.s204246] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/27/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION AND AIM Patient quality of life (QOL) while on long-term oral anticoagulant therapy has been receiving greater attention in recent years due to the increase in life expectancy brought about by advances in medical care. This study aimed to compare the QOL, treatment satisfaction, hospitalization and bleeding rate in patients on long-term warfarin versus direct oral anticoagulants (DOAC). METHODS This was a cross-sectional study of patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE) on long-term anticoagulant therapy attending the cardiology clinic and anticoagulation clinic of the University Malaya Medical Centre from July 1, 2016, to June 30, 2018. Patient QOL was assessed by using the Short Form 12 Health Survey (SF12), while treatment satisfaction was assessed by using the Perception of Anticoagulation Treatment Questionnaire 2 (PACT-Q2). RESULTS A total of 208 patients were recruited; 52.4% received warfarin and 47.6% received DOAC. There was no significant difference in QOL between warfarin and DOAC based on SF12 (physical QOL, P=0.083; mental QOL, P=0.665). Nevertheless, patients in the DOAC group were significantly more satisfied with their treatment compared to the warfarin group based on PACT-Q2 (P=0.004). The hospitalisation rate was significantly higher in the warfarin group than the DOAC group (15.6% versus 3.0%, P=0.002). Clinically relevant minor bleeds and severe bleeding events were non-significantly higher in the warfarin group than the DOAC group (66.7% versus 40.0%, P=0.069). CONCLUSION Compared to warfarin, treatment of NVAF and VTE with DOAC showed comparable QOL, higher treatment satisfaction, lesser hospitalization, and a non-significant trend toward fewer bleeding episodes.
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Affiliation(s)
- Diana Leh-Ching Ng
- Department of Medicine, Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Gin-Gin Gan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Correspondence: Gin-Gin GanDepartment of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur50603, MalaysiaTel +60 37 949 2741Fax +60 37 955 6936Email
| | - Chee-Shee Chai
- Department of Medicine, Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Kok-Han Chee
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kok-Leng Tan
- Department of Medicine, Faculty of Medicine, University Science Malaysia, Penang, Malaysia
| | - Seng-Beng Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ping-Chong Bee
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Witt DM, Nieuwlaat R, Clark NP, Ansell J, Holbrook A, Skov J, Shehab N, Mock J, Myers T, Dentali F, Crowther MA, Agarwal A, Bhatt M, Khatib R, Riva JJ, Zhang Y, Guyatt G. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv 2018; 2:3257-3291. [PMID: 30482765 PMCID: PMC6258922 DOI: 10.1182/bloodadvances.2018024893] [Citation(s) in RCA: 284] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE). OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants. CONCLUSIONS Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti-factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding.
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Affiliation(s)
- Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation and Anemia Service, Kaiser Permanente Colorado, Aurora, CO
| | - Jack Ansell
- School of Medicine, Hofstra Northwell, Hempstead, NY
| | - Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jane Skov
- Unit for Health Promotion Research, Department of Public Health, University of Southern Denmark, Esbjerg, Denmark
| | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Meha Bhatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL; and
| | - John J Riva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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From chronic disease management to person-centered eHealth; a review on the necessity for blended care. CLINICAL EHEALTH 2018. [DOI: 10.1016/j.ceh.2018.01.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Talboom-Kamp EPWA, Verdijk NA, Kasteleyn MJ, Harmans LM, Talboom IJSH, Numans ME, Chavannes NH. Effect of a combined education and eHealth programme on the control of oral anticoagulation patients (PORTALS study): a parallel cohort design in Dutch primary care. BMJ Open 2017; 7:e017909. [PMID: 28963313 PMCID: PMC5623459 DOI: 10.1136/bmjopen-2017-017909] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES To analyse the effect on therapeutic control and self-management skills of the implementation of self-management programmes, including eHealth by e-learning versus group training. SETTING Primary Care Thrombosis Service Center. PARTICIPANTS Of the 247 oral anticoagulation therapy (OAT) patients, 63 started self-management by e-learning, 74 self-management by group training and 110 received usual care. INTERVENTION AND METHODS Parallel cohort design with two randomised self-management groups (e-learning and group training) and a group receiving usual care. The effect of implementation of self-management on time in therapeutic range (TTR) was analysed with multilevel linear regression modelling. Usage of a supporting eHealth platform and the impact on self-efficacy (Generalised Self-Efficacy Scale (GSES)) and education level were analysed with linear regression analysis. After intervention, TTR was measured in three time periods of 6 months. MAIN OUTCOME MEASURES (1) TTR, severe complications,(2) usage of an eHealth platform,(3) GSES, education level. RESULTS Analysis showed no significant differences in TTR between the three time periods (p=0.520), the three groups (p=0.460) or the groups over time (p=0.263). Comparison of e-learning and group training showed no significant differences in TTR between the time periods (p=0.614), the groups (p=0.460) or the groups over time (p=0.263). No association was found between GSES and TTR (p=0.717) or education level and TTR (p=0.107). No significant difference was found between the self-management groups in usage of the platform (0-6 months p=0.571; 6-12 months p=0.866; 12-18 months p=0.260). The percentage of complications was low in all groups (3.2%; 1.4%; 0%). CONCLUSIONS No differences were found between OAT patients trained by e-learning or by a group course regarding therapeutic control (TTR) and usage of a supporting eHealth platform. The TTR was similar in self-management and regular care patients. With adequate e-learning or group training, self-management seems safe and reliable for a selected proportion of motivated vitamin K antagonist patients. TRIAL REGISTRATION NUMBER NTR3947.
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Affiliation(s)
- Esther P W A Talboom-Kamp
- Public Health and Primary Care Department, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Thrombosis Service Centre, Saltro Diagnostic Centre, Utrecht, The Netherlands
| | - Noortje A Verdijk
- Public Health and Primary Care Department, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Thrombosis Service Centre, Saltro Diagnostic Centre, Utrecht, The Netherlands
| | - Marise J Kasteleyn
- Public Health and Primary Care Department, Leiden University Medical Centre, Leiden, The Netherlands
| | - Lara M Harmans
- Department of Thrombosis Service Centre, Saltro Diagnostic Centre, Utrecht, The Netherlands
| | - Irvin J S H Talboom
- Department of Information Management, Caregroup DOH, Eindhoven, The Netherlands
| | - Mattijs E Numans
- Public Health and Primary Care Department, Leiden University Medical Centre, Leiden, The Netherlands
| | - Niels H Chavannes
- Public Health and Primary Care Department, Leiden University Medical Centre, Leiden, The Netherlands
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Clarkesmith DE, Pattison HM, Khaing PH, Lane DA. Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation. Cochrane Database Syst Rev 2017; 4:CD008600. [PMID: 28378924 PMCID: PMC6478129 DOI: 10.1002/14651858.cd008600.pub3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Current guidelines recommend oral anticoagulation therapy for patients with atrial fibrillation (AF) with one or more risk factors for stroke; however, anticoagulation control (time in therapeutic range (TTR)) with vitamin K antagonists (VKAs) is dependent on many factors. Educational and behavioural interventions may impact patients' ability to maintain their international normalised ratio (INR) control. This is an updated version of the original review first published in 2013. OBJECTIVES To evaluate the effects of educational and behavioural interventions for oral anticoagulation therapy (OAT) on TTR in patients with AF. SEARCH METHODS We updated searches from the previous review by searching the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library (January 2016, Issue 1), MEDLINE Ovid (1949 to February week 1 2016), EMBASE Classic + EMBASE Ovid (1980 to Week 7 2016), PsycINFO Ovid (1806 to Week 1 February 2016) and CINAHL Plus with Full Text EBSCO (1937 to 16/02/2016). We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials evaluating the effect of any educational and behavioural intervention compared with usual care, no intervention, or intervention in combination with other self-management techniques among adults with AF who were eligible for, or currently receiving, OAT. DATA COLLECTION AND ANALYSIS Two of the review authors independently selected studies and extracted data. Risk of bias was assessed using the Cochrane 'Risk of bias' tool. We included outcome data on TTR, decision conflict (patient's uncertainty in making health-related decisions), percentage of INRs in the therapeutic range, major bleeding, stroke and thromboembolic events, patient knowledge, patient satisfaction, quality of life (QoL), beliefs about medication, illness perceptions, and anxiety and depression. We pooled data for three outcomes - TTR, anxiety and depression, and decision conflict - and reported mean differences (MD). Where insufficient data were present to conduct a meta-analysis, we reported effect sizes and confidence intervals (CI) from the included studies. We evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. MAIN RESULTS Eleven trials with a total of 2246 AF patients (ranging from 14 to 712 by study) were included within the review. Studies included education, decision aids, and self-monitoring plus education interventions. The effect of self-monitoring plus education on TTR was uncertain compared with usual care (MD 6.31, 95% CI -5.63 to 18.25, I2 = 0%, 2 trials, 69 participants, very low-quality evidence). We found small but positive effects of education on anxiety (MD -0.62, 95% CI -1.21 to -0.04, I2 = 0%, 2 trials, 587 participants, low-quality evidence) and depression (MD -0.74, 95% CI -1.34 to -0.14, I2 = 0%, 2 trials, 587 participants, low-quality evidence) compared with usual care. The effect of decision aids on decision conflict favoured usual care (MD -0.1, 95% CI -0.17 to -0.02, I2 = 0%, 2 trials, 721 participants, low-quality evidence). AUTHORS' CONCLUSIONS This review demonstrates that there is insufficient evidence to draw definitive conclusions regarding the impact of educational or behavioural interventions on TTR in AF patients receiving OAT. Thus, more trials are needed to examine the impact of interventions on anticoagulation control in AF patients and the mechanisms by which they are successful. It is also important to explore the psychological implications for patients suffering from this long-term chronic condition.
