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León-García M, Humphries B, Xie F, Gravholt DL, Golembiewski E, Eckman MH, Bates SM, Hargraves I, Pelayo I, López SR, Caño JAM, Alcántara MAS, D'Souza R, Shehata N, Jack SM, Guyatt G, Perestelo-Perez L, Alonso-Coello P. Values and preferences towards the use of prophylactic low-molecular-weight heparin during pregnancy: a convergent mixed-methods secondary analysis of data from the decision analysis in shared decision making for thromboprophylaxis during pregnancy (DASH-TOP) study. Thromb J 2024; 22:81. [PMID: 39243049 PMCID: PMC11380320 DOI: 10.1186/s12959-024-00648-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 08/21/2024] [Indexed: 09/09/2024] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) in pregnancy is a major cause of maternal morbidity and mortality, and the use of preventive low-molecular-weight heparin (LMWH) can be challenging. Clinical guidelines recommend eliciting pregnant individuals' preferences towards the use of daily injections of LMWH and discussing the best option through a shared decision-making (SDM) approach. Our aim was to identify individuals' preferences concerning each of the main clinical outcomes, and categorize attributes influencing the use of LMWH during pregnancy. METHODS Design: Convergent mixed-methods. PARTICIPANTS Pregnant women or those planning a pregnancy with VTE recurrence risk. INTERVENTION A SDM intervention about thromboprophylaxis with LMWH in pregnancy. ANALYSIS Quantitatively, we report preference scores assigned to each of the health states. Qualitatively, we categorized preference attributes using Burke's pentad of motives framework: act (what needs to be done), scene (patient's context), agent (perspectives and influence of people involved in the decision), agency (aspects of the medication), and purpose (patient's goals). We use mixed-method convergent analysis to report findings using side-by-side comparison of concordance/discordance. RESULTS We comprehensively determined preferences for using LMWH by pregnant individuals at risk of VTE: through value elicitation exercises we found that the least valued health state was to experience a pulmonary embolism (PE), followed by major obstetrical bleeding (MOB), deep vein thrombosis (DVT), and using daily injections of LMWH (valued as closest to a 'healthy pregnancy'); through interviews we found that: previous experiences, access to care (scene) and shared decision-making (agent) affected preferences. LMWH's benefits were noted, but substantial drawbacks were described (agency). For participants, the main goal of using LMWH was avoiding any risks in pregnancy (purpose). Side-by-side comparisons revealed concordance and discordance between health states and motives. CONCLUSIONS Mixed-methods provide a nuanced understanding of LMWH preferences, by quantifying health states preferences and exploring attributes qualitatively. Incorporating both methods may improve patient-centered care around preference-sensitive decisions in thromboprophylaxis during pregnancy.
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Affiliation(s)
- Montserrat León-García
- Institut of Research Sant Pau (IR Sant Pau), Barcelona, Spain.
- Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain.
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
- Iberoamerican Cochrane Centre, Barcelona, Spain.
| | - Brittany Humphries
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Derek L Gravholt
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
- Iberoamerican Cochrane Centre, Barcelona, Spain
| | - Elizabeth Golembiewski
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ian Hargraves
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Irene Pelayo
- Department of Obstetrics and Gynecology, Ramón y Cajal Hospital, Madrid, Spain
- Faculty of Medicine, Alcalá de Henares University, Madrid, Spain
| | - Sandra Redondo López
- Department of Angiology and Vascular Surgery, Ramón y Cajal Hospital, Madrid, Spain
| | | | - Milagros A Suito Alcántara
- Hemostasis and Thrombosis Unit, Hematology Service. Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Rohan D'Souza
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada
| | - Nadine Shehata
- Departments of Medicine, Laboratory Medicine and Pathobiology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Susan M Jack
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lilisbeth Perestelo-Perez
- Service for Evaluation and Planning of the Canary Islands Health Service (SESCS), Canary Islands Health Service (SCS), Tenerife, Spain
- Network for Research On Chronicity, Primary Care, and Health Promotion (RICAPPS), Tenerife, Spain
| | - Pablo Alonso-Coello
- Institut of Research Sant Pau (IR Sant Pau), Barcelona, Spain
- Iberoamerican Cochrane Centre, Barcelona, Spain
- CIBER of Epidemiology and Public Health, CIBERESP, Madrid, Spain
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2
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Chang SH, Svensson M, Hsin-Min Wang G, Wang Y, Kang HR, Park H. Cost-effectiveness of early vs delayed use of abemaciclib combination therapy for patients with high-risk hormone receptor-positive/human epidermal growth factor receptor 2-negative early breast cancer. J Manag Care Spec Pharm 2024; 30:942-953. [PMID: 39213142 PMCID: PMC11365564 DOI: 10.18553/jmcp.2024.30.9.942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND Abemaciclib was newly approved for hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) high-risk early breast cancer (EBC). Clinical guidelines recommended abemaciclib as the first-line treatment for HR+/ HER2- EBC (early use) or HR+/ HER2- metastatic breast cancer (MBC) (delayed use). OBJECTIVE To compare the cost-effectiveness of early vs delayed use of abemaciclib for treatment of HR+/HER2- high-risk EBC. Early use was defined as combined abemaciclib and endocrine therapy as first-line therapy for EBC, followed by treatment with fulvestrant for MBC. Delayed use was defined as endocrine therapy for EBC, followed by combined abemaciclib and fulvestrant therapy for MBC. METHODS A 5-state model was developed to estimate lifetime costs, life-years (LYs), and quality-adjusted life-years (QALYs) of hypothetical patients with HR+/ HER2- EBC from a third-party US payer's perspective. Key clinical and safety data were derived from the monarchE and MONARCH 2 clinical trials. Costs, utilities, and disutility values of adverse events were obtained from the literature. We calculated the incremental cost-effectiveness ratio (ICER) of early vs delayed abemaciclib use and compared it with a willingness-to-pay (WTP) threshold of $100,000 per LY or QALY. Deterministic and probabilistic sensitivity analyses (PSAs) were performed to test the robustness of the base-case model. RESULTS Base-case analysis showed early use yielded 21.08 LYs and 17.93 QALYs for $586,213 and delayed use yielded 11.14 LYs and 9.38 QALYs for $157,576. The ICER of early vs delayed use was $43,136/LY and $50,104/QALY, which was cost-effective at the WTP threshold of $100,000. The PSA result indicated that a 94.6% likelihood of early use (vs delayed use) was cost-effective at the WTP threshold of $100,000 per QALY. CONCLUSIONS This study suggests that giving abemaciclib in the early stage rather than waiting until patients develop metastatic disease (current standard of care in MBC) is a cost-effective strategy.
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Affiliation(s)
- Shao-Hsuan Chang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Mikael Svensson
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Grace Hsin-Min Wang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Yehua Wang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Hye-Rim Kang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Haesuk Park
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
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3
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Brozek J, Borowiack E, Sadowska E, Nowak A, Sousa-Pinto B, Vieira RJ, Bognanni A, Yepes Nuñez JJ, Zhang Y, Zuberbier T, Bousquet J, Schünemann HJ. Patients' values and preferences for health states in allergic rhinitis-An artificial intelligence supported systematic review. Allergy 2024; 79:1812-1830. [PMID: 38551028 DOI: 10.1111/all.16100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/21/2024] [Accepted: 02/29/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Allergic rhinitis (AR) impacts patients' physical and emotional well-being. Assessing patients' values and preferences (V&P) related to AR is an essential part of patient-centered care and of the guideline development process. We aimed to systematically summarize the information about patients' V&P on AR and its symptoms and impact on daily life. METHODS We conducted systematic review in a MEDLINE, Embase, PsychInfo, and CINAHL databases. We included studies which quantitatively assessed patients' V&P for specific outcomes in AR by assessing utilities, applying discrete choice approaches, or rating and ranking outcomes. We grouped outcomes as AR symptoms, functional status, and care-related patient experience. Study selection and data extraction were supported by the Laser AI tool. We rated the certainty of evidence (CoE) using the GRADE approach. RESULTS Thirty-six studies (41 records) were included: nine utility studies, seven direct-choice studies and 21 studies of rating or ranking outcomes. Utilities were lower with increased AR severity and with the concomitant presence of asthma, but not with whether AR was seasonal or perennial (CoE = low-high). Patients rated AR symptom-related outcomes as more important than those related to care-related patient experience and functional status (CoE = very low-moderate). Nasal symptoms (mainly nasal congestion) followed by breathing disorders, general and ocular symptoms were rated as the symptoms with the highest impact. CONCLUSIONS This systematic review provides a comprehensive overview of V&P of patients with AR. Patients generally considered nasal symptoms as the most important. Future studies with standardized methods are needed to provide more information on V&P in AR.
