Quality of Anticoagulation Control and Costs of Monitoring Warfarin Therapy among Patients with Atrial Fibrillation in Clinic Settings: A Multi-Site Managed-Care Study

2005 ◽  
Vol 39 (3) ◽  
pp. 446-451 ◽  
Author(s):  
Joseph Menzin ◽  
Luke Boulanger ◽  
Ole Hauch ◽  
Mark Friedman ◽  
Cheryl Beadle Marple ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Warfarin Therapy ◽  
Anticoagulation Clinic ◽  
Health Plans ◽  
Nonvalvular Atrial Fibrillation ◽  
Quality Of Control ◽  
Anticoagulation Clinics ◽  
Anticoagulation Control

BACKGROUND: Warfarin is recommended for prevention of stroke in patients with atrial fibrillation who are at moderate or high risk, but requires intensive management to achieve safe and optimal anticoagulation control. Anticoagulation clinics are often used to administer warfarin therapy more effectively. OBJECTIVE: To collect data from multiple sites and assess the quality and costs associated with anticoagulation clinic services. METHODS: A random sample of 600 adults with chronic nonvalvular atrial fibrillation (CNVAF) receiving warfarin was selected from anticoagulation clinics affiliated with 3 health plans. Patients were identified between 1996 and 1998 and followed for up to one year. We assessed the proportion of time that international normalized ratio (INR) values were within the recommended range (2.0–3.0) and the costs of anticoagulation clinic care. RESULTS: Patients had an average of 18 clinic contacts over a mean duration of follow-up of 10.5 months. On average, patients were within the recommended INR range 62% of this time, with 25% of days below range and 13% above range. The mean per-patient cost of warfarin monitoring over the follow-up period averaged $261 at site A, $305 at site B, and $205 at site C (in 2003 US$). Mean costs for patients treated for one full year were $288, $339, and $216, respectively. CONCLUSIONS: In 3 geographically diverse health plans, anticoagulation clinics provided a generally higher quality of control than previously reported in other observational studies. This study highlights the costs of obtaining this level of control.

scholarly journals Impact of Anticoagulation Clinic Intervention on Patient Centred Outcomes in a Tertiary Care Hospital

2020 ◽  
Author(s):  
S Sunil Kumar ◽  
Oliver Joel Gona ◽  
Nagaraj Desai ◽  
B Shyam Prasad Shetty ◽  
KS Poornima ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Outcomes ◽  
Therapeutic Range ◽  
Tertiary Care ◽  
Anticoagulation Clinic ◽  
Care Hospital ◽  
Thromboembolic Events ◽  
Co Morbidity

Introduction: Vitamin K Antagonists (VKAs) have been in use for more than 50 years. They have remained as mainstay therapy in the prevention of thromboembolic events in atrial fibrillation, mechanical heart valves and venous thromboembolism. Despite many years of clinical experience with VKAs, the quality of anticoagulation achieved in routine clinical practice is suboptimal. Aim: To study the effects of structured Anticoagulation Clinic (ACC) interventions on patient centred outcomes in subjects taking VKAs. Materials and Methods: A retrospective study was conducted among patients taking VKAs enrolled in ACC. A total of 169 patients receiving VKAs for at least six months with 4 INR (International Normalised Ratio) values and completed 12 months of follow-up were analysed. Anticoagulation related quality measures like Time in the Therapeutic Range (TTR), Percentage of International Normalised Ratios in the therapeutic Range (PINRR) and clinical outcomes like stroke, systemic embolic events and bleeding was analysed at the time of enrolment and compared with those during ACC care. Results: Among 352 patients enrolled in ACC, 169 patients were eligible for analysis. The mean age of the study population was 55.62±13.77 years. Atrial fibrillation (59%) was the most common indication for VKA therapy. Hypertension (66.3%) was the most common co-morbidity. Mean TTRs were significantly higher in the ACC care when compared with the pre-ACC care at 12 months follow-up (77.58±8.85% vs 51.01±16.7%, p<0.0001). There was a significant improvement in TTRs as early as three months of ACC intervention (73.18±13.56%). At the time of enrolment, 21.9% of patients had individual TTRs (i-TTR) >70% which increased to 70.4% at 12 months of follow-up. INR testing was done more frequently in ACC care. Adverse clinical events were higher in pre-ACC care than ACC care (4.7% vs 2.4%, p>0.05). Major bleeding and thromboembolic events were higher in pre-ACC care than ACC care (1.8% vs. 0.6% and 2.4% vs. 0.6% respectively). Conclusion: ACC services helps in achieving better quality of anticoagulation control as measured by time in therapeutic range translating into better clinical outcomes.