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Affiliation(s)
- Danielle E Clarkesmith
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS TrustDudley RoadBirminghamUKB18 7QH
| | - Helen M Pattison
- Aston UniversitySchool of Life and Health SciencesAston TriangleBirminghamUKB4 7ET
| | - Phyo H Khaing
- University of BirminghamCollege of Medical and Dental Sciences8 Minnesota DriveGreat SankeyBirminghamCheshireUKWA5 3SY
| | - Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS TrustDudley RoadBirminghamUKB18 7QH
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Márquez-Contreras E, Martell-Claros N, Gil-Guillén V, De la Figuera-Von Wichmann M, Sánchez-López E, Gil-Gil I, Márquez-Rivero S. Quality of life with rivaroxaban in patients with non-valvular atrial fibrilation by therapeutic compliance. Qual Life Res 2017; 26:647-654. [PMID: 28058574 DOI: 10.1007/s11136-016-1489-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the quality of life (QOL) with rivaroxaban in patients with non-valvular atrial fibrilation (NVAF) related to therapeutic compliance. METHODS Prospective, longitudinal, multicenter study was developed in 160 Spanish primary or specialized care centers. We included 412 patients treated with rivaroxaban, prescribed for stroke prevention. Three visits were conducted: baseline, 6 and 12 months. Compliance was measured by electronic monitoring systems. QOL was measured by a specific questionnaire. We calculated the percentage of compliance means, the percentage of daily compliers and the score of QOL. RESULTS Three hundred and seventy patients finished the study (mean age 75.19 SD: 7.5 years). Daily compliance was 83.5% (CI 78.53-88.57%) (n = 309) and 80% (CI 74.65-85.35%) at 6 and 12 months, respectively. Average QOL rating was 112.85 (SD 29.31) in non-compliant and 111.80 (SD 29.31) in the compliant group (p = Not significant), and after 12 months of 124.67 (SD 30.78) and 83.47 (SD 26.44), respectively (p < 0.0001), with a decrease in the score compliers (p < 0.01) and an increase in non-compliant group (p < 0.05). A higher number of drugs consumed, as well as the number of diseases/conditions suffered, the older age of the patients and having been previously treated with VKA were associated with a higher overall score (worse QOL). CONCLUSIONS QOL in NVAF patients treated with rivaroxaban improved significantly over the study group at the expense of compliers. A worse QOL was associated with pluripathology, polymedication, older patients and previous treatment with VKA.
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Tompson A, Heneghan C, Sutton S, Fitzmaurice D, Ward A. Impact of self-funding on patient experience of oral anticoagulation self-monitoring: a qualitative study. BMJ Open 2016; 6:e013123. [PMID: 28011812 PMCID: PMC5223672 DOI: 10.1136/bmjopen-2016-013123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To explore the impact self-funding has on patient experience of oral anticoagulation therapy self-monitoring. DESIGN Semistructured, qualitative interviews were conducted. Transcripts were analysed thematically using constant comparison. SETTING England. PARTICIPANTS Interviewees were participants of the Cohort Study of Anticoagulation Self-Monitoring (CASM). Cohort members were recruited as they bought a monitor from the major manufacturer in the UK. A purposive sample was invited to be interviewed on completion of the 12-month cohort follow-up. DATA Patient narratives on their experiences of self-monitoring their oral anticoagulation therapy in non-trial conditions. RESULTS 26 interviews were completed. Interviewees viewed purchasing the monitoring device as a long-term commitment balancing the limitations of clinic-based monitoring against the cost. They were unable to try out the monitor prior to purchase and therefore had to be confident in their own ability to use it. The variable provision of self-monitoring equipment caused resentment, and interviewees were uncomfortable negotiating with healthcare professionals. High test strip usage while learning how to use the monitor caused anxiety that was exacerbated by worries about their cost. However, self-funding did mean that interviewees felt a sense of ownership and were determined to persevere to overcome problems. CONCLUSIONS Self-funding has negative implications in terms of equity of access; however, the money invested acts as a barrier to discontinuation. If oral anticoagulation therapy self-monitoring devices and consumables were provided free of charge in routine care, the training and support available in England may need to be reviewed to prevent discontinuation rates rising to those observed in clinical trials.
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Affiliation(s)
- Alice Tompson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Stephen Sutton
- Institute of Public Health, University of Cambridge, Cambridge, UK
| | - David Fitzmaurice
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Alison Ward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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van Lint CL, van der Boog PJM, Romijn FPHTM, Schenk PW, van Dijk S, Rövekamp TJM, Kessler A, Siekmann L, Rabelink TJ, Cobbaert CM. Application of a point of care creatinine device for trend monitoring in kidney transplant patients: fit for purpose? Clin Chem Lab Med 2016; 53:1547-56. [PMID: 25719331 DOI: 10.1515/cclm-2014-0932] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 01/18/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND The StatSensor® Xpress-i™, a point-of-care system for blood creatinine measurement, offers patients the possibility of self-monitoring creatinine. In this study, the analytical performance of the StatSensor® for both detecting current renal function and monitoring renal (dys)function in kidney transplant patients was examined. METHODS Accuracy of the StatSensor® with capillary and venous whole blood was evaluated and compared to an isotopic dilution mass spectrometry (IDMS)-traceable enzymatic creatinine test in venous serum (n=138). Twenty Li-heparin samples were compared to the IDMS reference method performed by a Joint Committee for Traceability in Laboratory Medicine (JCTLM)-listed reference laboratory (RfB, Bonn, Germany). To evaluate StatSensor®'s suitability to monitor kidney function, both venous and capillary samples were obtained in 20 hospitalized transplantation patients. Venous samples were analyzed with an IDMS-traceable enzymatic test, capillary samples were measured using the StatSensor®. For all 2-day intervals, percentage change in creatinine was compared between both methods. RESULTS The StatSensor® did not meet total allowable error criterion of 6.9%. Average overall CVa for the StatSensor® was 10.4% and 5.2% for capillary and venous whole blood results, respectively. Overall CVa for the central laboratory serum creatinine method was <1.5%. For monitoring renal (dys)function, total agreement of the StatSensor® with an IDMS-traceable enzymatic test was 68% using a 10% Δ change. No significant differences were found between the changes observed by both methods. CONCLUSIONS Capillary blood testing with the StatSensor® is not advisable for determining current renal function with a single creatinine measurement in kidney transplant patients, mainly due to excessive analytical imprecision. However, our results suggest that capillary blood testing with the StatSensor® can be used for daily trend monitoring of kidney function after renal transplantation.
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Turker Y, Ekinozu I, Aytekin S, Turker Y, Basar C, Baltaci D, Kaya E. Comparison of Changes in Anxiety and Depression Level Between Dabigatran and Warfarin Use in Patients With Atrial Fibrillation. Clin Appl Thromb Hemost 2016; 23:164-167. [PMID: 26276685 DOI: 10.1177/1076029615600792] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We hypothesized that patients taking warfarin require frequent hospital follow-up and they are at higher risk for complications, so the incidence of depression and anxiety is higher in patients with atrial fibrillation (AF) in the period of taking warfarin compared to the period of taking dabigatran. Fifty patients having AF without valvular diseases under treatment of warfarin in whom a transition to dabigatran was planned were consecutively enrolled in this study and followed up prospectively between July 2013 and July 2014. All patients completed Beck Depression Inventory and Hamilton Anxiety Scale (HAS) at the initiation of study and 6 months after initiation of study. Of the patients enrolled in the study, age, gender, smoking status, and comorbidities were questioned. A total of 50 patients (28 women; mean age 74.6 ± 8.7 years) treated with warfarin in whom a transition to dabigatran was planned were included. Basal mean value of BDS (15.6 ± 7.8 vs 11.5 ± 4.8, P < .001) and HAS (16.8 ± 10.4 vs 12.6 ± 8.1, P < 0.001) was significantly higher in patients when they used warfarin than when they switched to dabigatran. In categorical analysis, frequency of patients with depression (mild, moderate, and severe) was significantly higher in period of warfarin use than after dabigatran transition (n = 24, 48% vs n = 14, 28%, P = .039). Our study demonstrates that patients with nonvalvular AF under treatment of dabigatran had lower BDS and HAS scores compared to warfarin. These findings suggest that dabigatran may increase quality of life and decrease morbidity and mortality due to reduction in anxiety and depression.