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Affiliation(s)
- Jan Brozek
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
- Evidence Prime, Hamilton, Ontario, Canada
| | | | | | | | - Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Health Technology and Services Research, Health Research Network (CINTESIS@RISE), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rafael José Vieira
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Health Technology and Services Research, Health Research Network (CINTESIS@RISE), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Antonio Bognanni
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Juan Jose Yepes Nuñez
- School of Medicine, Universidad de los Andes, Bogotá, Colombia
- Fundación Santa Fe de Bogotá Hospital University, Bogotá, Colombia
| | - Yuan Zhang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Torsten Zuberbier
- Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
- Fraunhofer Cluster of Excellence for Immune-Mediated Diseases CIMD, Frankfurt/Main, Germany
| | - Jean Bousquet
- Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
- Fraunhofer Cluster of Excellence for Immune-Mediated Diseases CIMD, Frankfurt/Main, Germany
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
- Clinical Epidemiology and Research Center (CERC), Humanitas University and Humanitas Research Hospital, Milan, Italy
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Karam SG, Zhang Y, Pardo-Hernandez H, Siebert U, Koopman L, Noyes J, Tarride JE, Stevens AL, Welch V, Saz-Parkinson Z, Ens B, Devji T, Xie F, Hazlewood G, Mbuagbaw L, Alonso-Coello P, Brozek JL, Schünemann HJ. ROBVALU: a tool for assessing risk of bias in studies about people's values, utilities, or importance of health outcomes. BMJ 2024; 385:e079890. [PMID: 38866410 PMCID: PMC11167527 DOI: 10.1136/bmj-2024-079890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 06/14/2024]
Affiliation(s)
- Samer G Karam
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Michael G DeGroote Cochrane Canada and McMaster GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Michael G DeGroote Cochrane Canada and McMaster GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Hector Pardo-Hernandez
- Iberoamerican Cochrane Centre, Sant Antoni Maria Claret, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL-University for Health Sciences and Technology, Hall in Tirol, Austria
- Center for Health Decision Science and Departments of Epidemiology and Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
- Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Laura Koopman
- Department of Specialist Medical Care, National Health Care Institute, Diemen, Netherlands
| | - Jane Noyes
- School of Medical and Health Sciences, Bangor University, Wales, UK
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics and Policy Analysis, McMaster University Faculty of Health Sciences, Hamilton, ON, Canada
- Programs for Assessment of Technologies in Health, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Adrienne L Stevens
- Centre for Immunisation Programmes, Public Health Agency of Canada, ON, Canada
| | - Vivian Welch
- Bruyère Research Institute and, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | | | - Brendalynn Ens
- Implementation Support and Knowledge Mobilisation, Canadian Agency for Drugs and Technologies in Health, Ottawa, ON, Canada
| | - Tahira Devji
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics and Policy Analysis, McMaster University Faculty of Health Sciences, Hamilton, ON, Canada
| | - Glen Hazlewood
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anaesthesia, McMaster University, Hamilton, ON, Canada
- Department of Paediatrics, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
- Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Sant Antoni Maria Claret, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Institut de Recerca Sant Pau (IR SANT PAU), Sant Quintí, Barcelona, Spain
| | - Jan L Brozek
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Michael G DeGroote Cochrane Canada and McMaster GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Clinical Epidemiology and Research Centre (CERC), Humanitas Universityand Humanitas Research Hospital, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
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Vieira RJ, Sousa‐Pinto B, Bognanni A, Yepes‐Nuñez JJ, Zhang Y, Lityńska J, Sadowska E, Borowiack E, Samolinski B, Togias A, Zuberbier T, Bousquet J, Schünemann HJ. Embedding patients' values and preferences in guideline development for allergic diseases: The case study of Allergic Rhinitis and its Impact on Asthma 2024. Clin Transl Allergy 2024; 14:e12377. [PMID: 38862272 PMCID: PMC11166500 DOI: 10.1002/clt2.12377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 06/01/2024] [Indexed: 06/13/2024] Open
Abstract
Recommendations for or against the use of interventions need to consider both desirable and undesirable effects as well as patients' values and preferences (V&P). In the decision-making context, patients' V&P represent the relative importance people place on the outcomes resulting from a decision. Therefore, the balance between desirable and undesirable effects from an intervention should depend not only on the difference between benefits and harms but also on the value that patients place on them. V&P are therefore one of the criteria to be considered when formulating guideline recommendations in the Evidence-to-Decision framework developed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group. Patients' V&P may be quantified through utilities, which can be elicited using direct methods (e.g., standard gamble or time trade-off) or indirect methods (using validated instruments to measure health-related quality of life, such as EQ-5D). The GRADE approach recommends conducting systematic reviews to summarise all the available evidence and assess the degree of certainty on V&P. In this article, we discuss the importance of considering patients' V&P and provide examples of how they are considered in the 2024 person-centred Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines.
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Affiliation(s)
- Rafael José Vieira
- Department of Community MedicineInformation and Health Decision Sciences (MEDCIDS)Faculty of MedicineUniversity of PortoPortoPortugal
- Centre for Health Technology and Services ResearchHealth Research Network (CINTESIS@RISE)Faculty of MedicineUniversity of PortoPortoPortugal
| | - Bernardo Sousa‐Pinto
- Department of Community MedicineInformation and Health Decision Sciences (MEDCIDS)Faculty of MedicineUniversity of PortoPortoPortugal
- Centre for Health Technology and Services ResearchHealth Research Network (CINTESIS@RISE)Faculty of MedicineUniversity of PortoPortoPortugal
| | - Antonio Bognanni
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Department of MedicineEvidence in Allergy GroupMcMaster UniversityHamiltonOntarioCanada
| | - Juan José Yepes‐Nuñez
- School of MedicineUniversidad de los AndesBogotáColombia
- Pulmonology ServiceInternal Medicine SectionFundación Santa Fe de BogotáUniversity HospitalBogotáColombia
| | - Yuan Zhang
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
| | | | | | | | - Boleslaw Samolinski
- Department of Prevention of Environmental Hazards, Allergology and ImmunologyMedical University of WarsawWarsawPoland
| | - Alkis Togias
- Division of Allergy, Immunology, and Transplantation (DAIT)National Institute of Allergy and Infectious DiseasesNIHBethesdaMarylandUSA
| | - Torsten Zuberbier
- Institute of AllergologyCharité – Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and AllergologyBerlinGermany
- Fraunhofer Cluster of Excellence for Immune‐Mediated Diseases CIMDFrankfurtGermany
| | - Jean Bousquet
- Institute of AllergologyCharité – Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and AllergologyBerlinGermany
- Fraunhofer Cluster of Excellence for Immune‐Mediated Diseases CIMDFrankfurtGermany
| | - Holger J. Schünemann
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Michael G. DeGroote Cochrane Canada & McMaster GRADE CentresMcMaster UniversityHamiltonOntarioCanada
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
- Department of Biomedical SciencesHumanitas UniversityMilanItaly
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6
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Davis S, Pandor A, Sampson FC, Hamilton J, Nelson-Piercy C, Hunt BJ, Daru J, Goodacre S. Estimating the value of future research into thromboprophylaxis for women during pregnancy and after delivery: a value of information analysis. J Thromb Haemost 2024; 22:1105-1116. [PMID: 38215911 DOI: 10.1016/j.jtha.2023.12.035] [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: 09/20/2023] [Revised: 12/28/2023] [Accepted: 12/30/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Risk assessment models (RAMs) are used to select women at increased risk of venous thromboembolism (VTE) during pregnancy and the puerperium for thromboprophylaxis. OBJECTIVES To estimate the value of potential future studies that would reduce the decision uncertainty associated with offering thromboprophylaxis according to available RAMs in the following groups: high-risk antepartum women (eg, prior VTE), unselected postpartum women, and postpartum women with risk factors (obesity or cesarean delivery). METHODS A decision-analytic model was developed to simulate clinical outcomes, lifetime costs, and quality-adjusted life-years for different thromboprophylaxis strategies, including thromboprophylaxis for all, thromboprophylaxis for none, and RAM-based thromboprophylaxis. The expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty. The value of future research studies was estimated using expected value of sample information analysis. Costs were assessed from a health and social services perspective. RESULTS The expected value of perfect information analysis identified high decision uncertainty for high-risk antepartum women (£21.8 million) and obese postpartum women (£13.4 million), which was largely attributable to uncertainty regarding the effectiveness of thromboprophylaxis in reducing VTE. A randomized controlled trial of thromboprophylaxis compared with none in obese postpartum women is likely to have substantial value (£2.8 million; 300 participants per arm). A trial in women with previous VTE would have higher value but would be less acceptable. CONCLUSION Future research should focus on estimating the effectiveness of thromboprophylaxis in obese postpartum women with additional risk factors who have not had a previous VTE.
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Affiliation(s)
- Sarah Davis
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom.