Abstract 171: Warfarin Use And Stroke Risk Among Patients With Nonvalvular Atrial Fibrillation In A Large Managed Care Population

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Steven B Deitelzweig ◽  
Erin Buysman ◽  
Brett Pinsky ◽  
Michael Lacey ◽  
Yonghua Jing ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Managed Care ◽  
Treatment Period ◽  
Real World ◽  
Warfarin Therapy ◽  
Stroke Risk ◽  
Nonvalvular Atrial Fibrillation ◽  
Chads2 Score ◽  
Warfarin Treatment

Introduction Warfarin discontinuation among real world nonvalvular atrial fibrillation (NVAF) patients is common. Hypothesis We hypothesized that in a managed care population, warfarin discontinuation is associated with increased stroke risk. Methods Patients who initiated warfarin therapy between Jan 2005 and Jun 2009 and had a healthcare claim related to AF within 30 days prior to the first warfarin claim, but no evidence of valvular disease, were included. Warfarin discontinuation was defined as a supply gap of >60 days without evidence of International Normalized Ratio (INR) measurements. Follow-up was divided into periods of warfarin treatment and discontinuation. Stroke events were identified based on claims for inpatient stays with a primary diagnosis for stroke or transient ischemic attack (TIA). Cox proportional hazards models were constructed to assess the relationship between warfarin discontinuation and incident stroke while adjusting for baseline demographics, stroke and bleeding risk, and comorbidities, as well as time-dependent antiplatelet use, stroke, and bleeding events in the prior warfarin treatment period. Results The mean (SD) age of the study sample (N=16,253) was 67±12 years; 64.8% was male. Mean CHADS2 score was 1.84±1.30; mean HAS-BLED score was 2.00±1.18. Half (51.4%) of patients discontinued warfarin therapy at least once and the overall sample had a mean of 1.87 warfarin treatment periods during a mean of 668 days follow-up. Approximately 1186 patients (7%) had a stroke or TIA at any site of service during follow-up. Risk of stroke significantly increased during warfarin discontinuation periods compared with therapy periods (HR 1.60; 95%CI 1.35-1.90; P<.0001). Stroke risk was significantly increased for patients with baseline CHADS2 score ≥2 (HR 2.69; 95%CI 1.44-5.03; P=.002), HAS-BLED score ≥3 (HR 1.46; 95%CI 1.05-2.05; P=.027), or who had a bleeding (HR 1.29; 95%CI 1.06-1.57; P=.013) or stroke event (HR 3.04; 95%CI 2.47-3.75; P<.0001) in the prior treatment period. Conclusions In the real world, over half of patients on anticoagulation therapy had treatment gaps or permanently discontinued therapy. These usage patterns, as well as prior bleeding, were associated with increased stroke risk.

scholarly journals Anticoagulation Control in Different Ethnic Groups Receiving Vitamin K Antagonist for Stroke Prevention in Atrial Fibrillation