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Affiliation(s)
- Yasin Turker
- 1 Department of Cardiology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey
| | - Ismail Ekinozu
- 2 Department of Cardiology, Faculty of Medicine, Duzce University, Duzce, Turkey
| | - Seda Aytekin
- 2 Department of Cardiology, Faculty of Medicine, Duzce University, Duzce, Turkey
| | | | - Cengiz Basar
- 4 Department of Cardiology, Düzce Atatürk State Hospital, Düzce Turkey
| | - Davut Baltaci
- 5 Department of Family Medicine, Faculty of Medicine, Duzce University, Duzce, Turkey
| | - Ertugrul Kaya
- 6 Department of Pharmacology, Duzce University, Medical School, Duzce, Turkey
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Heneghan CJ, Garcia-Alamino JM, Spencer EA, Ward AM, Perera R, Bankhead C, Alonso-Coello P, Fitzmaurice D, Mahtani KR, Onakpoya IJ. Self-monitoring and self-management of oral anticoagulation. Cochrane Database Syst Rev 2016; 7:CD003839. [PMID: 27378324 PMCID: PMC8078378 DOI: 10.1002/14651858.cd003839.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The introduction of point-of-care devices for the management of patients on oral anticoagulation allows self-testing by the patient at home. Patients who self-test can either adjust their medication according to a pre-determined dose-INR (international normalized ratio) schedule (self-management), or they can call a clinic to be told the appropriate dose adjustment (self-monitoring). Increasing evidence suggests self-testing of oral anticoagulant therapy is equal to or better than standard monitoring. This is an updated version of the original review published in 2010. OBJECTIVES To evaluate the effects on thrombotic events, major haemorrhages, and all-cause mortality of self-monitoring or self-management of oral anticoagulant therapy compared to standard monitoring. SEARCH METHODS For this review update, we re-ran the searches of the Cochrane Central Register of Controlled Trials (CENTRAL), 2015, Issue 6, the Cochrane Library, MEDLINE (Ovid, 1946 to June week 4 2015), Embase (Ovid, 1980 to 2015 week 27) on 1 July 2015. We checked bibliographies and contacted manufacturers and authors of relevant studies. We did not apply any language restrictions . SELECTION CRITERIA Outcomes analysed were thromboembolic events, mortality, major haemorrhage, minor haemorrhage, tests in therapeutic range, frequency of testing, and feasibility of self-monitoring and self-management. DATA COLLECTION AND ANALYSIS Review authors independently extracted data and we used a fixed-effect model with the Mantzel-Haenzel method to calculate the pooled risk ratio (RR) and Peto's method to verify the results for uncommon outcomes. We examined heterogeneity amongst studies with the Chi(2) and I(2) statistics and used GRADE methodology to assess the quality of evidence. MAIN RESULTS We identified 28 randomised trials including 8950 participants (newly incorporated in this update: 10 trials including 4227 participants). The overall quality of the evidence was generally low to moderate. Pooled estimates showed a reduction in thromboembolic events (RR 0.58, 95% CI 0.45 to 0.75; participants = 7594; studies = 18; moderate quality of evidence). Both, trials of self-management or self-monitoring showed reductions in thromboembolic events (RR 0.47, 95% CI 0.31 to 0.70; participants = 3497; studies = 11) and (RR 0.69, 95% CI 0.49 to 0.97; participants = 4097; studies = 7), respectively; the quality of evidence for both interventions was moderate. No reduction in all-cause mortality was found (RR 0.85, 95% CI 0.71 to 1.01; participants = 6358; studies = 11; moderate quality of evidence). While self-management caused a reduction in all-cause mortality (RR 0.55, 95% CI 0.36 to 0.84; participants = 3058; studies = 8); self-monitoring did not (RR 0.94, 95% CI 0.78 to 1.15; participants = 3300; studies = 3); the quality of evidence for both interventions was moderate. In 20 trials (8018 participants) self-monitoring or self-management did not reduce major haemorrhage (RR 0.95, 95% CI, 0.80 to 1.12; moderate quality of evidence). There was no significant difference found for minor haemorrhage (RR 0.97, 95% CI 0.67 to 1.41; participants = 5365; studies = 13). The quality of evidence was graded as low because of serious risk of bias and substantial heterogeneity (I(2) = 82%). AUTHORS' CONCLUSIONS Participants who self-monitor or self-manage can improve the quality of their oral anticoagulation therapy. Thromboembolic events were reduced, for both those self-monitoring or self-managing oral anticoagulation therapy. A reduction in all-cause mortality was observed in trials of self-management but not in self-monitoring, with no effects on major haemorrhage.
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Affiliation(s)
- Carl J Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Oxford, Oxfordshire, UK, OX2 6GG
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Abdou JK, Auyeung V, Patel JP, Arya R. Adherence to long-term anticoagulation treatment, what is known and what the future might hold. Br J Haematol 2016; 174:30-42. [DOI: 10.1111/bjh.14134] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- John K. Abdou
- Institute of Pharmaceutical Science; King's College London; London UK
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital Foundation NHS Trust, Denmark Hill; London UK
| | - Vivian Auyeung
- Institute of Pharmaceutical Science; King's College London; London UK
| | - Jignesh P. Patel
- Institute of Pharmaceutical Science; King's College London; London UK
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital Foundation NHS Trust, Denmark Hill; London UK
| | - Roopen Arya
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital Foundation NHS Trust, Denmark Hill; London UK
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Sharma P, Scotland G, Cruickshank M, Tassie E, Fraser C, Burton C, Croal B, Ramsay CR, Brazzelli M. The clinical effectiveness and cost-effectiveness of point-of-care tests (CoaguChek system, INRatio2 PT/INR monitor and ProTime Microcoagulation system) for the self-monitoring of the coagulation status of people receiving long-term vitamin K antagonist therapy, compared with standard UK practice: systematic review and economic evaluation. Health Technol Assess 2016; 19:1-172. [PMID: 26138549 DOI: 10.3310/hta19480] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Self-monitoring (self-testing and self-management) could be a valid option for oral anticoagulation therapy monitoring in the NHS, but current evidence on its clinical effectiveness or cost-effectiveness is limited. OBJECTIVES We investigated the clinical effectiveness and cost-effectiveness of point-of-care coagulometers for the self-monitoring of coagulation status in people receiving long-term vitamin K antagonist therapy, compared with standard clinic monitoring. DATA SOURCES We searched major electronic databases (e.g. MEDLINE, MEDLINE In Process & Other Non-Indexed Citations, EMBASE, Bioscience Information Service, Science Citation Index and Cochrane Central Register of Controlled Trials) from 2007 to May 2013. Reports published before 2007 were identified from the existing Cochrane review (major databases searched from inception to 2007). The economic model parameters were derived from the clinical effectiveness review, other relevant reviews, routine sources of cost data and clinical experts' advice. REVIEW METHODS We assessed randomised controlled trials (RCTs) evaluating self-monitoring in people with atrial fibrillation or heart valve disease requiring long-term anticoagulation therapy. CoaguChek(®) XS and S models (Roche Diagnostics, Basel, Switzerland), INRatio2(®) PT/INR monitor (Alere Inc., San Diego, CA USA), and ProTime Microcoagulation system(®) (International Technidyne Corporation, Nexus Dx, Edison, NJ, USA) coagulometers were compared with standard monitoring. Where possible, we combined data from included trials using standard inverse variance methods. Risk of bias assessment was performed using the Cochrane risk of bias tool. A de novo economic model was developed to assess the cost-effectiveness over a 10-year period. RESULTS We identified 26 RCTs (published in 45 papers) with a total of 8763 participants. CoaguChek was used in 85% of the trials. Primary analyses were based on data from 21 out of 26 trials. Only four trials were at low risk of bias. Major clinical events: self-monitoring was significantly better than standard monitoring in preventing thromboembolic events [relative risk (RR) 0.58, 95% confidence interval (CI) 0.40 to 0.84; p = 0.004]. In people with artificial heart valves (AHVs), self-monitoring almost halved the risk of thromboembolic events (RR 0.56, 95% CI 0.38 to 0.82; p = 0.003) and all-cause mortality (RR 0.54, 95% CI 0.32 to 0.92; p = 0.02). There was greater reduction in thromboembolic events and all-cause mortality through self-management but not through self-testing. Intermediate outcomes: self-testing, but not self-management, showed a modest but significantly higher percentage of time in therapeutic range, compared with standard care (weighted mean difference 4.44, 95% CI 1.71 to 7.18; p = 0.02). Patient-reported outcomes: improvements in patients' quality of life related to self-monitoring were observed in six out of nine trials. High preference rates were reported for self-monitoring (77% to 98% in four trials). Net health and social care costs over 10 years were £7295 (self-monitoring with INRatio2); £7324 (standard care monitoring); £7333 (self-monitoring with CoaguChek XS) and £8609 (self-monitoring with ProTime). The estimated quality-adjusted life-year (QALY) gain associated with self-monitoring was 0.03. Self-monitoring with INRatio2 or CoaguChek XS was found to have ≈ 80% chance of being cost-effective, compared with standard monitoring at a willingness-to-pay threshold of £20,000 per QALY gained. CONCLUSIONS Compared with standard monitoring, self-monitoring appears to be safe and effective, especially for people with AHVs. Self-monitoring, and in particular self-management, of anticoagulation status appeared cost-effective when pooled estimates of clinical effectiveness were applied. However, if self-monitoring does not result in significant reductions in thromboembolic events, it is unlikely to be cost-effective, based on a comparison of annual monitoring costs alone. Trials investigating the longer-term outcomes of self-management are needed, as well as direct comparisons of the various point-of-care coagulometers. STUDY REGISTRATION This study is registered as PROSPERO CRD42013004944. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Pawana Sharma