| | - Abdullah Pandor
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Fiona C Sampson
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Jean Hamilton
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Catherine Nelson-Piercy
- Women's Health Academic Centre, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Jahnavi Daru
- Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Steve Goodacre
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
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7
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Davis S, Pandor A, Sampson FC, Hamilton J, Nelson-Piercy C, Hunt BJ, Daru J, Goodacre S, Carser R, Rooney G, Clowes M. Thromboprophylaxis during pregnancy and the puerperium: a systematic review and economic evaluation to estimate the value of future research. Health Technol Assess 2024; 28:1-176. [PMID: 38476084 PMCID: PMC11017156 DOI: 10.3310/dfwt3873] [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] [Indexed: 03/14/2024] Open
Abstract
Background Pharmacological prophylaxis to prevent venous thromboembolism is currently recommended for women assessed as being at high risk of venous thromboembolism during pregnancy or in the 6 weeks after delivery (the puerperium). The decision to provide thromboprophylaxis involves weighing the benefits, harms and costs, which vary according to the individual's venous thromboembolism risk. It is unclear whether the United Kingdom's current risk stratification approach could be improved by further research. Objectives To quantify the current decision uncertainty associated with selecting women who are pregnant or in the puerperium for thromboprophylaxis and to estimate the value of one or more potential future studies that would reduce that uncertainty, while being feasible and acceptable to patients and clinicians. Methods A decision-analytic model was developed which was informed by a systematic review of risk assessment models to predict venous thromboembolism in women who are pregnant or in the puerperium. Expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty and should be the target of future research. To find out whether future studies would be acceptable and feasible, we held workshops with women who have experienced a blood clot or have been offered blood-thinning drugs and surveyed healthcare professionals. Expected value of sample information analysis was used to estimate the value of potential future research studies. Results The systematic review included 17 studies, comprising 19 unique externally validated risk assessment models and 1 internally validated model. Estimates of sensitivity and specificity were highly variable ranging from 0% to 100% and 5% to 100%, respectively. Most studies had unclear or high risk of bias and applicability concerns. The decision analysis found that there is substantial decision uncertainty regarding the use of risk assessment models to select high-risk women for antepartum prophylaxis and obese postpartum women for postpartum prophylaxis. The main source of decision uncertainty was uncertainty around the effectiveness of thromboprophylaxis for preventing venous thromboembolism in women who are pregnant or in the puerperium. We found that a randomised controlled trial of thromboprophylaxis in obese postpartum women is likely to have substantial value and is more likely to be acceptable and feasible than a trial recruiting women who have had a previous venous thromboembolism. In unselected postpartum women and women following caesarean section, the poor performance of risk assessment models meant that offering prophylaxis based on these models had less favourable cost effectiveness with lower decision uncertainty. Limitations The performance of the risk assessment model for obese postpartum women has not been externally validated. Conclusions Future research should focus on estimating the efficacy of pharmacological thromboprophylaxis in pregnancy and the puerperium, and clinical trials would be more acceptable in women who have not had a previous venous thromboembolism. Study registration This study is registered as PROSPERO CRD42020221094. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR131021) and is published in full in Health Technology Assessment; Vol. 28, No. 9. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Fiona C Sampson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Beverley J Hunt
- Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jahnavi Daru
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rosie Carser
- Patient and Public Involvement, Thrombosis UK, Llanwrda, UK
| | - Gill Rooney
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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8
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de Winter MA, Xu Y, Stacey D, Wells PS. Qualitative experiences, values, and decisional needs of patients with unprovoked venous thromboembolism who suffer bleeding-"This pill will keep you alive tonight". Res Pract Thromb Haemost 2024; 8:102360. [PMID: 38559571 PMCID: PMC10978529 DOI: 10.1016/j.rpth.2024.102360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 04/04/2024] Open
Abstract
Background Contemporary guidelines recommend extended-duration anticoagulation among patients with a first unprovoked venous thromboembolism (VTE). Little is known about whether this recommendation aligns with patient values after a bleeding complication. Objectives To explore the experiences, values, and decisional needs of patients with unprovoked VTE related to extended-duration treatment after an anticoagulant-associated bleed. Methods In this descriptive, qualitative study, face to face online semistructured interviews were conducted with patients with unprovoked VTE who had experienced bleeding and continued anticoagulant treatment in one academic hospital in Canada. Data were analyzed using directed content analysis to identify themes. Themes were mapped onto the Ottawa Decisional Support Framework to identify decisional needs. Results Between September and December 2021, 14 patients were interviewed (age 41-69 years; 9 females). Many patients were not aware of the option to stop anticoagulation and had limited understanding of the decision about treatment duration. Despite the negative quality-of-life impact of clinically relevant bleeding during VTE treatment, the majority continued anticoagulation due to emotional trauma of VTE diagnosis, a perception that bleeding would be more manageable than VTE recurrence, a desire to maintain a connection to subspecialty care or non-VTE related benefits (eg, cancer diagnosis, protection from COVID-19). Patients' decisional needs included lack of choice awareness, inadequate support for participation, lack of personalized risk stratification, and inadequate information on monitoring and managing heavy menstrual bleeding. Conclusion Despite the impact of anticoagulant-associated bleeding on quality of life, patients preferred continuing with anticoagulation for reasons extending beyond secondary VTE prevention. Effective decision-support interventions are needed to address unmet decisional needs.
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Affiliation(s)
- Maria A. de Winter
- Department of Acute Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Diakonessenhuis, Utrecht, The Netherlands
| | - Yan Xu
- Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dawn Stacey
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Philip S. Wells
- Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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9
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Font C, Gomez-Mesa JE, López-Núñez JJ, Calderón C, Galindo-Coral S, Wu CC, Ma J, Kroll MH, Rojas-Hernandez CM. Measurement of adherence and health-related quality of life during anticoagulation therapy in cancer-associated venous thromboembolism (VTE): a multicenter quantitative study. Support Care Cancer 2023; 31:615. [PMID: 37801086 DOI: 10.1007/s00520-023-08073-y] [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: 01/12/2023] [Accepted: 09/24/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE Therapy for cancer-associated venous thromboembolism (VTE) includes long-term anticoagulation, which may have substantial impact on the health-related quality of life (HRQL) of patients. We assessed patient-reported outcomes to characterize the HRQL associated with VTE treatment and to begin to examine those HRQL elements impacting anticoagulation adherence (AA). METHODS Participants were adult cancer patients with confirmed symptomatic acute lower extremity deep venous thrombosis. Patients were excluded if there was an indication for anticoagulation other than VTE, ECOG performance status >3, or life expectancy < 3 months. Participants were assessed with a self-reported adherence tool. HRQL was measured with a 6-domain questionnaire using a seven-point Likert scale. Evaluations were performed at 30 days and 3 months after enrollment. For the primary objective, an overall adherence rate was calculated at each time point of evaluation. For the HRQL domains, non-parametric testing was used to compare results between subgroups. RESULTS Seventy-four patients were enrolled. AA and HRQL at 30 days and 3 months were assessed in 50 and 36 participants, respectively. At 30 days the AA rate was 90%, and at 3 months it was 83%. In regard to HRQL, patients suffered frequent and moderate-severe distress in the domains of emotional and physical symptoms, sleep disturbance, and limitations to physical activity. An association between emotional or physical distress and AA was observed. CONCLUSION Patients with VTE suffer a substantial impairment of their HRQL. Increased emotional distress correlated with better long-term AA. These results can be used to inform additional research aimed at developing novel strategies to improve AA.
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Affiliation(s)
- Carme Font
- Department of Medical Oncology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Juan Esteban Gomez-Mesa
- Departamento de Cardiología, Fundación Valle del Lili, Cali, Colombia
- Departamento de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Juan J López-Núñez
- Hospital Germans i Trias Pujol, Badalona, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Fundació Institut d'Investigació Germans Trias i Pujol, Badalona, Spain
| | - Caterina Calderón
- Department of Clinical Psychology and Psychobiology, University of Barcelona, Barcelona, Spain
| | | | - Carol C Wu
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Junsheng Ma
- Biostatistics Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael H Kroll
- Section of Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Soler-Espejo E, Esteve-Pastor MA, Rivera-Caravaca JM, Roldan V, Marín F. Reducing bleeding risk in patients on oral anticoagulation therapy. Expert Rev Cardiovasc Ther 2023; 21:923-936. [PMID: 37905915 DOI: 10.1080/14779072.2023.2275662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/23/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION Oral anticoagulation (OAC) significantly mitigates thromboembolism risks in atrial fibrillation (AF) and venous thromboembolism (VTE) patients yet concern about major bleeding events persist. In fact, clinically relevant hemorrhages can be life-threatening. Bleeding risk is dynamic and influenced by factors such as age, new comorbidities, and drug therapies, and should not be assessed solely based on static baseline factors. AREAS COVERED We comprehensively review the bleeding risk associated with OAC therapy. Emphasizing the importance of assessing both thromboembolic and bleeding risks, we present clinical tools for estimating stroke and systemic embolism (SSE) and bleeding risk in AF and VTE patients. We also address overlapping risk factors and the dynamic nature of bleeding risk. EXPERT OPINION The OAC management is undergoing constant transformation, motivated by the primary objective of mitigating thromboembolism and bleeding hazards, thereby amplifying patient safety throughout the course of treatment. The future of OAC embraces personalized approaches and innovative therapies, driven by advanced pathophysiological insights and technological progress. This holds promise for improving patient outcomes and revolutionizing anticoagulation practices.
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Affiliation(s)
- Eva Soler-Espejo
- Department of Hematology and Hemotherapy, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Faculty of Nursing, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
| | - Vanessa Roldan
- Department of Hematology and Hemotherapy, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
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11
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Khan F, Coyle D, Thavorn K, van Katwyk S, Tritschler T, Hutton B, Le Gal G, Rodger MA, Fergusson DA. Indefinite Anticoagulant Therapy for First Unprovoked Venous Thromboembolism : A Cost-Effectiveness Study. Ann Intern Med 2023. [PMID: 37364263 DOI: 10.7326/m22-3559] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Clinical practice guidelines recommend indefinite anticoagulation for a first unprovoked venous thromboembolism (VTE). OBJECTIVE To estimate the benefit-harm tradeoffs of indefinite anticoagulation in patients with a first unprovoked VTE. DESIGN Markov modeling study. DATA SOURCES Systematic reviews and meta-analyses for the long-term risks and case-fatality rates of recurrent VTE and major bleeding. Published literature for costs, quality of life, and other clinical events. TARGET POPULATION Patients with a first unprovoked VTE who have completed 3 to 6 months of initial anticoagulant treatment. TIME HORIZON Lifetime. PERSPECTIVE Canadian health care public payer. INTERVENTION Indefinite anticoagulation with direct oral anticoagulants. OUTCOME MEASURES Recurrent VTE events, major bleeding events, costs in 2022 Canadian dollars (CAD), and quality-adjusted life-years (QALYs). RESULTS OF BASE-CASE ANALYSIS When compared with discontinuing anticoagulation after initial treatment in a hypothetical cohort of 1000 patients aged 55 years, indefinite anticoagulation prevented 368 recurrent VTE events, which included 14 fatal pulmonary emboli, but induced an additional 114 major bleeding events, which included 30 intracranial hemorrhages and 11 deaths from bleeding. Indefinite anticoagulation cost CAD $16 014 more per person and did not increase QALYs (-0.075 per person). RESULTS OF SENSITIVITY ANALYSIS Model results were most sensitive to the case-fatality rate of major bleeding and the annual risk for major bleeding during extended anticoagulation. LIMITATION The model assumed that risks for recurrent VTE and major bleeding measured in clinical trials at 1 year remained constant during extended anticoagulation. CONCLUSION Clinicians should use shared decision making to incorporate individual patient preferences and values when considering treatment duration for unprovoked VTE. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research.
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Affiliation(s)
- Faizan Khan
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada (F.K.)
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada (D.C.)
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa; and Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (K.T.)
| | | | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (T.T.)