2021 ◽  
Vol 8 ◽  
Author(s):  
Nur Azyyati Zawawi ◽  
Izzati Abdul Halim Zaki ◽  
Long Chiau Ming ◽  
Hui Poh Goh ◽  
Hanis Hanum Zulkifly
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Outcome ◽  
Ethnic Groups ◽  
Therapeutic Range ◽  
Stroke Prevention ◽  
Warfarin Therapy ◽  
Adverse Clinical Outcome ◽  
Time In Therapeutic Range ◽  
Anticoagulation Control

Vitamin K antagonist such as warfarin reduces the risk of stroke in atrial fibrillation (AF) patients. Since warfarin has a narrow therapeutic index, its administration needs to be regularly monitored to avoid any adverse clinical outcomes such as stroke and bleeding. The quality of anticoagulation control with warfarin therapy can be measured by using time in therapeutic range (TTR). This review focuses on the prevalence of AF, quality of anticoagulation control (TTR) and adverse clinical outcome in AF patients within different ethnic groups receiving warfarin therapy for stroke prevention. A literature search was conducted in Embase and PubMed using keywords of “prevalence,” “atrial fibrillation,” “stroke prevention,” “oral anticoagulants,” “warfarin,” “ethnicities,” “race” “time in therapeutic range,” “adverse clinical outcome,” “stroke, bleeding.” Articles published by 1st February 2020 were included. Forty-one studies were included in the final review consisting of AF prevalence (n = 14 studies), time in therapeutic range (n = 18 studies), adverse clinical outcome (n = 9 studies) within different ethnic groups. Findings indicate that higher prevalence of AF but better anticoagulation control among the Whites as compared to other ethnicities. Of note, non-whites had higher risk of strokes and bleeding outcomes while on warfarin therapy. Addressing disparities in prevention and healthcare resource allocation could potentially improve AF-related outcomes in minorities.

P3474Relationship between international normalized ratio variability, quality of anticoagulation control and outcomes in patients with atrial fibrillation: an AFFIRM post-hoc analysis

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Proietti ◽  
G F Romiti ◽  
B Olshansky ◽  
G Y H Lip
Keyword(s):  
Atrial Fibrillation ◽  
Regression Analysis ◽  
Standard Deviation ◽  
Major Bleeding ◽  
International Normalized Ratio ◽  
Cox Regression Analysis ◽  
Increased Risk ◽  
Anticoagulation Control

Abstract Introduction Quality of anticoagulation control is essential to ensure better clinical outcomes in patients with atrial fibrillation (AF). Time in therapeutic range (TTR) is recommended as a measure of the quality of anticoagulation control. The International normalized ratio (INR) variability has been suggested as an alternative index, even though large independent validations for this index are still lacking. Purpose To provide validation of clinical usefulness of INR variability as a measure of the quality of anticoagulation control in a large cohort of AF patients. Methods Data from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial were analysed. INR variability was defined as the standard deviation (SD) of mean INR values [INR-SD] recorded throughout the follow-up observation for each patient. All patients with available INR values were included in the analysis. Stroke, major bleeding, cardiovascular (CV) death and all-cause death were study outcomes. Results Among the original 4060 patients, a total of 3185 (78.4%) were available for analysis. Mean (SD) INR-SD was 0.58 (0.25). According to INR-SD patients were categorized into four quartiles. Mean (SD) CHA2DS2-VASc score was increased (p=0.040), with no difference in proportions of CHA2DS2-VASc ≥2 (p=0.582) between the subgroups. A significant inverse correlation was found between INR-SD and TTR (Spearman's Rho: −0.536, p<0.001). Continuous INR-SD, after multiple adjustments, was inversely associated with TTR (standardized beta: −0.451, p<0.001) and directly associated with SAMe-TT2R2score (standardized beta: 0.084, p<0.001). A fully adjusted Cox multivariate regression analysis found that INR-SD was directly associated with increased risk of stroke, major bleeding and all-cause death (Table). An INR-SD ≥0.85 was directly associated with all the study outcomes, on multivariate analysis (Table). Cox Regression Analysis INR-SD INR-SD ≥0.85 HR (95% CI) HR (95%) Stroke 2.52 (1.34–4.67) 1.62 (1.00–2.63) Major Bleeding 2.43 (1.49–3.96) 1.61 (1.10–2.36) CV Death 1.50 (0.87–2.59) 1.54 (1.07–2.24) All-Cause Death 1.79 (1.21–2.66) 1.55 (1.17–2.05) CI = Confidence Interval; CV = Cardiovascular; HR = Hazard Ratio; INR-SD = International Normalized Ratio Standard Deviation. Conclusions INR variability, expressed as INR-SD, was significantly correlated and associated with TTR. Both continuous INR-SD and INR-SD ≥0.85 were significantly associated with a higher risk of all study adverse outcomes. Acknowledgement/Funding None