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.,Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Emma Tassie
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Chris Burton
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
| | - Bernard Croal
- Department of Clinical Biochemistry, University of Aberdeen, Aberdeen, UK
| | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Biedermann JS, van Rein N, van den Besselaar AMHP, Buhre PN, de Maat MPM, van der Meer FJM, Leebeek FWG, Kruip MJHA. Impact of point-of-care international normalized ratio monitoring on quality of treatment with vitamin K antagonists in non-self-monitoring patients: a cohort study. J Thromb Haemost 2016; 14:695-703. [PMID: 26806724 DOI: 10.1111/jth.13272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 01/07/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Point-of-care (POC) international normalized ratio (INR) monitoring by healthcare professionals could eliminate the need for venous blood sampling in non-self-monitoring (NSM) patients on vitamin K antagonists (VKA). However, few studies have investigated the impact of POC INR monitoring on the quality of treatment in these patients and real-world data on this issue are lacking. OBJECTIVES To investigate the safety, efficacy and quality of anticoagulant control during POC INR monitoring as compared with laboratory INR monitoring in NSM patients. METHODS We performed a retrospective cohort study using data from the anticoagulation clinic of the Star-Medical Diagnostic Center (Rotterdam, the Netherlands). Patients who received treatment with VKA between 29 May 2012 and 29 May 2014 were eligible. Percentage of time in therapeutic range (TTR) and incidence rates of major clinical events (all-cause mortality, hospitalization, major bleeding and ischemic stroke) were compared for the year before and year after introduction of POC monitoring. Cox proportional hazard models were used to estimate hazard ratios and 95% confidence intervals for major clinical events between exposure groups. RESULTS In total, 1973 patients during the 1-year laboratory-monitoring observation period and 1959 patients during the 1-year POC-monitoring observation period were included. Median TTR was significantly lower during POC monitoring (77.9%; 95% CI, 67.2-87.4) than during laboratory INR monitoring (81.0%; 95% CI, 71.1-90.5). Adjusted hazard ratios for major clinical events were all around unity. CONCLUSIONS Although associated with lower TTR, POC INR monitoring is a safe and effective alternative to laboratory INR monitoring in NSM patients on VKA.
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Affiliation(s)
- J S Biedermann
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
- Star-Medical Diagnostic Center, Rotterdam, the Netherlands
| | - N van Rein
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | | | - P N Buhre
- Star-Medical Diagnostic Center, Rotterdam, the Netherlands
| | - M P M de Maat
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - F J M van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - F W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M J H A Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
- Star-Medical Diagnostic Center, Rotterdam, the Netherlands
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Bonaventura KR, Milner KA. Patient Engagement in Management of Warfarin: A Quality Improvement Study. J Nurse Pract 2016. [DOI: 10.1016/j.nurpra.2015.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Supporting patients to self-monitor their oral anticoagulation therapy: recommendations based on a qualitative study of patients' experiences. Br J Gen Pract 2015; 65:e438-46. [PMID: 26077266 PMCID: PMC4484944 DOI: 10.3399/bjgp15x685645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 02/18/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Clinical trials suggest that oral anticoagulation therapy (OAT) self-monitoring is safe and effective, however little is known about the patient experience of this process. There is a lack of understanding about how best to train and support patients embarking on OAT self-monitoring. AIM To collect in-depth information about patients' experiences of OAT self-monitoring outside of clinical trial conditions and to produce a set of recommendations on how best to support such patients. DESIGN AND SETTING Semi-structured qualitative interviews with patients who self-monitor and live in England. METHOD In total, 26 of the 267 (9.7%) who participated in the Cohort study of Anticoagulation Self-Monitoring (CASM) and were still self-monitoring after 12 months' follow-up were interviewed. Topics discussed included experiences of OAT self-monitoring, healthcare support, training, and decision making. Framework analysis was used. RESULTS Following initial problems using the monitoring device, interviewees described a mostly positive experience. Although less effort was expended attending monitoring appointments with health professionals, effort was required to conduct self-monitoring tests and to interpret and act on the results. Desire to self-manage was variable, especially when dosing advice systems worked promptly and reliably. Interviewees overcame patchy healthcare system knowledge and support of self-monitoring by educating themselves. Family and friends provided support with learning to use the monitor and managing OAT dosage adjustments. CONCLUSION Better, more-consistent training and health-service support would have alleviated a number of problems encountered by these patients who were self-monitoring. This training and support will become even more important if self-monitoring becomes more accessible to the general population of people on OAT.
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Ferrando F, Mira Y. Effective and Safe Management of Oral Anticoagulation Therapy in Patients Who Use the Internet-Accessed Telecontrol Tool SintromacWeb. Interact J Med Res 2015; 4:e10. [PMID: 25900775 PMCID: PMC4420842 DOI: 10.2196/ijmr.3610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 11/24/2014] [Accepted: 02/19/2015] [Indexed: 01/04/2023] Open
Abstract
Background Despite the existing evidence that highlights the benefits of oral anticoagulation therapy (OAT) self-testing and self-management by patients in comparison with conventional control, significant progress is still needed in the implementation of computer-based, Internet-assisted systems for OAT within health care centers. The telecontrol tool “SintromacWeb” is a previously validated system for OAT management at home, which is currently operative and accessed by patients through a hospital Web portal. Objective The intent of the study was to assess the effectiveness and safety of OAT management in patients using the SintromacWeb telecontrol system in reference to control in patients using the conventional system (management at the hematology department), in terms of time in therapeutic range (TTR) of International Normalized Ratio (INR). Methods In this observational prospective study, patients were identified by their physician and divided in two groups according to the OAT management system that they were already using (conventional control or telecontrol with SintromacWeb). For 6 months, patients were required to visit the hematology department every time their physician considered it necessary according to usual clinical practice. Sociodemographic and clinical variables for the study were collected at first visit (baseline) and at those visits closest to 2, 4, and 6 months after first visit. Results A total of 173 patients were evaluated, 87 with conventional control and 86 with telecontrol. Follow-up time was a median of 6.3 (range 5.2-8.1) months. The average time of OAT treatment prior to enrollment was 9.2 (SD 6.4) years. Patients in the telecontrol group tested their INR a median of 21 (range 4-22) days versus a median of 35 (range 14-45) days in patients in the conventional control group (P<.001). TTR in the telecontrol group was 107 (SD 37) days versus 94 (SD 37) days in the conventional control group (an increase of 12.6%; P=.02). In all visits, the percentage of TTR was higher in the telecontrol group (at the third visit: 59% vs 48%; P=.01). Higher TTR (positive coefficient) was associated with patients under OAT telecontrol (P=.03). Under-anticoagulation (INR<1.5) and over-anticoagulation (INR>5) were observed in 34 (19.7%, 34/173) and 38 (22.0%, 38/173) patients, respectively (no differences between treatment groups). Seven thrombotic and/or bleeding events were serious, 12 were non-serious, and most of them (5 and 10, respectively) occurred in the conventional control group. Conclusions In clinical practice, OAT management with the Internet-based tool SintromacWeb is effective and safe for those patients who are eligible for OAT telecontrol.