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (B.H.)
| | - Grégoire Le Gal
- Clinical Epidemiology Program, Ottawa Hospital Research Institute; and Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada (G.L.G.)
| | - Marc A Rodger
- Department of Medicine, McGill University, Montreal, Québec, Canada (M.A.R.)
| | - Dean A Fergusson
- School of Epidemiology and Public Health, University of Ottawa; Clinical Epidemiology Program, Ottawa Hospital Research Institute; and Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada (D.A.F.)
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12
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Górnicki T, Bułdyś K, Zielińska D, Chabowski M. Direct-Acting Oral Anticoagulant Therapy in Cancer Patients-A Review. Cancers (Basel) 2023; 15:2697. [PMID: 37345034 PMCID: PMC10216040 DOI: 10.3390/cancers15102697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/21/2023] [Accepted: 05/08/2023] [Indexed: 06/23/2023] Open
Abstract
Venous thromboembolism (VTE) is an important aspect in cancer patients. There are various pharmacological methods used for thrombotic event treatment. DOACs (direct-acting oral anticoagulants) are gaining popularity among both physicians and researchers and are slowly starting to replace VKAs (vitamin K antagonists), thus becoming a substitute or alternative option for LMWHs (low-molecular-weight heparins). In this article, we present DOACs' main therapeutic advantages and disadvantages in patients with cancer. The only major concern with using DOACs is the higher risk of bleeding; however, there are discrepancies in this matter. There are still some types of cancer for which DOACs are not recommended. Specific cancer types may influence the efficacy of DOAC therapy. Additionally, race and ethnicity may affect therapy in cancer patients with DOACs. A sizeable number of clinical trials are focused on comparing DOACs with other anticoagulants. The current guidelines of different scientific associations are not unanimous in their DOAC assessments. There is still a need for more evidence of DOACs' potential advantages over other methods of anticoagulation in cancer patients to facilitate their position in this recommendation. This literature review presents the current state of knowledge about the use of DOACs in patients with neoplastic growth.
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Affiliation(s)
- Tomasz Górnicki
- Student Research Club No. 180, Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (T.G.); (K.B.)
- Division of Histology and Embryology, Department of Human Morphology and Embryology, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Kacper Bułdyś
- Student Research Club No. 180, Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (T.G.); (K.B.)
| | - Dorota Zielińska
- Department of Surgery, 4th Military Teaching Hospital, 50-981 Wroclaw, Poland
| | - Mariusz Chabowski
- Department of Surgery, 4th Military Teaching Hospital, 50-981 Wroclaw, Poland
- Division of Anesthesiological and Surgical Nursing, Department of Nursing and Obstetrics, Faculty of Health Science, Wroclaw Medical University, 51-618 Wroclaw, Poland
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13
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Muchadeyi MT, Hernandez-Villafuerte K, Schlander M. Quality appraisal for systematic literature reviews of health state utility values: a descriptive analysis. BMC Med Res Methodol 2022; 22:303. [PMID: 36434521 PMCID: PMC9700894 DOI: 10.1186/s12874-022-01784-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 11/04/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Health state utility values (HSUVs) are an essential input parameter to cost-utility analysis (CUA). Systematic literature reviews (SLRs) provide summarized information for selecting utility values from an increasing number of primary studies eliciting HSUVs. Quality appraisal (QA) of such SLRs is an important process towards the credibility of HSUVs estimates; yet, authors often overlook this crucial process. A scientifically developed and widely accepted QA tool for this purpose is lacking and warranted. OBJECTIVES To comprehensively describe the nature of QA in published SRLs of studies eliciting HSUVs and generate a list of commonly used items. METHODS A comprehensive literature search was conducted in PubMed and Embase from 01.01.2015 to 15.05.2021. SLRs of empirical studies eliciting HSUVs that were published in English were included. We extracted descriptive data, which included QA tools checklists or good practice recommendations used or cited, items used, and the methods of incorporating QA results into study findings. Descriptive statistics (frequencies of use and occurrences of items, acceptance and counterfactual acceptance rates) were computed and a comprehensive list of QA items was generated. RESULTS A total of 73 SLRs were included, comprising 93 items and 35 QA tools and good recommendation practices. The prevalence of QA was 55% (40/73). Recommendations by NICE and ISPOR guidelines appeared in 42% (16/40) of the SLRs that appraised quality. The most commonly used QA items in SLRs were response rates (27/40), statistical analysis (22/40), sample size (21/40) and loss of follow up (21/40). Yet, the most commonly featured items in QA tools and GPRs were statistical analysis (23/35), confounding or baseline equivalency (20/35), and blinding (14/35). Only 5% of the SLRS used QA to inform the data analysis, with acceptance rates of 100% (in two studies) 67%, 53% and 33%. The mean counterfactual acceptance rate was 55% (median 53% and IQR 56%). CONCLUSIONS There is a considerably low prevalence of QA in the SLRs of HSUVs. Also, there is a wide variation in the QA dimensions and items included in both SLRs and extracted tools. This underscores the need for a scientifically developed QA tool for multi-variable primary studies of HSUVs.
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Affiliation(s)
- Muchandifunga Trust Muchadeyi
- Division of Health Economics, German Cancer Research Center (DKFZ), Foundation Under Public Law, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Karla Hernandez-Villafuerte
- Division of Health Economics, German Cancer Research Center (DKFZ), Foundation Under Public Law, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Health Economics, WifOR institute, Rheinstraße 22, Darmstadt, 64283 Germany
| | - Michael Schlander
- Division of Health Economics, German Cancer Research Center (DKFZ), Foundation Under Public Law, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Alfred Weber Institute for Economics (AWI), University of Heidelberg, Heidelberg, Germany
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14
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Badge H, Churches T, Naylor JM, Xuan W, Armstrong E, Gray L, Fletcher J, Gosbell I, Christine Lin CW, Harris IA. Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty: an observational study. J Patient Rep Outcomes 2022; 6:110. [PMID: 36224453 PMCID: PMC9556685 DOI: 10.1186/s41687-022-00502-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/02/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Surgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery. METHODS This prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs. RESULTS The sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (β = - 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (β = - 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (β = - 0.02 SE = 0.008, p = 0.011) and 365-days (β = - 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: β = - 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: β = - 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: β = - 0.06, SE = 0.41, p = 0.880 EQ-5D: β = - 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect. CONCLUSIONS Non-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.
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Affiliation(s)
- Helen Badge
- Whitlam Orthopaedic Research Centre, 1 Campbell Street, Liverpool, 2071 Australia ,grid.1005.40000 0004 4902 0432South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071 Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071 Australia ,grid.411958.00000 0001 2194 1270Australian Catholic University, 8-20 Napier Street, North Sydney, 2060 Australia
| | - Tim Churches
- grid.1005.40000 0004 4902 0432South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071 Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071 Australia
| | - Justine M. Naylor
- Whitlam Orthopaedic Research Centre, 1 Campbell Street, Liverpool, 2071 Australia ,grid.1005.40000 0004 4902 0432South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071 Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071 Australia
| | - Wei Xuan
- grid.1005.40000 0004 4902 0432South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071 Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071 Australia
| | - Elizabeth Armstrong
- grid.1005.40000 0004 4902 0432School of Population Health, The University of New South Wales, High St Kensington, Kensington, NSW 2052 Australia
| | - Leeanne Gray
- grid.410692.80000 0001 2105 7653South Western Sydney Local Health District, 1 Elizabeth Street, Liverpool, 2071 Australia
| | - John Fletcher
- grid.1013.30000 0004 1936 834XUniversity of Sydney, Fisher Road, Camperdown, NSW 2006 Australia ,grid.413252.30000 0001 0180 6477Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW 2145 Australia
| | - Iain Gosbell
- grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071 Australia ,grid.1029.a0000 0000 9939 5719Western Sydney University, Campbelltown, NSW 2560 Australia
| | - Chung-Wei Christine Lin
- grid.1013.30000 0004 1936 834XSydney School of Public Health, The University of Sydney, Edward Ford Building (A27) Fisher Road, Camperdown, NSW 2006 Australia
| | - Ian A. Harris
- Whitlam Orthopaedic Research Centre, 1 Campbell Street, Liverpool, 2071 Australia ,grid.1005.40000 0004 4902 0432South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071 Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071 Australia ,grid.410692.80000 0001 2105 7653South Western Sydney Local Health District, 1 Elizabeth Street, Liverpool, 2071 Australia
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Højen AA, Nielsen PB, Overvad TF, Albertsen IE, Klok FA, Rolving N, Søgaard M, Ording AG. Long-Term Management of Pulmonary Embolism: A Review of Consequences, Treatment, and Rehabilitation. J Clin Med 2022; 11:jcm11195970. [PMID: 36233833 PMCID: PMC9571065 DOI: 10.3390/jcm11195970] [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: 08/18/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 12/02/2022] Open
Abstract
The concept of pulmonary embolism is evolving. Recent and emerging evidence on the treatment of specific patient populations, its secondary prevention, long-term complications, and the unmet need for rehabilitation has the potential to change clinical practice for the benefit of the patients. This review discusses the recent evidence from clinical trials, observational studies, and guidelines focusing on anticoagulation treatment, rehabilitation, emotional stress, quality of life, and the associated outcomes for patients with pulmonary embolism. Guidelines suggest that the type and duration of treatment with anticoagulation should be based on prevalent risk factors. Recent studies demonstrate that an anticoagulant treatment that is longer than two years may be effective and safe for some patients. The evidence for extended treatment in cancer patients is limited. Careful consideration is particularly necessary for pulmonary embolisms in pregnancy, cancer, and at the end of life. The rehabilitation and prevention of unnecessary deconditioning, emotional distress, and a reduced quality of life is an important, but currently they are unmet priorities for many patients with a pulmonary embolism. Future research could demonstrate optimal anticoagulant therapy durations, follow-ups, and rehabilitation, and effective patient-centered decision making at the end of life. A patient preferences and shared decision making should be incorporated in their routine care when weighing the benefits and risks with primary treatment and secondary prevention.
