Comparing the effectiveness of pharmacist‐managed warfarin anticoagulation with other models: a systematic review and meta‐analysis

Coordination of oral anticoagulant care at hospital discharge (COACHeD): pilot randomised controlled trial

OBJECTIVES

To evaluate whether a focused, expert medication management intervention is feasible and potentially effective in preventing anticoagulation-related adverse events for patients transitioning from hospital to home.

DESIGN

Randomised, parallel design.

SETTING

Medical wards at six hospital sites in southern Ontario, Canada.

PARTICIPANTS

Adults 18 years of age or older being discharged to home on an oral anticoagulant (OAC) to be taken for at least 4 weeks.

INTERVENTIONS

Clinical pharmacologist-led intervention, including a detailed discharge medication management plan, a circle of care handover and early postdischarge virtual check-up visits to 1 month with 3-month follow-up. The control group received the usual care.

OUTCOMES MEASURES

Primary outcomes were study feasibility outcomes (recruitment, retention and cost per patient). Secondary outcomes included adverse anticoagulant safety events composite, quality of transitional care, quality of life, anticoagulant knowledge, satisfaction with care, problems with medications and health resource utilisation.

RESULTS

Extensive periods of restriction of recruitment plus difficulties accessing patients at the time of discharge negatively impacted feasibility, especially cost per patient recruited. Of 845 patients screened, 167 were eligible and 56 were randomised. The mean age (±SD) was 71.2±12.5 years, 42.9% females, with two lost to follow-up. Intervention patients were more likely to rate their ability to manage their OAC as improved (17/27 (63.0%) vs 7/22 (31.8%), OR 3.6 (95% CI 1.1 to 12.0)) and their continuity of care as improved (21/27 (77.8%) vs 2/22 (9.1%), OR 35.0 (95% CI 6.3 to 194.2)). Fewer intervention patients were taking one or more inappropriate medications (7 (22.5%) vs 15 (60%), OR 0.19 (95% CI 0.06 to 0.62)).

CONCLUSION

This pilot randomised controlled trial suggests that a transitional care intervention at hospital discharge for older adults taking OACs was well received and potentially effective for some surrogate outcomes, but overly costly to proceed to a definitive large trial.

TRIAL REGISTRATION NUMBER

NCT02777047.

Impact of Clinical Pharmacist Running Anticoagulation Clinic in Saudi Arabia

Despite the effectiveness of warfarin in extended anticoagulation, its narrow therapeutic index requires frequent dose adjustments and careful patient monitoring. Thus, we aimed to evaluate the outcomes of clinical pharmacists' intervention in warfarin therapy management in terms of International Normalized Ratio (INR) control, reduction of bleeding, and hospitalization in a tertiary care hospital. An observational retrospective cohort study was conducted on 96 patients taking warfarin therapy in a clinical pharmacist-led anticoagulation clinic. We observed that 39.6% of patients required dose adjustments at their first and second visits. However, dose adjustments during the third, fourth, and fifth weeks were required at 31.1%, 20.8%, and 4.2%, respectively, to achieve INR levels. We also observed that 36.46% of the patients attained the target INR at baseline, which was increased over the first week to the fifth week to 57.29%, 61.46%, 61.46%, 68.75%, and 85.42%, respectively. No one reported the ADR between the third and fifth weeks. Based on our findings, the study strongly suggests that pharmacists' interventions can improve the health-related quality of life of patients undergoing warfarin therapy. Thus, competent pharmacy personnel must be a priority in both usual patient care and critical care among primary care networks.

Perceptions of patients and healthcare providers on patient education to improve oral anticoagulant management

RATIONALE AND OBJECTIVES

Education of patients is thought to be key to high-quality oral anticoagulant (OAC) medication management. Theoretically, improving patients' knowledge should improve their self-management skills and adherence. The study's objective was to explore the opinions of healthcare providers and patients on the desired content and format of patient education on OACs, in addition to perceived barriers to high-quality patient education.

METHODS

We applied qualitative descriptive methods in a focus group study on OAC management. Five focus group discussions were conducted in two health regions in Southwestern Ontario from 2017 to 2018 with 19 patients, 7 caregivers and 16 healthcare providers (physicians, nurses and pharmacists). During the focus groups, participants discussed their experiences with OAC education and made suggestions about the content and format for patient education on OACs. Transcripts were analysed using conventional content analysis.

RESULTS

We identified the five themes of patient education on OAC management: content of OAC education (rationale, risk and appropriate drug administration methods), the best times for providing OAC education (time of OACs initiation along with continuing education), preferred education delivery strategies (case management targeted patient information summaries from authoritative sources such as Thrombosis Canada and video education), patient and community pharmacist engagement in OAC education, and perceived barriers to optimal patient education (patients depending too much on their healthcare providers for advice, the limited time patients spend with healthcare providers, gaps in clear communication between providers and the lack of a nationally or provincially coordinated OAC management programme).