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Affiliation(s)
- Fernando Ferrando
- Hospital Universitari i Politècnic La Fe, Unidad de Hemostasia y Trombosis, Valencia, Spain.
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van Lint CL, van der Boog PJM, Wang W, Brinkman WP, Rövekamp TJM, Neerincx MA, Rabelink TJ, van Dijk S. Patient experiences with self-monitoring renal function after renal transplantation: results from a single-center prospective pilot study. Patient Prefer Adherence 2015; 9:1721-31. [PMID: 26673985 PMCID: PMC4676625 DOI: 10.2147/ppa.s92108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND After a kidney transplantation, patients have to visit the hospital often to monitor for early signs of graft rejection. Self-monitoring of creatinine in addition to blood pressure at home could alleviate the burden of frequent outpatient visits, but only if patients are willing to self-monitor and if they adhere to the self-monitoring measurement regimen. A prospective pilot study was conducted to assess patients' experiences and satisfaction. MATERIALS AND METHODS For 3 months after transplantation, 30 patients registered self-measured creatinine and blood pressure values in an online record to which their physician had access to. Patients completed a questionnaire at baseline and follow-up to assess satisfaction, attitude, self-efficacy regarding self-monitoring, worries, and physician support. Adherence was studied by comparing the number of registered with the number of requested measurements. RESULTS Patients were highly motivated to self-monitor kidney function, and reported high levels of general satisfaction. Level of satisfaction was positively related to perceived support from physicians (P<0.01), level of self-efficacy (P<0.01), and amount of trust in the accuracy of the creatinine meter (P<0.01). The use of both the creatinine and blood pressure meter was considered pleasant and useful, despite the level of trust in the accuracy of the creatinine device being relatively low. Trust in the accuracy of the creatinine device appeared to be related to level of variation in subsequent measurement results, with more variation being related to lower levels of trust. Protocol adherence was generally very high, although the range of adherence levels was large and increased over time. CONCLUSION Patients' high levels of satisfaction suggest that at-home monitoring of creatinine and blood pressure after transplantation offers a promising strategy. Important prerequisites for safe implementation in transplant care seem to be support from physicians and patients' confidence in both their own self-monitoring skills and the accuracy of the devices used.
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Affiliation(s)
- Céline L van Lint
- Department of Nephrology, Leiden University Medical Centre (LUMC), Leiden, the Netherlands
- Correspondence: Céline L van Lint, Department of Nephrology, Leiden University Medical Centre (LUMC), PO Box 9600, Leiden 2300 RC, the Netherlands, Tel +31 71 526 2214, Email
| | - Paul JM van der Boog
- Department of Nephrology, Leiden University Medical Centre (LUMC), Leiden, the Netherlands
| | - Wenxin Wang
- Faculty of Electrical Engineering, Mathematics and Computer Science, Delft University of Technology, Delft, the Netherlands
- Department of Technology in Healthcare, Prevention and Health, Dutch Organization for Applied Scientific Research (TNO), Leiden, the Netherlands
| | - Willem-Paul Brinkman
- Faculty of Electrical Engineering, Mathematics and Computer Science, Delft University of Technology, Delft, the Netherlands
| | - Ton JM Rövekamp
- Department of Technology in Healthcare, Prevention and Health, Dutch Organization for Applied Scientific Research (TNO), Leiden, the Netherlands
| | - Mark A Neerincx
- Faculty of Electrical Engineering, Mathematics and Computer Science, Delft University of Technology, Delft, the Netherlands
| | - Ton J Rabelink
- Department of Nephrology, Leiden University Medical Centre (LUMC), Leiden, the Netherlands
| | - Sandra van Dijk
- Department of Nephrology, Leiden University Medical Centre (LUMC), Leiden, the Netherlands
- Department of Health, Medical and Neuropsychology, Faculty of Social and Behavioural Sciences, Leiden University, Leiden, the Netherlands
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Modi RA, McGwin G, Westfall AO, Powell DW, Burkholder GA, Raper JL, Willig JH. Venous thromboembolism among HIV-positive patients and anticoagulation clinic outcomes integrated within the HIV primary care setting. Int J STD AIDS 2014; 26:870-8. [PMID: 25414089 DOI: 10.1177/0956462414561033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/30/2014] [Indexed: 02/05/2023]
Abstract
The purpose of this study was to explore factors associated with venous thromboembolism (VTE) among a cohort of HIV-infected patients and to describe early outcomes of warfarin anticoagulation therapy treated in a pharmacist-based anticoagulation clinic (ACC). A nested case-control study was conducted using the University of Alabama at Birmingham 1917 HIV Clinic Cohort. Conditional logistic regression was used to estimate factors associated with VTE. Among HIV-infected VTE cases, ACC-managed patients were compared to primary care provider (PCP)-managed patients to determine Time within Therapeutic INR Range (TTR). CD4 < 200 cells/µl (OR = 4.50; 95% CI = 1.52, 13.37; p = 0.007) and prior surgical procedures (13.20; 1.56; 111.4; p = 0.018) demonstrated positive associations with VTE, whereas longer HIV duration demonstrated a negative association (0.87; 0.78, 0.98; p = 0.019). TTR was 56.2% among ACC-managed patients compared to 30.5% of PCP-managed patients (p = 0.174). Overall, prior surgical procedures and low CD4 count were associated with an increased risk of VTE among HIV-infected patients. Despite small sample size, patients managed in ACC tend to achieve greater proportion of TTR compared to those managed by PCPs, suggesting that this model of therapy may provide additional benefits to HIV-infected patients.
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Affiliation(s)
- Riddhi A Modi
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Gerald McGwin
- Department of Epidemiology, School of Public Health, UAB, Birmingham, AL, USA
| | | | - Deon W Powell
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Greer A Burkholder
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA University of Alabama School of Medicine (UAB), Birmingham, AL, USA
| | - James L Raper
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA University of Alabama School of Medicine (UAB), Birmingham, AL, USA
| | - James H Willig
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA University of Alabama School of Medicine (UAB), Birmingham, AL, USA
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Gallagher J, Mc Carthy S, Woods N, Ryan F, O' Shea S, Byrne S. Economic evaluation of a randomized controlled trial of pharmacist-supervized patient self-testing of warfarin therapy. J Clin Pharm Ther 2014; 40:14-9. [DOI: 10.1111/jcpt.12215] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 09/10/2014] [Indexed: 12/19/2022]
Affiliation(s)
- J. Gallagher
- Clinical Pharmacy Research Group; School of Pharmacy; University College Cork; Cork Ireland
| | - S. Mc Carthy
- Clinical Pharmacy Research Group; School of Pharmacy; University College Cork; Cork Ireland
| | - N. Woods
- Centre for Policy Studies; University College Cork; Cork Ireland
| | - F. Ryan
- McGee Pharma International; Dublin UK
| | - S. O' Shea
- Department of Haematology; Cork University Hospital; Cork UK
| | - S. Byrne
- Clinical Pharmacy Research Group; School of Pharmacy; University College Cork; Cork Ireland
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Mani H, Lindhoff-Last E. New oral anticoagulants in patients with nonvalvular atrial fibrillation: a review of pharmacokinetics, safety, efficacy, quality of life, and cost effectiveness. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:789-98. [PMID: 24970997 PMCID: PMC4069048 DOI: 10.2147/dddt.s45644] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Atrial fibrillation (AF) continues to be a leading cause of cerebrovascular morbidity and mortality resulting from cardioembolic stroke. Oral anticoagulation therapy has been shown to decrease the incidence of cardioembolic stroke in patients with AF by more than 50%. Appropriate use of anticoagulation with vitamin K antagonists requires precise adherence and monitoring. A number of factors that potentially induce patients’ dissatisfaction reduce quality of patient life. New direct oral anticoagulants, such as the direct factor Xa inhibitors rivaroxaban, apixaban, edoxaban, and the thrombin inhibitor dabigatran, were developed to overcome the limitations of the conventional anticoagulant drugs. However, models to optimize the benefit of therapy and to ensure that therapy can be safely continued are missing for the new oral anticoagulants. This review will briefly describe the new oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban with focus on their use for prevention of embolic events in AF. Moreover, it will discuss the safety, efficacy, cost data, and benefit for patients’ quality of life and adherence.