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Affiliation(s)
- Anette Arbjerg Højen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Thure Filskov Overvad
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Clinical Pharmacology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Ida Ehlers Albertsen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, 2333 Leiden, The Netherlands
| | - Nanna Rolving
- Department of Physical and Occupational Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark
- Department of Public Health, Aarhus University, 8200 Aarhus, Denmark
| | - Mette Søgaard
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Anne Gulbech Ording
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
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León-García M, Humphries B, Maraboto A, Rabassa M, Boehmer KR, Perestelo-Perez L, Xie F, Pelayo I, Eckman M, Bates S, Selva A, Alonso-Coello P. Women's values and preferences on low-molecular-weight heparin and pregnancy: a mixed-methods systematic review. BMC Pregnancy Childbirth 2022; 22:747. [PMID: 36199014 PMCID: PMC9533610 DOI: 10.1186/s12884-022-05042-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/09/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) in pregnancy is an important cause of maternal morbidity and mortality. Low-molecular-weight heparin (LMWH) is the cornerstone of prophylaxis and treatment of thrombotic events during pregnancy. LMWH has fewer adverse effects than other anticoagulants, does not cross the placenta, and is safe for the fetus. However, the use of LMWH during pregnancy is sensitive to womens' underlying preferences. The objective of this review is to systematically assess women's values and preferences research evidence on this topic. METHODS We searched four electronic databases from inception to March 2022, and included studies examining values and preferences of using LMWH among pregnant women at risk of VTE. We followed a convergent integrated mixed-methods design to compare and contrast quantitative outcomes (utility and non-utility measures) and qualitative findings. We assessed the certainty of the values and preferences evidence with the GRADE approach for quantitative findings, and with GRADE-CERqual for qualitative evidence. Results were presented in a conjoint display. RESULTS We screened 3,393 references and identified seven eligible studies. The mixed methods analysis resulted in four themes. Datasets confirmed each other in that: 1) the majority of women consider that benefits of treatment outweigh the inconveniences of daily injections; and 2) main concerns around medication are safety and injections administration. Quantitative outcomes expanded on the qualitative findings in that: 3) participants who perceived a higher risk of VTE were more willing to take LMWH. Finally, we found a discrepancy between the datasets around: 4) the amount of information preferred to make the decision; however, qualitative data expanded to clarify that women prefer making informed decisions and receive support from their clinician in their decision-making process. CONCLUSIONS We are moderately confident that in the context of pregnancy, using LMWH is preferred by women given its net beneficial balance. Integrating data from different sources of evidence, and representing them in a jointly manner helps to identify patient's values and preferences. Our results may inform clinical practice guidelines and support shared decision-making process in the clinical encounter for the management of VTE in the context of pregnancy.
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Affiliation(s)
- Montserrat León-García
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
- Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain.
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Brittany Humphries
- Cytel Inc, Toronto, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Andrea Maraboto
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Kasey R Boehmer
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Lilisbeth Perestelo-Perez
- Evaluation Unit (SESCS), Canary Islands Health Service (SCS), Tenerife, Spain
- Research Network On Health Services in Chronic Diseases (REDISSEC), Tenerife, Spain
- Network for Research On Chronicity, Primary Care, and Health Promotion (RICAPPS), Tenerife, Spain
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Irene Pelayo
- Department of Obstetrics and Gynecology, Ramón y Cajal Hospital, Madrid, Spain
- Faculty of Medicine, Alcalá de Henares University, Madrid, Spain
| | - Mark Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Shannon Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anna Selva
- Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
- Clinical Epidemiology and Cancer Screening, Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, Spain
| | - Pablo Alonso-Coello
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- CIBER of Epidemiology and Public Health, CIBERESP, Madrid, Spain
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17
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Genge L, Krala A, Tritschler T, Le Gal G, Langlois N, Dubois S, West C, Duffett L, Skeith L. Evaluation of patients' experience and related qualitative outcomes in venous thromboembolism: A scoping review. J Thromb Haemost 2022; 20:2323-2341. [PMID: 35730241 DOI: 10.1111/jth.15788] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/25/2022] [Accepted: 06/06/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a prevalent disease with high morbidity and mortality. VTE has well-documented physical sequelae; however, the psychological and emotional impacts are seldom evaluated in randomized controlled trials. OBJECTIVE We conducted a scoping review of published qualitative studies aiming to understand the physical, psychological, and emotional impact of VTE as reflected from patients' perspectives. This scoping review is part of a larger initiative to develop a core outcome set for VTE treatment studies. METHODS A systematic literature search was conducted to identify qualitative studies assessing patient experience of VTE. Two authors independently screened titles and abstracts using Covidence systematic review software. Full-text reviews were conducted independently by 2 study team members. A modified method of "thematic synthesis" was used to collate themes upon reading and rereading of the publications. RESULTS Our search strategy returned a total of 4944 citations; 28 were ultimately included in the analysis. The studies were conducted across 13 countries and representative of 436 participants including a spectrum of VTE subpopulations. There were seven major themes identified: Acute impacts: an unforeseen blow, Sustained psychological distress, Loss of self: life is changed, Challenges of thrombosis management, Balancing coping and control, Negative experience with the medical system, and VTE in the context of other conditions. CONCLUSIONS The physical, psychological, and emotional impacts of VTE extend beyond objective outcomes typically evaluated in clinical trials. An improved understanding of the outcomes most important to patients will improve patient-centered care in VTE.
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Affiliation(s)
- Leanne Genge
- Division of Hematology and Hematological Malignancies, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alexa Krala
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gregoire Le Gal
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Nicole Langlois
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Suzanne Dubois
- Canadian Venous Thromboembolism Research Network (CanVECTOR), Ottawa, ON, Canada
| | - Carol West
- Canadian Venous Thromboembolism Research Network (CanVECTOR), Ottawa, ON, Canada
| | - Lisa Duffett
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Leslie Skeith
- Division of Hematology and Hematological Malignancies, Department of Medicine, University of Calgary, Calgary, AB, Canada
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18
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and Mitigation of Bleeding Risk in Atrial Fibrillation and Venous Thromboembolism: Executive Summary of a European and Asia-Pacific Expert Consensus Paper. Thromb Haemost 2022; 122:1625-1652. [PMID: 35793691 DOI: 10.1055/s-0042-1750385] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
While there is a clear clinical benefit of oral anticoagulation in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision for initiating and continuing anticoagulation is often based on a careful assessment of both thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static "one-off" assessment based on baseline factors but is dynamic, being influenced by aging, incident comorbidities, and drug therapies. In this executive summary of a European and Asia-Pacific Expert Consensus Paper, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with a view to summarizing "best practice" when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, and review established bleeding risk factors and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism, are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom.,Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge and Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Spain.,BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Andrea Rubboli
- Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, München, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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19
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Fralick M, Sholzberg M. Pharmacologic Thromboprophylaxis for Patients Admitted to General Medicine - Is It Necessary? NEJM EVIDENCE 2022; 1:EVIDtt2200085. [PMID: 38319277 DOI: 10.1056/evidtt2200085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Necessity of Pharmacologic ThromboprophylaxisIt is a busy night on call, with 15 new admissions to general internal medicine. The senior resident checks over the admission orders, including low-molecular-weight heparin for venous thromboembolism prophylaxis. The resident wonders: Does everyone admitted to general medicine really require pharmacologic thromboprophylaxis?
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Affiliation(s)
- Michael Fralick
- Division of General Internal Medicine, Department of Medicine, Sinai Health, Toronto
| | - Michelle Sholzberg
- Division of Hematology, Department of Medicine, St. Michael's Hospital, Toronto
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20
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van de Brug A, de Winter MA, Ten Wolde M, Kaasjager K, Nijkeuter M. Deciding on Treatment Duration for Unprovoked Venous Thromboembolism: What is Important to Patients? Thromb Haemost 2022; 122:600-610. [PMID: 34169494 DOI: 10.1055/a-1535-8726] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND After 3 months of anticoagulation for unprovoked venous thromboembolism (VTE), a decision must be made to stop or continue indefinitely by weighing risks of recurrence and bleeding through shared decision-making (SDM). Despite the importance of patient involvement, patients' perspectives on treatment duration are understudied. AIM To describe the knowledge of VTE and anticoagulation, need for education, perception of risks and benefits of extended treatment, and factors influencing patient's preference to stop or continue treatment after unprovoked VTE. METHODS Semistructured interviews were conducted between May 2019 and August 2020 with adults with unprovoked VTE in one university hospital and one general hospital. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using conventional content analysis. RESULTS Eighteen patients were interviewed (median age 64, range: 32-83 years). Three major themes were identified: diagnosis and initial treatment, SDM, and perception of treatment. Education, knowledge, coping, and attitude toward health care suffused major themes. The impact of VTE on daily life varied between individuals, as did the preferred extent of SDM. Overall, patients who felt involved and informed were more satisfied with received care, more aware of risks and benefits of treatment, and more likely to be treatment adherent. Generally, patients were more concerned with risk of recurrent VTE than with risk of bleeding during anticoagulation. We identified a multitude of aspects important to patients when deciding to stop or continue anticoagulation. CONCLUSION Sufficient information and an individualized extent of SDM are of crucial importance for patients when deciding on treatment duration after unprovoked VTE.