CONCLUSION

Our findings suggest that patients, caregivers and healthcare providers support the need for education on OACs, including for patients taking DOACs. Specific important content and proper education format are needed. The optimal combination of content, format, duration, timing and sources for OAC education requires further research.

Oral anticoagulants: a systematic overview of reviews on efficacy and safety, genotyping, self-monitoring, and stakeholder experiences

BACKGROUND

This systematic overview was commissioned by England's Department of Health and Social Care (DHSC) to assess the evidence on direct (previously 'novel') oral anticoagulants (OACs), compared with usual care, in adults, to prevent stroke related to atrial fibrillation (AF), and to prevent and treat venous thromboembolism (VTE). Specifically, to assess efficacy and safety, genotyping, self-monitoring, and patient and clinician experiences of OACs.

METHODS

We searched MEDLINE, Embase, ASSIA, and CINAHL, in October, 2017, updated in November 2021. We included systematic reviews, published from 2014, in English, assessing OACs, in adults. We rated review quality using AMSTAR2 or the JBI checklist. Two reviewers extracted and synthesised the main findings from the included reviews.

RESULTS

We included 49 systematic reviews; one evaluated efficacy, safety, and cost-effectiveness, 17 assessed genotyping, 23 self-monitoring or adherence, and 15 experiences (seven assessed two topics). Generally, the direct OACs, particularly apixaban (5 mg twice daily), were more effective and safer than warfarin in preventing AF-related stroke. For VTE, there was little evidence of differences in efficacy between direct OACs and low-molecular-weight heparin (prevention), warfarin (treatment), and warfarin or aspirin (secondary prevention). The evidence suggested that some direct OACs may reduce the risk of bleeding, compared with warfarin. One review of genotype-guided warfarin dosing assessed AF patients; no significant differences in stroke prevention were reported. Education about OACs, in patients with AF, could improve adherence. Pharmacist management of coagulation may be better than primary care management. Patients were more adherent to direct OACs than warfarin. Drug efficacy was highly valued by patients and most clinicians, followed by safety. No other factors consistently affected patients' choice of anticoagulant and adherence to treatment. Patients were more satisfied with direct OACs than warfarin.

CONCLUSIONS

For stroke prevention in AF, direct OACs seem to be more effective and safer than usual care, and apixaban (5 mg twice daily) had the best profile. For VTE, there was no strong evidence that direct OACs were better than usual care. Education and pharmacist management could improve coagulation control. Both clinicians and patients rated efficacy and safety as the most important factors in managing AF and VTE.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017084263-one deviation; efficacy and safety were from one review.

Validation and comparison between two warfarin dosing clinical algorithms and warfarin fixed dosing in specialized heart center: cross-sectional study

Background

Warfarin is well known as a narrow therapeutic index that has prodigious variability in response which challenges dosing adjustment for the maintenance of therapeutic international normalized ratio. However, an appreciated population not on new oral anticoagulants may still need to be stabilized with warfarin dosing.

Objective

The current study's main objective was to validate and compare two models of warfarin clinical algorithm models namely the Gage and the International Warfarin Pharmacogenetics Consortium (IWPC) with warfarin 5 mg fixed standard dosing strategy in a sample of Sudanese subjects.

Method

We have conducted a cross-sectional study recruited from the out-patient clinic at a tertiary specialized heart center. We included subjects with unchanged warfarin dose (stabilized), and with therapeutic international normalized ratio. The predicted doses of warfarin in the two models were calculated by three different methods (accuracy, clinical practicality, and the clinical safety of the clinical algorithms).

Main outcome measure

The primary outcomes were the measurements of the clinical (accuracy, practicality, and safety) in each of the two clinical algorithms models compared to warfarin 5 mg fixed standard dose strategy.

Results

We have enrolled 71 Sudanese subjects with mean age (51.7 ± 14 years), of which (49, 69.0%) were females. There was no significant difference between the warfarin 5 mg fixed standard dose strategy and the predicted doses of the two clinical algorithm models (MAE 1.44, 1.45, and 1.49 mg/day [P =0.4]) respectively. In the clinical practicality, all of the three models had a high percent of subjects (95.0%, 51.9%, and 66.7%) in the ideal dose range in middle dose group (3-7 mg/ day) for warfarin 5 mg fixed standard dosing strategy, Gage, and IWPC clinical algorithm models respectively. However, a small percent of subjects was exhibited in the warfarin low dose group ≤ 3 mg/day (0.0%, 15.0%, and 10.0%) and warfarin high dose group ≥ 7 mg/day (0.0%, 33.3%, and 33.3%) for warfarin 5 mg fixed standard dosing strategy, Gage, and IWPC clinical algorithms respectively. In terms of clinical safety, the percent of subjects with severely over-prediction were 28.2%, 22.5%, and 22.5% for warfarin 5 mg fixed standard dosing, Gage, and IWPC, respectively. While the percent of severely under-prediction was 12.7%, 7.0%, and 5.6% for the warfarin 5 mg fixed standard dosing, Gage, and IWPC, respectively.