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Affiliation(s)
- Helen Mani
- Johann Wolfgang Goethe-University Hospital Frankfurt/Main, Department of Internal Medicine, Division of Haemostasis, Frankfurt, Germany
| | - Edelgard Lindhoff-Last
- Johann Wolfgang Goethe-University Hospital Frankfurt/Main, Department of Internal Medicine, Division of Haemostasis, Frankfurt, Germany
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Ynsaurriaga FA, Peinado RP, Ormaetxe Merodio JM. Atrial fibrillation and quality of life related to disease and treatment: focus on anticoagulation. Future Cardiol 2014; 10:381-93. [DOI: 10.2217/fca.14.13] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
ABSTRACT: Anticoagulation therapy is essential to reduce the risk of stroke in patients with atrial fibrillation. Traditionally, clinical trials have focused only on determining the efficacy and safety of anticoagulation but not on quality of life. In the last few years there has been a growing interest in determining the quality of life of patients treated with oral anticoagulation. In fact, specific tools that can evaluate quality of life related to atrial fibrillation and anticoagulation have been developed. Vitamin K antagonists have been shown to be effective in the prevention of thromboembolic complications. However, the use of vitamin K antagonists implies changes in behavior and lifestyle modifications that may have a negative impact on the quality of life. It has been suggested that self-monitoring of international normalized ratio could improve this impact. On the other hand, as new oral anticoagulants overcome these limitations, they may improve quality of life related with anticoagulant therapy. Unfortunately, although encouraging, the clinical experience with them is still quite limited.
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Affiliation(s)
| | - Rafael Peinado Peinado
- Sección de Arritmias, Servicio de Cardiología, Hospital Universitario La Paz, Madrid, Spain
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Criado-Álvarez JJ, González González J, Martín García S, Romo Barrientos C. [Quality of life in patients with oral anticoagulation therapy]. Med Clin (Barc) 2014; 144:46-7. [PMID: 24703422 DOI: 10.1016/j.medcli.2014.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Juan José Criado-Álvarez
- Consultorio Médico de San Bartolomé de las Abiertas, Centro de Salud de La Pueblanueva, Gerencia de Atención Integrada de Talavera de la Reina, Servicio de Salud de Castilla-La Mancha (SESCAM), Talavera de la Reina, Toledo, España; Facultad de Terapia Ocupacional, Logopedia y Enfermería, Universidad de Castilla-La Mancha, Talavera de la Reina, Toledo, España.
| | - Jaime González González
- Facultad de Terapia Ocupacional, Logopedia y Enfermería, Universidad de Castilla-La Mancha, Talavera de la Reina, Toledo, España; Consultorio Médico de Otero, Centro de Salud de Santa Olalla, Gerencia de Atención Integrada de Talavera de la Reina, Servicio de Salud de Castilla-La Mancha (SESCAM), Talavera de la Reina, Toledo, España
| | - Silvia Martín García
- Consultorio Médico de San Bartolomé de las Abiertas, Centro de Salud de La Pueblanueva, Gerencia de Atención Integrada de Talavera de la Reina, Servicio de Salud de Castilla-La Mancha (SESCAM), Talavera de la Reina, Toledo, España
| | - Carmen Romo Barrientos
- Servicio de Salud Mental, Gerencia de Atención Integrada de Talavera de la Reina, Servicio de Salud de Castilla-La Mancha (SESCAM), Talavera de la Reina, Toledo, España
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McMillin GA, Vazquez SR, Pendleton RC. Current challenges in personalizing warfarin therapy. Expert Rev Clin Pharmacol 2014; 4:349-62. [DOI: 10.1586/ecp.11.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Alegret JM, Viñolas X, Arias MA, Martínez-Rubio A, Rebollo P, Ràfols C, Martínez-Sande JL. New oral anticoagulants vs vitamin K antagonists: benefits for health-related quality of life in patients with atrial fibrillation. Int J Med Sci 2014; 11:680-4. [PMID: 24843316 PMCID: PMC4025166 DOI: 10.7150/ijms.8916] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 04/01/2014] [Indexed: 11/19/2022] Open
Abstract
New oral anticoagulants (NOAC) have demonstrated their efficacy as an alternative to vitamin K antagonists (VKA) in the prophylaxis of cardioembolic events in patients with atrial fibrillation (AF). However, evidence on the benefits of NOAC in health-related quality of life (HRQoL) is lacking.We evaluated changes in HRQoL related to oral anticoagulation therapy employing a specific questionnaire in a cohort of 416 patients with AF undergoing electrical cardioversion. In terms of HRQoL, we observed a progressive adaptation to treatment with VKA; satisfaction with NOAC remained constant. Older age, higher left ventricular ejection fraction and NOAC were associated with better HRQoL.
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Affiliation(s)
- Josep M Alegret
- 1. Grup de Recerca Cardiovascular, Hospital Universitari de Sant Joan, IISPV, Universitat Rovira i Virgili, Reus, Spain
| | | | | | | | | | - Carles Ràfols
- 6. Medical Department, Bayer HealthCare, Barcelona, Spain
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De Caterina R, Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Huber K, Jespersen J, Kristensen SD, Lip GYH, Morais J, Rasmussen LH, Siegbahn A, Verheugt FWA, Weitz JI. Vitamin K antagonists in heart disease: current status and perspectives (Section III). Position paper of the ESC Working Group on Thrombosis--Task Force on Anticoagulants in Heart Disease. Thromb Haemost 2013; 110:1087-107. [PMID: 24226379 DOI: 10.1160/th13-06-0443] [Citation(s) in RCA: 277] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 08/19/2013] [Indexed: 12/27/2022]
Abstract
Oral anticoagulants are a mainstay of cardiovascular therapy, and for over 60 years vitamin K antagonists (VKAs) were the only available agents for long-term use. VKAs interfere with the cyclic inter-conversion of vitamin K and its 2,3 epoxide, thus inhibiting γ-carboxylation of glutamate residues at the amino-termini of vitamin K-dependent proteins, including the coagulation factors (F) II (prothrombin), VII, IX and X, as well as of the anticoagulant proteins C, S and Z. The overall effect of such interference is a dose-dependent anticoagulant effect, which has been therapeutically exploited in heart disease since the early 1950s. In this position paper, we review the mechanisms of action, pharmacological properties and side effects of VKAs, which are used in the management of cardiovascular diseases, including coronary heart disease (where their use is limited), stroke prevention in atrial fibrillation, heart valves and/or chronic heart failure. Using an evidence-based approach, we describe the results of completed clinical trials, highlight areas of uncertainty, and recommend therapeutic options for specific disorders. Although VKAs are being increasingly replaced in most patients with non-valvular atrial fibrillation by the new oral anticoagulants, which target either thrombin or FXa, the VKAs remain the agents of choice for patients with atrial fibrillation in the setting of rheumatic valvular disease and for those with mechanical heart valves.
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Affiliation(s)
- Raffaele De Caterina
- Raffaele De Caterina, MD, PhD, Institute of Cardiology, "G. d'Annunzio" University - Chieti, Ospedale SS. Annunziata, Via dei Vestini, 66013 Chieti, Italy, E-mail:
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Clarkesmith DE, Pattison HM, Lane DA. Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation. Cochrane Database Syst Rev 2013:CD008600. [PMID: 23736948 DOI: 10.1002/14651858.cd008600.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Current guidelines recommend oral anticoagulation therapy for patients with atrial fibrillation who are at moderate-to-high risk of stroke, however anticoagulation control (time in therapeutic range (TTR)) is dependent on many factors. Educational and behavioural interventions may impact on patients' ability to maintain their International Normalised Ratio (INR) control. OBJECTIVES To evaluate the effects on TTR of educational and behavioural interventions for oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library (2012, Issue 7 of 12), MEDLINE Ovid (1950 to week 4 July 2012), EMBASE Classic + EMBASE Ovid (1947 to Week 31 2012), PsycINFO Ovid (1806 to 2012 week 5 July) on 8 August 2012 and CINAHL Plus with Full Text EBSCO (to August 2012) on 9 August 2012. We applied no language restrictions. SELECTION CRITERIA The primary outcome analysed was TTR. Secondary outcomes included decision conflict (patient's uncertainty in making health-related decisions), percentage of INRs in the therapeutic range, major bleeding, stroke and thromboembolic events, patient knowledge, patient satisfaction, quality of life (QoL), and anxiety. DATA COLLECTION AND ANALYSIS The two review authors independently extracted data. Where insufficient data were present to conduct a meta-analysis, effect sizes and confidence intervals (CIs) of the included studies were reported. Data were pooled for two outcomes, TTR and decision conflict. MAIN RESULTS Eight trials with a total of 1215 AF patients (number of AF participants included in the individual trials ranging from 14 to 434) were included within the review. Studies included education, decision aids, and self-monitoring plus education.For the primary outcome of TTR, data for the AF participants in two self-monitoring plus education trials were pooled and did not favour self-monitoring plus education or usual care in improving TTR, with a mean difference of 6.31 (95% CI -5.63 to 18.25). For the secondary outcome of decision conflict, data from two decision aid trials favoured usual care over the decision aid in terms of reducing decision conflict, with a mean difference of -0.1 (95% CI -0.2 to -0.02). AUTHORS' CONCLUSIONS This review demonstrated that there is insufficient evidence to draw definitive conclusions regarding the impact of educational or behavioural interventions on TTR in AF patients receiving OAT. Thus, more trials are needed to examine the impact of interventions on anticoagulation control in AF patients and the mechanisms by which they are successful. It is also important to explore the psychological implications for patients suffering from this long-term chronic condition.