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Affiliation(s)
- Anouk van de Brug
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Internal Medicine, St Jansdal Hospital, Harderwijk, The Netherlands
| | - Maria A de Winter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marije Ten Wolde
- Department of Internal Medicine, Flevo Hospital, Almere, The Netherlands
| | - Karin Kaasjager
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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21
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Neumann I, Quiñelen E, Nahuelhual P, Burdiles P, Celedón N, Cerda K, Herrera-Omegna P, Kraemer P, Cancino KD, Valenzuela JP, Sepúlveda D, Morgano GP, Akl EA, Schünemann HJ. Using explicit thresholds for benefits and harms in partially contextualized GRADE guidelines. Pilot experience from a living COVID-19 guideline. J Clin Epidemiol 2022; 147:69-75. [PMID: 35364230 PMCID: PMC8963975 DOI: 10.1016/j.jclinepi.2022.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 03/11/2022] [Accepted: 03/21/2022] [Indexed: 12/15/2022]
Abstract
Objectives Guideline panels must assess the magnitude of health benefits and harms to develop sensible recommendations. However, they rarely use explicit thresholds. In this paper we report on the piloting and the use thresholds for benefits and harms. Study Design and Setting We piloted the use of thresholds in a Chilean COVID-19 living guideline. For each of the critical outcomes, we asked panelists to suggest values of the thresholds for large, moderate, small, or trivial or no effect. We collected this information through a survey and an on-line discussion. Results Twelve panelists decided on thresholds for three critical outcomes (mortality, need for mechanical ventilation and serious adverse events). For all outcomes, an absolute risk reduction was considered larger with more than 50 events, moderate with less than 50 events, small with less than 25 events, and trivial with less than 10 events. Having these a priori thresholds in place significantly impacted on the development of recommendations. Conclusion Explicit thresholds were a valuable addition to the judgment of the certainty in the evidence, to decide the direction and strength of the recommendation and to evaluate the need for update. We believe this is a line of research worth perusing.
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Affiliation(s)
- Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Department of Health Technology Assessments, Ministerio de Salud de Chile, Santiago, Chile; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Eduardo Quiñelen
- Department of Health Technology Assessments, Ministerio de Salud de Chile, Santiago, Chile
| | - Paula Nahuelhual
- Department of Health Technology Assessments, Ministerio de Salud de Chile, Santiago, Chile
| | - Pamela Burdiles
- Department of Health Technology Assessments, Ministerio de Salud de Chile, Santiago, Chile
| | - Natalia Celedón
- Department of Health Technology Assessments, Ministerio de Salud de Chile, Santiago, Chile
| | - Katherine Cerda
- Department of Health Technology Assessments, Ministerio de Salud de Chile, Santiago, Chile
| | - Paloma Herrera-Omegna
- Department of Health Technology Assessments, Ministerio de Salud de Chile, Santiago, Chile
| | - Patricia Kraemer
- Department of Health Technology Assessments, Ministerio de Salud de Chile, Santiago, Chile
| | - Karen Dominguez Cancino
- Department of Health Technology Assessments, Ministerio de Salud de Chile, Santiago, Chile; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Escuela de Enfermería, Universidad Científica del Sur, Lima, Peru
| | - Juan Pablo Valenzuela
- Department of Health Technology Assessments, Ministerio de Salud de Chile, Santiago, Chile
| | - Dino Sepúlveda
- Department of Health Technology Assessments, Ministerio de Salud de Chile, Santiago, Chile
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Elie A Akl
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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22
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GRADE summary of findings tables Enhanced Understanding of Values and Preferences Evidence. J Clin Epidemiol 2022; 147:60-68. [PMID: 35364232 DOI: 10.1016/j.jclinepi.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 03/08/2022] [Accepted: 03/20/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We conceptualize patient values and preferences as the relative importance of health outcomes (RIO) which are often obtained through utility elicitation research. A transparent and structured approach to present synthesized RIO evidence and the certainty of this evidence is needed. This study aims to adapt the summary of findings (SoF) table to describe the RIO. STUDY DESIGN AND SETTING We performed three interactive workshops with a protype version of the SoF table for RIO evidence adapted from the SoF table for intervention effects. We then tested the new format through semi-structured interviews with professionals who interpret RIO evidence (e.g., systematic review authors and guideline developers). RESULTS We adapted the SoF table for the presentation of RIO evidence. This SoF table may be easy to use but bears one risk: some participants misunderstood the utility information and the variability around the RIO. We added a visual analogue scale to clarify the concept of utilities. CONCLUSION Through a multi-stage process including brainstorming sessions and interviews, we adapted the SoF table to present RIO evidence. This table may enhance understanding of evidence synthesis of values and preferences, facilitating the incorporation of this type of evidence in decision making.
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23
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A Position Paper from the ESC Working Group on Thrombosis, in collaboration with the European Heart Rhythm Association, the Association for Acute CardioVascular Care and the Asia-Pacific Heart Rhythm Society. Europace 2022; 24:1844-1871. [PMID: 35323922 DOI: 10.1093/europace/euac020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/08/2022] [Indexed: 12/26/2022] Open
Abstract
Whilst there is a clear clinical benefit of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision to initiate and continue anticoagulation is often based on a careful assessment of both the thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static 'one off' assessment based on baseline factors but is dynamic, being influenced by ageing, incident comorbidities, and drug therapies. In this Consensus Document, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with the view to summarizing 'best practice' when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, review established bleeding risk factors, and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, College Lane, Hatfield, UK.,Faculty of Medicine, National Heart & Lung Institute, Imperial College, London, UK
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Barcelona, Spain.,BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, España
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases-AUSL Romagna, SMaria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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24
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Wiercioch W, Nieuwlaat R, Zhang Y, Alonso-Coello P, Dahm P, Iorio A, Manja V, Mustafa RA, Neumann I, Ortel TL, Rochwerg B, Santesso N, Vesely SK, Akl EA, Schünemann HJ. New methods facilitated the process of prioritizing questions and health outcomes in guideline development. J Clin Epidemiol 2021; 143:91-104. [PMID: 34843861 DOI: 10.1016/j.jclinepi.2021.11.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/06/2021] [Accepted: 11/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Health guideline development requires sequential prioritization of the guideline topic, questions, and health outcomes. In this paper we report on new approaches for prioritizing questions and outcomes in guidelines. METHODS Ten guideline panels on venous thromboembolism rated potential guideline questions on a 9-point scale according to their overall importance and 6 criteria: common in practice, uncertainty in practice, variation in practice, new evidence available, cost consequences, not previously addressed. We randomized panelists to rate one potential question with and without the 6 criteria. Panelists rated importance of outcomes, defined with health outcome descriptors (HODs), using a 9-point scale, and health utility of outcomes on a visual analogue scale. RESULTS Of 469 potential questions identified, 72.5% were rated as important but not of high priority, and 25.4% as high priority. Each criterion was significantly associated with the overall importance rating. The overall importance rating means were 5.96 (SD 2.38) and 6.53 (SD 2.45) (P = 0.25) for those randomized to rate questions with and without the criteria, respectively. The mean importance rating for 121 outcomes was 6.01 (SD 1.25), with 35.5% rated as critical for decision-making. Panelists provided health utility ratings for 127 outcomes, with a minimum mean rating of 0.12 (SD 0.10) and maximum of 0.91 (SD 0.15). CONCLUSION Our structured process provided information to help explain perspectives of question importance, to facilitate panels' outcome prioritization, and to facilitate decision-making in guideline development.
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Affiliation(s)
- Wojtek Wiercioch
- Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Robby Nieuwlaat
- Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yuan Zhang
- Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau-CIBERESP), Barcelona, Spain
| | - Philipp Dahm
- Minneapolis VAMC, Urology Section and University of Minnesota Department of Urology, Minneapolis, Minnesota
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Veena Manja
- Department of Surgery, University of California Davis, California, USA; Department of Medicine, Veterans Affairs Northern California Health Care System, Mather, California
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Division of Nephrology and Hypertension, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Thomas L Ortel
- Departments of Medicine and Pathology, Duke University Medical Center, Durham, North Carolina
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Nancy Santesso
- Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Elie A Akl
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Internal Medicine, American University of Beirut, Lebanon
| | - Holger J Schünemann
- Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Canada; Institut für Evidence in Medicine, Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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25
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Perino AC, Fan J, Schmitt S, Guo JD, Hlavacek P, Din N, Kothari M, Pundi K, Russ C, Emir B, Turakhia MP. Anticoagulation Treatment and Outcomes of Venous Thromboembolism by Weight and Body Mass Index: Insights From the Veterans Health Administration. Circ Cardiovasc Qual Outcomes 2021; 14:e008005. [PMID: 34724801 DOI: 10.1161/circoutcomes.121.008005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Consensus statements have recommended against the use of direct oral anticoagulants (DOACs) in venous thromboembolism (VTE) for patients ≥120 kg and ≥40 kg/m2. We sought to determine use and outcomes of DOACs for VTE across weight and body mass index (BMI). METHODS We performed a retrospective cohort study of patients with first-time VTE 2013 to 2018 that were treated with DOAC or warfarin in the Veterans Health Administration. The Veterans Health Administration has implemented system-wide guidance for patient selection and shared decision-making for use of DOACs in VTE at extremes of weight. We stratified patients by weight and BMI and assessed (1) association of weight and BMI category to outcomes in those prescribed DOAC; and (2) association of DOAC, as compared to warfarin, to outcomes by weight and BMI categories. Outcomes of interest included major bleeding, clinically relevant nonmajor bleeding, and recurrent VTE. RESULTS The analysis cohort included 51 871 patients prescribed DOAC or warfarin within 30 days of index VTE diagnosis (age 64.5±13.1 years; 6.0% female; median weight 93.4 kg [25th-75th: 80.5-108.6 kg]). For patients ≥120 kg (N=6934 patients), 38.4% were treated with DOAC, as compared to 45.4% of those ≥60 to <100 kg (N=30 645; P<0.0001). DOAC prescription was not associated with major bleeds, clinically relevant nonmajor bleeds, or recurrent VTE for those in higher weight and BMI categories as compared to those in average weight and BMI categories. DOAC prescription, as compared to warfarin, was not associated with increased recurrent VTE in any weight or BMI category. CONCLUSIONS Patients ≥120 kg and ≥40 kg/m2 with VTE are frequently prescribed DOAC by the Veterans Health Administration, without an increase in bleeding or recurrent VTE. These findings suggest DOACs can be safe and effective in this population and may argue for broader adoption of pharmacy policies that promote careful patient selection and shared decision making.