Conclusion

The Gage and IWPC clinical algorithm models were accurate, more clinically practical, and clinically safe than warfarin 5 mg standard dosing in the study population. The cardiologist can use either models (Gage and IWPC) to stratify subjects for accurate, practical, and clinically safe warfarin dosing..

Comparison of Warfarin Initiation at 3 mg Versus 5 mg for Anticoagulation of Patients with Mechanical Mitral Valve Replacement Surgery: A Prospective Randomized Trial

Background

The increased warfarin sensitivity observed after mechanical mitral valve replacement (MVR) operations dictates clinical discretion in warfarin dose initiation. Evidence is still lacking with regard to anticoagulation management of MVR patients.

Objective

This study aimed to compare initiating warfarin at the recommended dosing regimen versus empirically lowered doses intended to account for the variation in warfarin sensitivity.

Methods

A prospective, single-blind, randomized, comparative study was conducted in postoperative MVR patients. Patients were randomly assigned to either the 5 mg group (n = 25) or the 3 mg group (n = 25) and were initiated on a 5 or 3 mg warfarin dose, respectively. Time to target international normalized ratio (INR), time in therapeutic range, occurrence of bleeding/thromboembolic events, and cost of bridging with enoxaparin were assessed for both groups.

Results

Target INR was achieved earlier in the 5 mg group than in the 3 mg group (p = 0.033), with a mean ± SD of 5.3 ± 2.0 and 6.6 ± 2.0, respectively (95% confidence interval of the mean difference 1.022–1.890). Bleeding events did not differ significantly between the two groups. The cost of enoxaparin consumption per patient was significantly higher in the 3 mg group versus the 5 mg group (p = 0.002).

Conclusions

The initiation of warfarin at a 5 mg dose in MVR patients was more efficacious than the 3 mg dose in terms of time to reach the target INR. Moreover, the cost of enoxaparin bridging was significantly reduced with a 5 mg warfarin initiation dose. Bleeding events were comparable.

ClinicalTrials.gov ID

NCT04235569, 22 January 2020.

Effects of Pharmacist Interventions on Cardiovascular Risk Factors and Outcomes: An Umbrella Review of Meta-analysis of Randomized Controlled Trials

AIM

To grade the evidence from published meta-analyses of randomized controlled trials (RCTs) that assessed effects of pharmacist intervention on cardiovascular risk factors and cardiovascular outcomes.

METHODS

MEDLINE, Embase, and the Cochrane Library were searched from database inception to July 2021. Meta-analyses of RCTs were eligible. Quality of evidence were assessed by GRADE approach.

RESULTS

From 9,308 publications, 149 full-text articles were evaluated for eligibility, and 24 studies with 85 unique meta-analyses that assessed effects of pharmacist intervention on cardiovascular risk factors and cardiovascular outcomes. Overall, 71.7% (61/85) of unique meta-analyses showed significant impacts of pharmacist intervention. For the quality of evidence, 63.4% of meta-analyses had large heterogeneity (I² > 50%) while 1.2%, 16.5%, 32.9% and 49.4% of meta-analyses were graded as high, moderate, low and very low quality based on GRADE approach, respectively. Among meta-analyses with moderate quality, pharmacist interventions significantly mitigated risk factors (including 6/3 mmHg reduction of blood pressure, increased the rate of lipid control, glucose control and smoking cessation (pooled OR 1.91 (1.55, 2.35), 3.11 (2.3, 4.3), and 2.3 (1.33, 3.97), respectively)) and improved medication adherence (pooled OR 1.67 (1.38, 2.02)). Furthermore, pharmacist interventions significantly reduced all-cause mortality (pooled OR 0.72 (0.58, 0.89)) and improved quality of life in patients suffering from chronic heart failure.

CONCLUSION

This umbrella review found convincing evidence that pharmacist intervention can provide a wide range of benefits in cardiovascular disease management, ranging from risk factor control, improvement in medication adherence and in some setting, reduction in morbidity and mortality.