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Affiliation(s)
- Danielle E Clarkesmith
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK. 2School of Life and Health Sciences,Aston University, Birmingham, UK
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Wong PYH, Schulman S, Woodworth S, Holbrook A. Supplemental patient education for patients taking oral anticoagulants: systematic review and meta-analysis. J Thromb Haemost 2013; 11:491-502. [PMID: 23279062 DOI: 10.1111/jth.12107] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 12/06/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Lack of patient knowledge has been associated with poor anticoagulation control, but the effect of patient education on clinical outcomes is unclear. We systematically reviewed the effect of supplemental patient education vs. usual care on hemorrhage, thromboembolic events (TEEs), time in therapeutic range (TTR) and knowledge test scores for all oral anticoagulants. DATA SOURCES The data sources were electronic databases, including MEDLINE, EMBASE, CENTRAL, CINAHL and IPA, to February 2012 examining any oral anticoagulant. We reviewed references for additional potentially relevant studies. METHODS Only randomized controlled trials (RCTs) were considered. Data extraction and quality assessment were conducted with GRADE. Pooled relative risks (RRs) were calculated, and heterogeneity was determined by use of χ(2) and I(2) statistics. RESULTS Seven RCTs (n = 1209) were included in the systematic review, and five RCTs (n = 847) in the meta-analysis. All included studies examined vitamin K antagonists. No significant difference was found for hemorrhage (RR 0.92, 95% confidence interval [CI] 0.04-20.56), TEE (RR 0.66, 95% CI 0.10-4.39), a composite outcome of hemorrhage or TEE (RR 0.48, 95% CI 0.23-1.01), or TTR (mean absolute difference of 2.02%, 95% CI - 2.81 to 6.84). Evidence was conflicting on the impact of supplemental education on test scores. All trials had at least one substantial methodologic limitation. CONCLUSION Current evidence does not support supplemental patient education as a means to improve patient outcomes, but the quality of this evidence is poor. Larger randomized trials are needed with longer follow-up, recruitment of patients initiating anticoagulation in primary care settings, and clearly defined education interventions.
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Affiliation(s)
- P Y H Wong
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Verret L, Couturier J, Rozon A, Saudrais-Janecek S, St-Onge A, Nguyen A, Basmadjian A, Tremblay S, Brouillette D, de Denus S. Impact of a Pharmacist-Led Warfarin Self-Management Program on Quality of Life and Anticoagulation Control: A Randomized Trial. Pharmacotherapy 2012; 32:871-9. [DOI: 10.1002/j.1875-9114.2012.01116] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Lucie Verret
- Department of Pharmacy; Montreal Heart Institute-Université de Montréal; Montreal; Quebec; Canada
| | - Justine Couturier
- Department of Pharmacy; Montreal Heart Institute-Université de Montréal; Montreal; Quebec; Canada
| | - Andréanne Rozon
- Department of Pharmacy; Montreal Heart Institute-Université de Montréal; Montreal; Quebec; Canada
| | - Sarah Saudrais-Janecek
- Department of Pharmacy; Montreal Heart Institute-Université de Montréal; Montreal; Quebec; Canada
| | - Amélie St-Onge
- Department of Pharmacy; Montreal Heart Institute-Université de Montréal; Montreal; Quebec; Canada
| | - Angela Nguyen
- Department of Pharmacy; Montreal Heart Institute-Université de Montréal; Montreal; Quebec; Canada
| | | | - Simon Tremblay
- Department of Pharmacy; Montreal Heart Institute-Université de Montréal; Montreal; Quebec; Canada
| | - Denis Brouillette
- Department of Pharmacy; Montreal Heart Institute-Université de Montréal; Montreal; Quebec; Canada
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Anticoagulation early after mechanical valve replacement: improved management with patient self-testing. J Thorac Cardiovasc Surg 2012; 146:599-604. [PMID: 22921821 DOI: 10.1016/j.jtcvs.2012.03.088] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 03/15/2012] [Accepted: 03/28/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Self-testing to determine the international normalized ratio improves management with warfarin and reduces the risks of adverse events. Self-testing usually begins several weeks after hospital dismissal after valve replacement. We aimed to compare the in-hospital initiation of international normalized ratio self-testing with usual care in mechanical heart valve recipients. METHODS A total of 200 adult mechanical heart valve recipients were randomly assigned to in-hospital international normalized ratio self-testing instruction or usual care. Instruction for self-testing patients began on the fourth postoperative day. The patients were followed up for 3 months to compare the number of international normalized ratio tests, percentage of time in the therapeutic range, and adverse events. RESULTS The baseline characteristics were similar between the 2 groups. During the first 3 postoperative months, the usual-care group underwent an average of 10 international normalized ratio tests, and the self-testing group completed 14 international normalized ratio tests. The mean ± SD percentage of international normalized ratio tests within the therapeutic range was 45% ± 22% for the usual-care group and 52% ± 22% for the self-testing group (P = .05). Within 90 days after dismissal, transient ischemic attack occurred in 1 patient in the usual-care group and 2 patients in the self-testing group. Bleeding complications occurred in 3 patients in the usual-care group and 5 patients in the self-testing group. CONCLUSIONS Management of anticoagulation with warfarin after mechanical valve replacement is improved with self-testing, even during the early postoperative phase when international normalized ratio testing is performed frequently. Although the incidence of adverse events was similar in the 2 groups, better control of the international normalized ratio would be expected to improve outcome in large populations of patients.
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Siebenhofer A, Hemkens LG, Rakovac I, Spat S, Didjurgeit U. Self-management of oral anticoagulation in elderly patients - effects on treatment-related quality of life. Thromb Res 2012; 130:e60-6. [PMID: 22749961 DOI: 10.1016/j.thromres.2012.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 05/29/2012] [Accepted: 06/13/2012] [Indexed: 10/28/2022]
Abstract
UNLABELLED BACKGROUND - RATIONALE FOR STUDY: In elderly patients, long-term self-management of oral anticoagulation has been shown to reduce the number of major thromboembolic and bleeding complications and improve the quality of oral anticoagulation (OAC) control compared to routine care for a mean follow-up period of three years. This article presents the results of the predefined secondary endpoint treatment-related quality of life (QoL). METHODS AND RESULTS The effect of self-management on five aspects of QoL was evaluated in comparison with routine care. A validated questionnaire specifically designed for patients receiving OAC was used. The evaluation was possible for 141 patients, comprising 90% of surviving patients on OAC. At baseline, all patients had high scores for the following QoL-aspects: general treatment satisfaction, self-efficacy, daily hassles and strained social network. A high proportion of patients in both groups explicitly reported high distress, indicating that general psychological distress seems to be of particular concern in this population. After about 3 years of follow-up, patients performing self-management showed a significantly greater improvement in general treatment satisfaction than controls (median score increase [25th percentile, 75th percentile]: 0.9 [0.0, 1.6] vs. 0.0 [-0.2, 0.6], p=0.002; scale 1-6). Changes in general psychological distress, self-efficacy, daily hassles and strained social network were not significant. CONCLUSION Treatment related quality of life in elderly patients performing self-management of OAC was similar as for patients in routine care setting, with a tendency of higher general treatment satisfaction, after three years of follow up.
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Affiliation(s)
- Andrea Siebenhofer
- Institute for General Practice, Goethe University, Frankfurt am Main, Germany.