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Affiliation(s)
- Alexander C Perino
- Department of Medicine (A.C.P., K.P., M.P.T.) and Center for Digital Health (A.C.P., N.D., M.P.T.), Stanford University School of Medicine, CA
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., S.S., N.D., M.K., M.P.T.)
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., S.S., N.D., M.K., M.P.T.)
| | - Susan Schmitt
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., S.S., N.D., M.K., M.P.T.)
| | | | | | - Natasha Din
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., S.S., N.D., M.K., M.P.T.)
| | - Mitra Kothari
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., S.S., N.D., M.K., M.P.T.)
| | - Krishna Pundi
- Department of Medicine (A.C.P., K.P., M.P.T.) and Center for Digital Health (A.C.P., N.D., M.P.T.), Stanford University School of Medicine, CA
| | | | | | - Mintu P Turakhia
- Department of Medicine (A.C.P., K.P., M.P.T.) and Center for Digital Health (A.C.P., N.D., M.P.T.), Stanford University School of Medicine, CA
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., S.S., N.D., M.K., M.P.T.)
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26
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Xu Y, Siegal DM. Anticoagulant-associated gastrointestinal bleeding: Framework for decisions about whether, when and how to resume anticoagulants. J Thromb Haemost 2021; 19:2383-2393. [PMID: 34273241 DOI: 10.1111/jth.15466] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 11/27/2022]
Abstract
Gastrointestinal (GI) bleeding is the most frequent single site of oral anticoagulant (OAC)-associated major bleeding. Patients with major GI bleeding experience morbidity and a substantial risk of short-term all-cause mortality up to 10%. While OACs are frequently discontinued during acute bleeding, there is substantial uncertainty about whether, when, and how OACs should be resumed after bleeding has resolved. Limited evidence suggests a lower risk of thromboembolism and death, and a higher risk of recurrent bleeding with OAC resumption. However, the absolute risks and optimal timing of anticoagulation remain uncertain based on these observational studies at risk of bias, particularly due to baseline confounding. In addition to an individualized approach to determining the benefits and harms of treatment decisions informed by the best available evidence about thrombosis and recurrent bleeding, discussions should meaningfully incorporate patient values and preferences. The objective of this review is to provide a framework for decision-making by summarizing the epidemiology and clinical outcomes of OAC-associated GI bleeding, providing an approach for assessment and risk stratification for OAC resumption and its timing, and outlining strategies for the prevention of recurrent GI bleeding.
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Affiliation(s)
- Yan Xu
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Deborah M Siegal
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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27
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Wumaier K, Li W, Chen N, Cui J. Direct oral anticoagulants versus low molecular weight heparins for the treatment of cancer-associated thrombosis: a cost-effectiveness analysis. Thromb J 2021; 19:68. [PMID: 34587969 PMCID: PMC8479897 DOI: 10.1186/s12959-021-00319-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/05/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Recently, direct oral anticoagulants (DOACs) have been included in guidelines for the treatment of cancer-associated thrombosis (CAT) to be extended to suitable cancer patients. The purpose of this study was to compare the cost-effectiveness of using DOACs and low molecular weight heparins (LMWHs) for treating CAT from the perspective of the Chinese healthcare system. METHODS A Markov model was constructed to estimate the cost-effectiveness of the two strategies with a 6-month and 5-year time horizon. Input parameters were either sourced from the clinical trial, published literature. The primary outcome of the model was reported as incremental cost-effectiveness ratios (ICERs). Sensitivity analyses were performed to test model uncertainty. RESULTS The 6-month cost of DOACs was $ 654.65 with 0.40 quality adjusted life-years (QALYs) while the 6-month cost of LMWHs was $USD 1719.31 with 0.37 QALYs. Similarly, treatment with DOACs had a lower cost ($USD 657.85 vs. $USD 1716.56) and more health benefits (0.40 QALYs vs. 0.37 QALYs) than treatment with LMWHs in a subgroup of patients with gastrointestinal malignancy. We found treatment with DOACs would result in a large reduction in cost ($USD 1447.22 vs. $USD 3374.70) but a small reduction in QALYs (3.07 QALYs vs. 3.09 QALYs) compared with LMWHs over a 5-year time frame, resulting in an ICER of $USD 112895.50/QALYs. Sensitivity analysis confirmed the robustness of the results. CONCLUSION As compared to LMWHs, DOACs can be a cost-saving anticoagulant choice for the treatment of CAT in the general oncology population and gastrointestinal malignancy population.
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Affiliation(s)
| | | | - Naifei Chen
- Department of Cancer center, the First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Jiuwei Cui
- Department of Cancer center, the First Hospital of Jilin University, Changchun, Jilin, 130021, China.
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28
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Lanéelle D, Le Brun C, Mauger C, Guillaumat J, Le Pabic E, Omarjee L, Mahé G. Patient Characteristics and Preferences Regarding Anticoagulant Treatment in Venous Thromboembolic Disease. Front Cardiovasc Med 2021; 8:675969. [PMID: 34235186 PMCID: PMC8255622 DOI: 10.3389/fcvm.2021.675969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/25/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Anticoagulants are the recommended treatment for venous thromboembolic disease (VTE). The mode of anticoagulant administration may influence compliance, and therefore the effectiveness of the treatment. Unlike in atrial fibrillation or cancer-associated thrombosis, there is only limited data on patient preferences regarding the choice of anticoagulation in VTE. This study aims to evaluate patient preferences regarding anticoagulants in terms of administration: types (oral or injectable treatment) and number of doses or injections per day. Patients and Methods: This is a national survey through a questionnaire sent by e-mail to 1936 French vascular physicians between February and April 2019. They recorded the responses for each patient admitted for VTE. Results: Three hundred and eleven (response rate of 16%) of the 1936 contacted physicians responded for 364 patients. Among these, there were 167 fully completed questionnaires. Most patients (63%) express concerns about VTE and prefer oral treatment (81.5%), justified by the ease of administration (74%) and a fear of the injections (22%). When patients were taking more than three oral treatments they statistically chose injectable treatment more often (54%) than oral treatment (25%, p = 0.002). Patients who chose injectable treatment were also older (70 ± 16 vs. 58 ± 17 years old, p = 0.001). There was no statistically difference in anticoagulation preference according to gender or to the expected duration of treatment (6 weeks, 3 months, 6 months or unlimited). When oral treatment was preferred (81%), most chose oral treatment without dose adjustment and biomonitoring (74.3%). Among them, very few (5.8%) preferred a twice-daily intake. Conclusion: Patient preference in terms of anticoagulant treatment in VTE disease is in favor of oral treatment without adjustment or biomonitoring and with once-daily intake. When an injectable treatment is chosen, a prolonged duration of treatment does not seem to be a constraint for the patient. Clinical Trial Registration: ClinicalTrials.gov, identifier [NCT03889457].
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Affiliation(s)
- Damien Lanéelle
- Centre Hospitalier Universitaire Caen Normandie, Service de Médecine Vasculaire, Caen, France.,Université de Caen, COMETE, Caen, France
| | - Charles Le Brun
- Centre Hospitalier Universitaire de Rennes, Department of Vascular Medicine, Rennes, France
| | - Chadi Mauger
- Centre Hospitalier Universitaire de Rennes, Department of Vascular Medicine, Rennes, France
| | - Jérôme Guillaumat
- Centre Hospitalier Universitaire Caen Normandie, Service de Médecine Vasculaire, Caen, France
| | - Estelle Le Pabic
- Centre Hospitalier Universitaire de Rennes, Department of Vascular Medicine, Rennes, France
| | - Loukman Omarjee
- Centre Hospitalier Universitaire de Rennes, Department of Vascular Medicine, Rennes, France.,Université de Rennes 1, Rennes, France
| | - Guillaume Mahé
- Centre Hospitalier Universitaire de Rennes, Department of Vascular Medicine, Rennes, France.,Université de Rennes 1, Rennes, France
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29
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A user guide to the American Society of Hematology clinical practice guidelines. Blood Adv 2021; 4:2095-2110. [PMID: 32396622 DOI: 10.1182/bloodadvances.2020001755] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 03/25/2020] [Indexed: 12/19/2022] Open
Abstract
Since November 2018, Blood Advances has published American Society of Hematology (ASH) clinical practice guidelines on venous thromboembolism, immune thrombocytopenia, and sickle cell disease. More ASH guidelines on these and other topics are forthcoming. These guidelines have been developed using consistent processes, methods, terminology, and presentation formats. In this article, we describe how patients, clinicians, policymakers, researchers, and others may use ASH guidelines and the many related derivates by describing how to interpret information and how to apply it to clinical decision-making. Also, by exploring how these documents are developed, we aim to clarify their limitations and possible inappropriate usage.
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30
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DOACs vs LMWHs in hospitalized medical patients: a systematic review and meta-analysis that informed 2018 ASH guidelines. Blood Adv 2021; 4:1512-1517. [PMID: 32289163 DOI: 10.1182/bloodadvances.2019000840] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 02/19/2020] [Indexed: 02/07/2023] Open
Abstract
Venous thromboembolism (VTE) is a relatively frequent complication in hospitalized patients, especially in those with risk factors. The benefit of using direct oral anticoagulants (DOACs) for prevention is controversial. This systematic review was performed as part of the American Society of Hematology (ASH) guidelines on VTE, developed in partnership with McMaster University. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Epistemonikos were used as data sources from date of inception to November 2019. We included randomized trials in patients hospitalized for an acute medical disease, evaluating any DOACs vs other pharmacological prophylaxis, and included 3 trials with low risk of bias. We analyzed the effects of DOACs vs low-molecular-weight heparins (LMWHs) at 2 different time points: at the end of the short-term treatment phase (both drugs given for the same period of time) and at the end of the extended prophylaxis period (extended DOACs vs a shorter course of LMWHs). We observed that the use of DOACs did not reduce the risk of pulmonary embolism or symptomatic deep venous thrombosis (DVT) in comparison with LMWHs. However, the risk of major bleeding was slightly increased. Additionally, we observed that the benefit of DOACs previously reported was largely based on the reduction of asymptomatic DVT and was not apparent when only symptomatic events were considered. The use of DOACs in hospitalized medical patients slightly increases the risk of major bleeding with no appreciable benefit over LMWHs.