Changing from mandatory to optional genotyping results in higher acceptance of pharmacist-guided warfarin dosing

Aim: We evaluated the clinical acceptance and feasibility of a pharmacist-guided personalized consult service following its transition from a mandatory (mPGx) to optional (oPGx) CYP2C9/VKORC1/CYP4F2 genotyping for warfarin. Methods: A total of 1105 patients were included. Clinical acceptance and feasibility outcomes were analyzed using bivariate and multivariable analyses. Results: After transitioning to optional genotyping, genotype testing was still ordered in a large segment of the eligible population (52.1%). Physician acceptance of pharmacist-recommended doses improved from 83.9% (mPGx) to 86.6% (oPGx; OR: 1.3; 95% CI: 1.1-1.5; p = 0.01) with a shorter median genotype result turnaround time (oPGX: 23.6 h vs mPGX: 25.1 h; p < 0.01). Conclusion: Ordering of genotype testing and provider acceptance of dosing recommendations remained high after transitioning to optional genotyping.

The Impact of Pharmacist-Managed Service on Warfarin Therapy in Patients after Mechanical Valve Replacement

OBJECTIVE

To evaluate the impact of pharmacist interventions on international normalized ratio (INR) control during the warfarin initiation phase after mechanical valve replacement.

METHODS

This was a retrospective cohort study conducted in a cardiovascular surgery ward in a tertiary hospital from August 1, 2015, to July 31, 2019. Patients aged ≥20 years who were admitted for mechanical valve replacement were enrolled in this study and further classified into conventional and pharmacist-managed warfarin therapy (PMWT) groups. All participants were prospectively followed up until the first outpatient appointment after valve replacement. The effectiveness outcomes were time in therapeutic range (TTR), time to therapeutic INR, number of patients with therapeutic INR at discharge and at first outpatient appointment, and length of hospital stay. The safety outcome was the number of patients with any supratherapeutic INR during the hospital stay. Multivariate logistic regression analyses were also used to determine the predictors of a therapeutic INR at discharge or with any supratherapeutic INR during admission.

RESULTS

A total of 39 and 33 patients were enrolled in the conventional and PMWT groups, respectively. At discharge, 18 patients (46.2%) in the conventional group and 24 patients (72.7%) in the PMWT group had achieved the therapeutic INR (P=0.023). Compared to the conventional group, fewer patients in the PMWT group had supratherapeutic INR during hospital stay (35.9% vs. 9.0%, P=0.008). No significant differences were found in TTR, time to therapeutic INR, number of patients with therapeutic INR at return appointment, and length of stay between the study groups. In the multivariate regression analyses, PMWT predicted achieving therapeutic INR at discharge (odds ratio (OR) and 95% confidence interval (CI), 3.14 [1.08-9.14]) and was inversely associated with supratherapeutic INRs during admission (OR = 0.21 [0.05-0.82]).

CONCLUSIONS

Among patients admitted for mechanical valve replacement, the implementation of PMWT was associated with optimal therapeutic INR at discharge and no supratherapeutic INR during admission. Therefore, pharmacist participation is essential for improving the quality of warfarin therapy.

Evaluation of a pharmacist vs. Haematologist-managed anticoagulation clinic: A retrospective cohort study

INTRODUCTION

Warfarin is the core component in the management of various thromboembolic disorders, which requires specialized expertise to optimize outcomes. There is limited data comparing a pharmacist vs. a haematologist-managed anticoagulation clinic in our setting, and in the Middle East. We aimed to evaluate the effectiveness and safety of a pharmacist vs. a haematologist-managed anticoagulation clinic in the Ambulatory Care Center at King Abdulaziz Medical City, Jeddah, Saudi Arabia.

METHODS

A retrospective cohort study was conducted from 2016 to 2018, which included adult patients who have been followed-up for at least six months and who received warfarin for an extended period. The primary outcome was the proportion of time the patients in the two arms were in the therapeutic range. The secondary outcomes were the differences in expanded time in the therapeutic range, as well as the frequency of bleeding and thromboembolic events between the two arms.

RESULTS

We enrolled 104 and 124 patients in the pharmacist and haematologist arms respectively. The median time in the therapeutic range for the pharmacist arm was 71.4%, IQR (60.8-83.8) vs. 65%, IQR (43.5-79.1), in the haematologist arm (p = 0.0049). The median expanded time in the therapeutic range was 86.4%, IQR (77.5-95.3) vs. 81.21%, IQR (67.1-93.3) in the pharmacist vs. haematologist arm (p = 0.015) respectively. Major bleeding events occurred in 5.7 % vs. 3.2 %, and thromboembolic events in 5.7% vs. 4%, in the pharmacist vs. haematologist arm respectively.

CONCLUSIONS

Our results demonstrated that the time in the therapeutic range was significantly higher in the pharmacist arm, with no significant difference in bleeding and thromboembolic events compared to the haematologist arm.