Relation of Renal Dysfunction to Quality of Anticoagulation Control in Patients with Atrial Fibrillation: The FANTASIIA Registry

2018 ◽  
Vol 118 (02) ◽  
pp. 279-287 ◽  
Author(s):  
María Esteve-Pastor ◽  
José Rivera-Caravaca ◽  
Inmaculada Roldán-Rabadán ◽  
Vanessa Roldán ◽  
Javier Muñiz ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Major Bleeding ◽  
Cardiovascular Mortality ◽  
Real World ◽  
Cardiovascular Events ◽  
Vitamin K Antagonists ◽  
Major Adverse Cardiovascular Events ◽  
Anticoagulation Control

Background One-third of atrial fibrillation (AF) patients have chronic kidney disease (CKD), a condition that itself increases thromboembolic and major bleeding risks, especially in patients with severe CKD. Bleeding would be accentuated by suboptimal anticoagulation control with vitamin K antagonists (VKA). Purpose This article aimed to investigate the incidence of cardiovascular events, mortality and quality of anticoagulation in relation to CKD in a ‘real-world’ prospective cohort of AF patients included in the FANTASIIA registry. Methods We analysed consecutive AF patients who were prospectively recruited with a year of follow-up. The quality of anticoagulation was estimated by time in therapeutic range (TTR). The annual incidence of events was analysed. Results We studied 1,936 patients (male: 55.7%, mean: 73.8 ± 9.4 years): 445 (22.9%) had normal function, 698 (36.1%) had mild CKD, 713 (36.8%) had moderate CKD and 80 (4.2%) had severe CKD. Patients with estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2 (severe CKD) had lower TTR (53.3 ± 25.6% vs. 61.8 ± 25.1%, p = 0.007) and higher proportion of poor TTR (67.2 vs. 51.8%; p = 0.014) than patients with eGFR ≥30 mL/min/1.73 m2. Severe CKD was significantly associated with cardiovascular mortality (hazard ratio [HR]: 9.33; p = 0.002), major bleeding (HR: 2.94; p = 0.036) and major adverse cardiovascular events (MACE) (HR: 4.93; p = 0.004). Importantly, 375 patients (21.1%) showed a deteriorating eGFR of ≥10 mL/min during the follow-up, with significantly higher mortality and cardiovascular events. Conclusion In a prospective and real-world AF registry, approximately 67% of patients with severe CKD had poor anticoagulation control while taking VKA. The presence of severe CKD was an independent factor for cardiovascular mortality, MACE and major bleeding. Worsening eGFR of only ≥10 mL/min during follow-up was significantly associated with mortality and major bleeding.

Quality of Anticoagulation Monitoring in Nonvalvular Atrial Fibrillation Patients: Comparison of Anticoagulation Clinic versus Usual Care

2008 ◽  
Vol 42 (1) ◽  
pp. 62-70 ◽  
Author(s):  
Michael B Nichol ◽  
Tara K Knight ◽  
Tom Dow ◽  
Gail Wygant ◽  
Gerald Borok ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Usual Care ◽  
Anticoagulation Clinic ◽  
Nonvalvular Atrial Fibrillation
Sign in / Sign up

Export Citation Format

Share Document