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31
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Højen AA, Overvad TF, Nybo M, Kümler T, Rasmussen MS, Christensen TD, Larsen TB. Management of Cancer-Associated Venous Thrombosis: A Nationwide Survey among Danish Oncologists. TH OPEN 2021; 5:e188-e194. [PMID: 34151136 PMCID: PMC8208837 DOI: 10.1055/s-0041-1729754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/19/2021] [Indexed: 10/28/2022] Open
Abstract
Background Treatment patterns for cancer-associated venous thrombosis (CAT) has been shown to be nonconsistent with contemporary guideline recommendations, resulting in poor patient outcomes. Objectives The study aimed to describe contemporary CAT management in Danish oncology departments and identify knowledge gaps and inconsistencies between guidelines and clinical practice. Patients and Methods A survey questionnaire in Danish was developed based on contemporary national guidelines. Using an open recruitment strategy, invitations to participate in the electronic survey were sent to physicians employed at oncology departments in Denmark in winter of 2018/2019. The questionnaire was based on current national guidelines and included 10 items with multiple choices and a free-text option to specify or comment. The questionnaire was pilot-tested by a junior and senior oncologist. Results A total of 142 physicians completed the survey, representing all Danish geographical regions and various seniority. The majority reported that CAT was treated and followed up in oncology departments. However, 36.6% of the physicians were unaware of the existence of designated cancer thrombosis guidelines. Risk of venous thrombosis was generally assessed without diagnostic scores. Almost all (98.6%) reported low-molecular-weight heparin to be first-line treatment for CAT. Treatment duration seemed wrongly influenced by subtype of venous thrombosis, and 44.5% responded that thromboprophylaxis among hospitalized patients was substantially underused. Conclusion The variability in the daily clinical management of CAT demonstrated through this survey indicates a potential to increase awareness of available guidelines, standardized use of inpatient thromboprophylaxis, and organized treatment and follow-up in a multidisciplinary setting, which would potentially improve management of CAT in Denmark.
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Affiliation(s)
- Anette Arbjerg Højen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Thure Filskov Overvad
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Department of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Thomas Kümler
- Department of Cardiology, Herlev- Gentofte Hospital, Copenhagen, Denmark
| | | | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery and Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Torben Bjerregaard Larsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
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32
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Overvad TF, Larsen TB, Søgaard M, Albertsen IE, Ording AG, Noble S, Højen AA, Nielsen PB. Cancer-associated venous thromboembolism and the non-vitamin K antagonist oral anticoagulants: a review of clinical outcomes and patient perspectives. Expert Rev Cardiovasc Ther 2020; 18:791-800. [PMID: 32909840 DOI: 10.1080/14779072.2020.1822167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Cancer-associated venous thromboembolism remains an important but challenging aspect in the treatment of patients with cancer. Recently, alternatives to injection of low-molecular-weight heparin (LMWH) have been introduced, the non-vitamin K antagonist oral anticoagulants (NOACs), which could potentially alleviate patients from burdensome daily injections. AREAS COVERED This review discusses the available evidence exploring the role of NOACs in the treatment and secondary prevention of cancer-associated venous thromboembolism, from randomized trials, observational data, contemporary guideline recommendations, and patient perspectives. EXPERT OPINION Edoxaban, rivaroxaban, and apixaban have proven attractive alternatives to LMWH for the treatment of cancer-associated venous thromboembolism. Contemporary guidelines have promptly endorsed the use of NOACs in patients with most cancer types. Nonetheless, issues remain regarding bleeding risk, interactions with medical cancer treatment, and the effectiveness and safety for extended treatment periods. There are head-to-head comparisons of the NOACs, and therefore no data favoring the use of one NOAC over the others. Patient's preferences are highly diverse and should be part of routine considerations when weighing risks and benefits associated with various available anticoagulant drugs.
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Affiliation(s)
- Thure Filskov Overvad
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Oncology, Aalborg University Hospital , Aalborg, Denmark
| | - Torben Bjerregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Mette Søgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Ida Ehlers Albertsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Anne Gulbech Ording
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University , Cardiff, UK
| | - Anette Arbjerg Højen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
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33
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Controversy and Debate Series on Core Outcome Sets: The SOLAR (Standardized Outcomes Linking Across StakeholdeRs) system and hub and spokes model for direct core outcome measures in health care and its relation to GRADE. J Clin Epidemiol 2020; 125:216-221. [DOI: 10.1016/j.jclinepi.2020.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 05/05/2020] [Indexed: 01/06/2023]
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Glickman A, Brennecke A, Tayebnejad A, Matsuo K, Guntupalli SR, Sheeder J. Cost-effectiveness of apixaban for prevention of venous thromboembolic events in patients after gynecologic cancer surgery. Gynecol Oncol 2020; 159:476-482. [PMID: 32854972 DOI: 10.1016/j.ygyno.2020.07.096] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The cost-effectiveness of apixaban was compared with enoxaparin for prevention of postoperative venothromboembolic events (VTE) in gynecologic oncology patients. Current guidelines recommend thromboprophylaxis with low molecular weight heparin for 28 days following gynecologic cancer surgery, but recent trials suggest that oral apixaban may be a safe, patient-preferred alternative. Apixaban was superior to enoxaparin in a Canadian cost-effectiveness analysis using orthopedics trial data. METHODS Medication costs, adherence rates, event rates, event costs, and utility decrements were estimated using prior clinical trial data and literature review for input into a short-term decision model to simulate outcomes in a hypothetical cohort of 1000 patients. Incremental cost-effectiveness ratios (ICERs) were calculated as net cost difference per quality-adjusted life year (QALY) gained. Input values at which net costs and QALYs were equivalent and ICERs at upper and lower bounds were evaluated. RESULTS Using aggregated costs, apixaban was less expensive and more effective than enoxaparin, and remained so or had high value in all scenarios on sensitivity analysis. Examining disaggregated ICERs, apixaban was cost-effective for deep venous thrombosis (DVT); of high value for clinically-relevant non-major bleeding (CRNMB) ($411); low value for major bleeding ($183,465), VTE-related death ($2,711,229), and all-cause mortality ($297,522); and not cost-effective for pulmonary embolism prevention. CONCLUSIONS Apixaban is more cost-effective than enoxaparin for the prevention of postoperative VTE in patients with gynecologic cancer. This appears to be driven largely by DVT and CRNMB prevention.
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Affiliation(s)
- Amanda Glickman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Alyse Brennecke
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Anna Tayebnejad
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Saketh R Guntupalli
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Jeanelle Sheeder
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA.
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Wiercioch W, Nieuwlaat R, Akl EA, Kunkle R, Alexander KE, Cuker A, Rajasekhar A, Alonso-Coello P, Anderson DR, Bates SM, Cushman M, Dahm P, Guyatt G, Iorio A, Lim W, Lyman GH, Middeldorp S, Monagle P, Mustafa RA, Neumann I, Ortel TL, Rochwerg B, Santesso N, Vesely SK, Witt DM, Schünemann HJ. Methodology for the American Society of Hematology VTE guidelines: current best practice, innovations, and experiences. Blood Adv 2020; 4:2351-2365. [PMID: 32453843 PMCID: PMC7252554 DOI: 10.1182/bloodadvances.2020001768] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/02/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Methods for the development of clinical guidelines have advanced dramatically over the past 2 decades to strive for trustworthiness, transparency, user-friendliness, and rigor. The American Society of Hematology (ASH) guidelines on venous thromboembolism (VTE) have followed these advances, together with application of methodological innovations. OBJECTIVE In this article, we describe methods and methodological innovations as a model to inform future guideline enterprises by ASH and others to achieve guideline standards. Methodological innovations introduced in the development of the guidelines aim to address current challenges in guideline development. METHODS We followed ASH policy for guideline development, which is based on the Guideline International Network (GIN)-McMaster Guideline Development Checklist and current best practices. Central coordination, specialist working groups, and expert panels were established for the development of 10 VTE guidelines. Methodological guidance resources were developed to guide the process across guidelines panels. A methods advisory group guided the development and implementation of methodological innovations to address emerging challenges and needs. RESULTS The complete set of VTE guidelines will include >250 recommendations. Methodological innovations include the use of health-outcome descriptors, online voting with guideline development software, modeling of pathways for diagnostic questions, application of expert evidence, and a template manuscript for publication of ASH guidelines. These methods advance guideline development standards and have already informed other ASH guideline projects. CONCLUSIONS The development of the ASH VTE guidelines followed rigorous methods and introduced methodological innovations during guideline development, striving for the highest possible level of trustworthiness, transparency, user-friendliness, and rigor.
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Affiliation(s)
- Wojtek Wiercioch
- Michael G. DeGroote Cochrane Canada Centre
- McMaster GRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Robby Nieuwlaat
- Michael G. DeGroote Cochrane Canada Centre
- McMaster GRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | | | | | - Adam Cuker
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau-Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública), Barcelona, Spain
| | - David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mary Cushman
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, VT
| | - Philipp Dahm
- Urology Section, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wendy Lim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gary H Lyman
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Division of Nephrology and Hypertension, Department of Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Thomas L Ortel
- Department of Medicine and
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Nancy Santesso
- Michael G. DeGroote Cochrane Canada Centre
- McMaster GRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK; and
| | - Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Holger J Schünemann
- Michael G. DeGroote Cochrane Canada Centre
- McMaster GRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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