Atrial Fibrillation Patients on Warfarin and Their Transition to Direct Oral Anticoagulants

BACKGROUND

The standard of care for stroke prevention in nonvalvular atrial fibrillation (AF) is the use of direct oral anticoagulants (DOACs). However, many patients established on warfarin therapy have not been considered for a transition to a DOAC.

OBJECTIVES

Assess the AF patient population of Brigham and Women's Hospital (BWH) Anticoagulation Management Service (AMS) currently being treated with warfarin, transition eligible patients to a DOAC, and identify barriers to the transitional process.

METHODS

Patient characteristics were analyzed to describe the overall AF population and a systematic process was used to determine clinical candidacy for a transition from warfarin to a DOAC. After being deemed eligible by both the referring physician and the AMS pharmacist, each patient was contacted and offered the opportunity for DOAC transition. Endpoints included number of successful transitions and commonly encountered barriers.

RESULTS

Out of the 1407 total AF patients on warfarin managed by BWH AMS, there were 787 patients identified as candidates for DOAC transition and a successful transition was completed for 250 (31.8%) of them. Barriers to transition included patient preference for warfarin (n = 247, 31.4%), referring physician preference for warfarin (n = 112, 14.2%), cost (n = 88, 11.2%), AMS pharmacist preference for warfarin (n = 70, 8.9%), and previous DOAC intolerance (n = 20, 2.5%).

CONCLUSIONS

Every institution or provider network that manages AF patients on warfarin should assess their population on a regular basis to identify candidates for DOAC therapy. Our initiative outlines a process for identifying and transitioning DOAC-eligible AF patients established on warfarin therapy and describes the most commonly encountered barriers to DOAC therapy.

Association of pharmacist counseling with adherence, 30-day readmission, and mortality: A systematic review and meta-analysis of randomized trials

OBJECTIVE(S)

To determine the association of pharmacist medication counseling with medication adherence, 30-day hospital readmission, and mortality.

METHODS

The initial search identified 21,590 citations. After applying the inclusion and exclusion criteria, 62 randomized controlled trials (RCTs) (49 for the meta-analysis) were included in the final analysis. Data were pooled using a random-effects model.

RESULTS

The participants in most of the studies were older patients with chronic diseases who, therefore, were taking many drugs. The overall methodologic quality of evidence ranged from low to very low. Pharmacist medication counseling versus no such counseling was associated with a statistically significant 30% increase in relative risk (RR) for medication adherence, a 24% RR reduction in 30-day hospital readmission (number needed to treat = 4.2), and a 30% RR reduction in emergency department visits. RR reductions for primary care visits and mortality were not statistically significant.

CONCLUSION

The evidence supports pharmacist medication counseling to increase medication adherence and to reduce 30-day hospital readmissions and emergency department visits. However, higher-quality RCT studies are needed to confirm or refute these findings.

The Effects of Educational Programs on Knowledge, International Normalized Ratio, Warfarin Adherence, and Warfarin-Related Complications in Patients Receiving Warfarin Therapy: An Integrative Review

BACKGROUND

Education is considered a crucial element in anticoagulation management for patients with atrial fibrillation, valvular disease, ischemic heart disease, and venous thromboembolism. However, the effects of education on the patients prescribed warfarin are seldom investigated.

OBJECTIVES

This integrative review was conducted to explore the effects of educational programs on patients prescribed warfarin for the aforementioned cardiovascular diseases and to identify the components of effective programs.

METHODS

A systematic search of clinical trials was performed in 8 databases from inception to August 2020. Two reviewers performed the eligibility assessment, methodological evaluation, and data extraction. A total of 9 studies were included and analyzed via narrative synthesis.

RESULTS

Nine studies involving a combined total of 1335 patients were included in the review. The findings suggest that educational programs have potential benefits related to international normalized ratio control and warfarin knowledge. However, their effects on major bleeding and thromboembolic events are unremarkable. Stronger evidence is recommended to confirm these findings, and the limited evidence examining the effects of education on warfarin adherence, minor bleeding, abnormal international normalized ratio, readmission rate, and warfarin-related mortality requires further exploration. Verbal education supported by written materials was the main educational delivery mode. A lecture length of approximately 45 minutes was likely appropriate. Notably, the integration of educational strategies, application of follow-up interventions and monitoring measures, adoption of psychological theories in program development, and inclusion of nurses or pharmacists in program conduction seemed to be effective program components.