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Nutescu EA, Bathija S, Sharp LK, Gerber BS, Schumock GT, Fitzgibbon ML. Anticoagulation patient self-monitoring in the United States: considerations for clinical practice adoption. Pharmacotherapy 2012; 31:1161-74. [PMID: 22122179 DOI: 10.1592/phco.31.12.1161] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Systematic management models such as anticoagulation clinics have emerged in order to optimize warfarin effectiveness and to minimize related complications. Most of these models are structured so that patients come to a clinic for in-person testing and evaluation, thus making this model of care difficult to access and time consuming for many patients. The emergence of portable instruments for measuring anticoagulant effect in capillary whole blood made it possible for patients receiving warfarin to self-monitor the effect of their anticoagulant therapy. Self-monitoring empowers patients, offers the advantage of more frequent monitoring, and increases patient convenience by allowing testing at home and avoiding the need for frequent laboratory and clinic visits. Self-monitoring can entail patient self-testing (PST) and/or patient self-management (PSM). Several studies have evaluated and shown the benefit of both PST and PSM models of care when compared with either routine medical care or anticoagulation clinic management of anticoagulation therapy. Self-monitoring (PSM and/or PST) of anticoagulation results in lower thromboembolic events, lower mortality, and no increase in major bleeding when compared with standard care. Despite favorable results and enhanced patient convenience, the adoption of self-monitoring into clinical practice in the United States has been limited, especially in higher risk, disadvantaged populations. Although the emergence of a multitude of novel oral anticoagulants will permit clinicians to better individualize anticoagulant therapy options by choosing the optimum regimen based on individual patient characteristics, it is also expected that traditional agents will continue to play a role in a significant subset of patients. For those patients treated with traditional anticoagulants such as warfarin, future models of care will entail patient-centered management such as PST and PSM. The incorporation of technology (i.e., Web-based expert systems) is expected to further improve the outcomes realized by PST and PSM. Further studies are needed to explore factors that influence the adoption of self-monitoring in the United States and to evaluate the feasibility and implementation in real-life clinical settings.
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Affiliation(s)
- Edith A Nutescu
- Department of Pharmacy Practice and Pharmacy Administration, University of Illinois at Chicago, Chicago, Illinois 60612-7230, USA.
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Pelegrino FM, Dantas RAS, Corbi ISA, da Silva Carvalho AR, Schmidt A, Filho AP. Cross-cultural adaptation and psychometric properties of the Brazilian-Portuguese version of the Duke Anticoagulation Satisfaction Scale. J Clin Nurs 2011; 21:2509-17. [DOI: 10.1111/j.1365-2702.2011.03869.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Almeida GDQ, Noblat LDACB, Passos LCS, do Nascimento HF. Quality of life analysis of patients in chronic use of oral anticoagulant: an observational study. Health Qual Life Outcomes 2011; 9:91. [PMID: 22027368 PMCID: PMC3221633 DOI: 10.1186/1477-7525-9-91] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 10/25/2011] [Indexed: 12/03/2022] Open
Abstract
Background Treatment with oral anticoagulant may influence the quality of life perception as it promotes changes in the patient's life, not offering an evident symptomatic relief and presenting well defined risks, such as bleeding. In this trial, the influence of chronic use of anticoagulants on the quality of life perception has been analyzed in patients assisted at the anticoagulation outpatient unit. Methods The health related quality of life was evaluated through a cross-section study with a sample composed of 72 patients seen from July 23, 2009 to September 2, 2010 at the Anticoagulation Outpatient Unit of the Federal University of Bahia's University Hospital. The study's population was composed by patients with atrial fibrillation and mechanical heart valve. The patients were submitted to two quality of life evaluation questionnaires: a generic questionnaire - the Medical Outcomes Study SF-36 Health Survey (SF36) - and a specific questionnaire - the Duke Anticoagulation Satisfaction Scale (DASS). Results The quality of life perception of the patients studied, based on both the DASS and the SF36, was positive regarding the treatment with oral anticoagulant. The SF36 presented an average score of 62.2 (± 20.0). Among the SF36 evaluated domains, the physical-emotional aspect was the most compromised one regarding life quality perception. The DASS presented an average score of 67.1 (± 18.2) and the domain presenting a greater compromise was the one related to the treatment inconveniences (annoyances, burdens and obligations). Previous hemorrhagic event, comorbidities, drug interactions with medicines that increase the anticoagulant effect, lower education level in the SF36 and younger age group influence a more negative perception of the quality of life, whereas lower education level in the DASS and the duration of treatment for more than 1 year offer a more positive perception. Conclusion Patients seen at the anticoagulation outpatient unit of the University Hospital of Federal University of Bahia/Brazil had a positive perception of the treatment. Factors such as hemorrhagic event, comorbidities, drug interactions, education level, age group and duration of treatment have an influence on the quality of life perception.
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Affiliation(s)
- Geisa de Queiroz Almeida
- Medicine and Health Graduation Program, Federal University of Bahia, Rua Odilon Dorea n°1 edf, Suzana apt° 202 Brotas, Salvador, Bahia, 40,285-450, Brazil.
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Nasser S, Mullan J, Bajorek B. Challenges of Older Patients’ Knowledge About Warfarin Therapy. J Prim Care Community Health 2011; 3:65-74. [DOI: 10.1177/2150131911416365] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To review the challenges of warfarin education for older patients (aged 65 years or older) in terms of knowledge, access to warfarin education, and education resources. Methods: A quasi-systematic review of the literature was performed via electronic database searches (eg, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, Meditext, and Google Scholar) from 1990 to May 2011. Results: The 62 articles reviewed found that improved patient knowledge results in better anticoagulation control. The review also found that between 50% and 80% of older patients have inadequate knowledge about the basic aspects of warfarin therapy (eg, action, benefits and risks, interactions with other drugs or foods, international normalized ratio management). Demographic factors, such as advancing age, lower family income, and limited health literacy, were found to inversely affect patients’ warfarin knowledge, and access to warfarin education and information resources were often suboptimal in different practice settings. Finally, a number of educational strategies and resources that could be readily incorporated to improve the effectiveness of current warfarin education programs were extracted from the review. Conclusion: This comprehensive review highlights that education about warfarin in older patients is currently suboptimal and may in part contribute to poor therapeutic outcomes. This review article also acknowledges the need to identify, target, and develop educational strategies and resources to further improve older patients’ knowledge about their warfarin therapy.
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Corbi ISA, Dantas RAS, Pelegrino FM, Carvalho ARDS. Health related quality of life of patients undergoing oral anticoagulation therapy. Rev Lat Am Enfermagem 2011; 19:865-73. [DOI: 10.1590/s0104-11692011000400003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 05/17/2011] [Indexed: 11/22/2022] Open
Abstract
This is a descriptive cross-sectional study, which aimed to analyze the health related quality of life (HRQoL) and its relationship with gender, age, duration and indication for the use of oral anticoagulants. A total of 178 patients were interviewed and the HRQoL was assessed through eight domains of the SF-36. The descriptive statistics used were, the Student's t, ANOVA and Tukey's tests for the comparison of the means between the groups. The indication for use was predominantly the metallic prosthetic heart valve (50%) with warfarin the most widely prescribed anticoagulant (83.3%). The means of the domains of the SF-36 ranged from 82 (Social aspects) to 54.8 (Physical aspects). Women, elderly, patients diagnosed with atrial fibrillation and with less than one year of medication use, presented a worse HRQoL evaluation. The results obtained can guide nursing actions, in that they indicate possible associations between the HRQoL and the sociodemographic and clinical variables of the patients.
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McCahon D, Murray ET, Murray K, Holder RL, Fitzmaurice DA. Does self-management of oral anticoagulation therapy improve quality of life and anxiety? Fam Pract 2011; 28:134-40. [PMID: 21068191 DOI: 10.1093/fampra/cmq089] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Research related to service requirements for anticoagulation management has focussed on clinical and health economic outcomes and paid little attention to the impact of treatment and service delivery on patients' quality of life. This was the first large UK study to evaluate the effect of patient self-management (PSM) of oral anticoagulation on treatment-related quality of life (TRQoL) and anxiety in comparison with routine care (RC) and to explore the effect of level of therapeutic control on TRQoL and anxiety across and within each model of care. METHODS A quantitative survey, set in primary care in the West Midlands. The subjects were 517 randomized controlled trial participants, 242 receiving PSM and 275 RC. Postal questionnaires at baseline and 12 months comprised the State Trait Anxiety Inventory and a treatment-specific measure of positive (satisfaction and self-efficacy) and negative aspects (daily hassles, strained social network and psychological distress) of TRQoL. Change in anxiety and TRQoL scores were compared between PSM and RC. Subgroup analysis was based upon level of therapeutic control (high, medium and low). RESULTS Overall, 83% (n = 202) PSM and 55% (n = 161) RC patients contributed data. Anxiety scores were similar in both groups. PSM demonstrated greater improvement in self-efficacy than RC across the study period. A statistically significant between-group difference (PSM versus RC) in the self-efficacy also existed in subgroups with medium and high levels of therapeutic control. CONCLUSIONS PSM is not associated with increased anxiety and has a positive effect upon some aspects of TRQoL compared to RC.
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Affiliation(s)
- Deborah McCahon
- Primary Care Clinical Sciences, School of Health and Population Sciences, Primary Care Clinical Sciences Building, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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Jones S, Newall F, Manias E, Monagle P. Assessing outcome measures of oral anticoagulation management in children. Thromb Res 2011; 127:75-80. [DOI: 10.1016/j.thromres.2010.09.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 08/19/2010] [Accepted: 09/01/2010] [Indexed: 11/29/2022]
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