CONCLUSIONS

The effects of educational programs on patients prescribed warfarin mainly for atrial fibrillation, valvular disease, ischemic heart disease, and venous thromboembolism remain inconclusive. Further research using randomized controlled trials is warranted.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

Technology-Based Interventions in Oral Anticoagulation Management: Meta-Analysis of Randomized Controlled Trials

Background

An increasing number of patients have received prophylactic or therapeutic oral anticoagulants (OACs) for thromboembolic complications of diseases. The use of OACs is associated with both clinical benefits and risks. Considering the challenges imposed by this class of drugs, as well as the enormous progress made in portable device technology, it is possible that technology-based interventions may improve clinical benefits for patients and optimize anticoagulation management.

Objective

This study was designed to comprehensively evaluate the role of technology-based interventions in the management of OACs.

Methods

We searched 6 databases—PubMed, EMBASE, Cochrane, Cumulative Index to Nursing and Allied Health Literature, Scopus, and PsycINFO—to retrieve relevant studies published as of November 1, 2019, to evaluate the effect of technology-based interventions on oral anticoagulation management. RevMan (version 5.3; Cochrane) software was used to evaluate and analyze clinical outcomes. The methodological quality of studies was assessed by the Cochrane risk of bias tool.

Results

A total of 15 randomized controlled trials (RCTs) were selected for analysis. They reported data for 2218 patients (1110 patients in the intervention groups and 1108 patients in the control groups). A meta-analysis was performed on the effectiveness and safety data reported in the RCTs. Technology-based interventions significantly improved the effectiveness of oral anticoagulation management (mean difference [MD]=6.07; 95% CI 0.84-11.30; I²=72%; P=.02). The safety of oral anticoagulation management was also improved, but the results were not statistically significant. Bleeding events were reduced (major bleeding events MD=1.02; 95% CI 0.78-1.32; I²=0%; P=.90; minor bleeding events MD=1.06, 95% CI 0.77-1.44; I²=41%; P=.73) and thromboembolism events were reduced (MD=0.71; 95% CI 0.49-1.01; I²=0%; P=.06). In general, patients were more satisfied with technology-based interventions, which could also improve their knowledge of anticoagulation management, improve their quality of life, and reduce mortality and hospitalization events.

Conclusions

Using technology to manage OACs can improve the effectiveness and safety of oral anticoagulation management, result in higher patient satisfaction, and allow greater understanding of anticoagulation.

[Pharmacist-led anticoagulation monitoring can significantly improve the effectiveness and safety of warfarin for patients during hospitalization]

OBJECTIVE

To investigate the role of pharmacist-led anticoagulation monitoring service for warfarin anticoagulation therapy in patients during hospitalization.

METHODS

We retrospectively analyzed the data of 421 patients receiving warfarin anticoagulation therapy during hospitalization between April, 2016 and December, 2017. Of these patients, 316 received daily pharmacist-led anticoagulation monitoring service including checking the patients' International Normalized Ratio (INR) and other pertinent laboratory test results and reviewing medication changes and the patients' clinical status (monitoring group); the other 105 patients receiving warfarin anticoagulation therapy without pharmaceutical care served as the control group. The data including compliance rate of anticoagulant indicators, incidence and rate of prompt management of INR alert, thrombosis and bleeding events during hospitalization were analyzed among these patients.

RESULTS

Compared with the control patients, the patients in the monitoring group showed a significantly higher percentage time within target INR range [(73.20±9.46)% vs (46.32±17.11)%, P &lt; 0.001] and a higher qualified rate of INR before discharge (98.42% vs 60.95%, P &lt; 0.001) as well as a higher proper INR-monitoring frequency (97.15% vs 66.67%, P &lt; 0.001). The patients in the monitoring group showed a significantly lower incidence of INR alert than the control patients (8.23% vs 20.00%, P &lt; 0.001) with also a much higher rate of prompt management (96.15% vs 33.33%). The two groups had similar incidences of clinical events except that the control group reported a higher incidence of minor bleeding episodes (9.52% vs 2.53%, P=0.005).

CONCLUSIONS

Pharmacist-led anticoagulation monitoring service can significantly improve the effectiveness and safety of warfarin anticoagulation therapy for patients during hospitalization.

Clinical Outcomes of Telephone Service for Patients on Warfarin: A Systematic Review and Meta-Analysis

Objective: To evaluate clinical outcomes of telephone-based service for patients on warfarin. Methods: Five bibliographic databases and gray literature were searched for articles that reported the effects of telephone interventions provided to patients using warfarin compared with those receiving usual clinic-based care. Mean difference (MD) and relative risk (RR) were used to calculate the effects of telephone intervention on time in therapeutic range (TTR) and visit in range (VIR), respectively. Adverse events (AEs) were pooled and reported as incidence rate ratios. Results: A total of 1,840 articles were examined. Eight articles involving 8,087 subjects were included in the quantitative synthesis. The pooled estimates from seven studies showed no difference on TTR between the telephone service group and the usual care group (MD 2.30; 95% confidence interval [CI] -3.56 to 8.16). In addition, VIR in the telephone service group was not different from the usual care group (RR 1.22, 95% CI 0.87-1.71). Moreover, patients in telephone service groups appeared to have a lower incidence of AEs compared with usual care groups. Discussion: Telephone-based service could be considered as an alternative anticoagulant management. However, owing to a lack of evidence from well-designed studies, further high-quality randomized control trials are warranted.

Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: a randomised controlled trial

OBJECTIVES

This study was designed to evaluate the impact of a pharmacist-led anticoagulation service on international normalised ratio (INR) control and other outcomes among patients receiving warfarin therapy at a tertiary hospital in Zhuhai, China.

METHODS

In this randomised controlled trial, adult patients who were newly initiated on warfarin with intended treatment duration of at least 3 months were recruited. Participants were randomly allocated to receive the pharmacist-led education and follow-up service (PEFS) or usual care (UC). Anticoagulation control was calculated as the proportions of time within the target INR range (TTR) and time within the expanded target range (TER).

KEY FINDINGS

A total of 152 participants (77 in the PEFS group and 75 in the UC group) were included. Within 180 days after hospital discharge, the PEFS group spent more TER than the UC group (54.4% versus 42.0%; P = 0.024), whereas the difference in TTR did not reach statistical significance (35.9% versus 29.5%; P = 0.203). No major bleeding events were observed, and the cumulative incidences of major thromboembolic events (6.5% versus 9.3%) and mortality (1.3% versus 1.3%) were similar between the two groups (P> 0.05). At 30 days postdischarge, the PEFS group had better warfarin knowledge by answering 57.5% of questions correctly, compared with the UC group (43.0%) (P = 0.003).

CONCLUSIONS

The PEFS markedly enhanced anticoagulation control and warfarin knowledge but there was room for improvement. The expansion of pharmacists' clinical role and the development of more effective education and follow-up strategies are warranted to optimise anticoagulation management services in China.

First evidence for a pharmacist-led anticoagulant clinic in a medicare part A long term care environment

Anticoagulation risks in older adult, long-term care patients are known to be high, especially in those with frequent transitions between care environments. Introduction of collaborative practice agreements (CPA) in specific settings is encouraged in the United States and has provided an additional option for the care of medically challenging patients. The aim of this study was to investigate the time in therapeutic range (TTR) in a Medicare Part A sponsored long-term care environment managed by pharmacists through a collaborative practice agreement in South-Central Appalachia. A retrospective review of all warfarin patient admissions from a large long-term care pharmacy's anticoagulant clinic was conducted for residents over an 18-month period. For all patients (n = 104), the overall TTR was 46.7% (INR 43% in range). Average management duration was 19.5 days per patient. Further studies are required to optimize CPA and transition strategies for complex, advanced age warfarin patients.

American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy

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.

Anticoagulation management following left ventricular assist device implantation is similar across all provider strategies

OBJECTIVES

Thromboembolic and bleeding events are potential complications following left ventricular assist device implantation. A tight control of the international normalized ratio (INR) is believed to be crucial in the reduction of postimplant complications. There is significant variability among institutions as to whether a device implanting centre should be managing the INR. In this study, we evaluated the effect of INR management strategies in maintaining a therapeutic INR.

METHODS

A retrospective review was utilized to identify patients implanted with either the HeartMate II or the HeartWare HVAD between January 2011 and February 2016. Patients were stratified into 4 groups based on the post-discharge INR management strategy: outside hospital system anticoagulation clinic, outside hospital primary care provider, implanting centre anticoagulation clinic or implanting centre ventricular assist device office. The INR data were collected and analysed for both the early (discharge, 7, 14, 21 and 30 days) and late (3, 6, 9 and 12 months) postoperative periods.

RESULTS

There were 163 patients identified during the study period who met the study inclusion criteria: 49 (30%) patients were managed by an outside hospital system anticoagulation clinic, 59 (36.2%) patients by an outside hospital physician/primary care provider, 22 (13.5%) patients by the implanting centre anticoagulation clinic and 33 (20.2%) patients by the implanting centre ventricular assist device office. There were no statistically significant differences found between management strategies across all time points.

CONCLUSIONS

There was no statistically significant difference found between the management strategies examined. Regardless of the chosen INR management strategy, patients have similar INR values and postoperative outcomes.

Interventions and Strategies to Improve Oral Anticoagulant Use in Patients with Atrial Fibrillation: A Systematic Review of Systematic Reviews

INTRODUCTION

Anticoagulation therapy is the fundamental approach for stroke prevention in atrial fibrillation (AF) patients. Numerous systematic reviews comparing anticoagulation strategies have been published. We aim to summarize the efficacy and safety evidence of these strategies in AF patients from previously published systematic reviews.

METHODS

We searched PubMed, EMBASE and Cochrane library from inception to Feb 24th, 2017, to identify systematic reviews and meta-analyses of randomized controlled trials that assessed interventions or strategies to improve oral anticoagulant use in AF patients.

RESULTS

Thirty-four systematic reviews were eligible for inclusion but only 11 were included in the qualitative analyses, corresponding to 40 unique meta-analyses, as the remaining systematic reviews had overlapping primary studies. There was insufficient evidence to support the efficacy of genotype-guided dosing and pharmacist-managed anticoagulation clinics for stroke prevention in AF patients. Conversely, patient's self-management and novel oral anticoagulants (NOACs), in general were superior to warfarin for preventing stroke and reducing mortality. All interventions showed comparable risk of major bleeding with warfarin.

CONCLUSION

Findings from this overview support the superiority of NOACs and patient's self-management for preventing stroke in AF patients. However, uncertainties remain on the benefits of genotype-guided dosing and pharmacist-managed anticoagulation clinics due to poor quality evidence, and future research is warranted.

Medication Regimen Complexity Measured by MRCI: A Systematic Review to Identify Health Outcomes

Objective: To perform a systematic review to identify health outcomes related to medication regimen complexity as measured by the Medication Regimen Complexity Index (MRCI) instrument. Data Sources: Cochrane Library, LILACS, PubMed, Scopus, EMBASE, Open Thesis, and Web of Science were searched from January 1, 2004, until April 02, 2018, using the following search terms: outcome assessment, drug therapy, and Medication Regimen Complexity Index and their synonyms in different combinations. Study Selection and Data Extraction: Studies that used the MRCI instrument to measure medication regimen complexity and related it to clinical, humanistic, and/or economic outcomes were evaluated. Two reviewers independently carried out the analysis of the titles, abstracts, and complete texts according to the eligibility criteria, performed data extraction, and evaluated study quality. Data Synthesis: A total of 23 studies met the inclusion criteria; 18 health outcomes related to medication regimen complexity were found. The health outcomes most influenced by medication regimen complexity were hospital readmission, medication adherence, hospitalization, adverse drug events, and emergency sector visit. Only one study related medication regimen complexity with humanistic outcomes, and no study related medication regimen complexity to economic outcomes. Most of the studies were of good methodological quality. Relevance to Patient Care and Clinical Practice: Health care professionals should pay attention to medication regimen complexity of the patients because this may influence health outcomes. Conclusion: This study identified some health outcomes that may be influenced by medication regimen complexity: hospitalization, hospital readmission, and medication adherence were more prevalent, showing a significant association between MRCI increase and these health outcomes.

Quality of Pharmacist-Managed Anticoagulation Therapy in Long-Term Ambulatory Settings: A Systematic Review

OBJECTIVE

To perform a systematic review to evaluate the quality of warfarin anticoagulation control in outpatient pharmacist-managed anticoagulation services (PMAS) compared with routine medical care (RMC).

DATA SOURCES

MEDLINE, SCOPUS, EMBASE, IPA, CINAHL, and Cochrane CENTRAL, from inception to May 2017. Search terms employed: ("pharmacist-managed" OR "pharmacist-provided" OR "pharmacist-led" OR "pharmacist-directed") AND ("anticoagulation services" OR "anticoagulation clinic" OR "anticoagulation management" OR "anticoagulant care") AND ("quality of care" OR "outcomes" OR "bleeding" OR "thromboembolism" OR "mortality" OR "hospitalization" OR "length of stay" OR "emergency department visit" OR "cost" OR "patient satisfaction").

STUDY SELECTION AND DATA EXTRACTION

Criteria used to identify selected articles: English language; original studies (comments, letters, reviews, systematic reviews, meta-analyses, editorials were excluded); warfarin use; outpatient setting; comparison group present; time in therapeutic range (TTR) included as a measure of quality of anticoagulant control; study design was not a case report.

DATA SYNTHESIS

Of 177 articles identified, 25 met inclusion criteria. Quality of anticoagulation control was better in the PMAS group compared with RMC in majority of the studies (N = 23 of 25, 92.0%). Clinical outcomes were also favorable in the PMAS group as evidenced by lower or equal risk of major bleeding (N = 10 of 12, 83.3%) or thromboembolic events (N = 9 of 10, 90.0%), and lower rates of hospitalization or emergency department visits (N = 9 of 9, 100%). When reported, PMAS have also resulted in cost-savings in all (N=6 of 6, 100%) of studies.

CONCLUSIONS

Compared with routine care, pharmacist-managed outpatient-based anticoagulation services attained better quality of anticoagulation control, lower bleeding and thromboembolic events, and resulted in lower health care utilization.