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Anticoagulation control in the peri-hospitalization period.

ABSTRACT: Oral anticoagulants (OAC) are effective and safe if the international normalized ratio (INR) is maintained within a narrow therapeutic range. Hospitalization is independently associated with poor anticoagulation control. The objective of this study is to describe how anticoagulation control changes in the peri-hospitalization period. This study is a retrospective cohort study using population-based administrative databases. INR results were retrieved from a population-based laboratory database. INR levels between laboratory measures were estimated using linear interpolation. Auto-regressive, integrated, moving average (ARIMA) time-series modeling was used to determine how anticoagulation control changed in the peri-hospitalization period. The study included 5,380 elderly patients in Eastern Ontario between 1 September 1999 and 1 September 2000 taking OACs. Results showed that 951 (17.7%) were hospitalized during their OAC therapy [thrombotic, n = 52 (1.0%); hemorrhagic, n = 140 (2.6%); other hospitalization types, n = 759 (14.1%)]. All measures of anticoagulation control changed significantly in the peri-hospitalization period. Before hemorrhagic admissions, mean INR and proportion with INR > 5 increased significantly (daily increase 0.024, P = .03 and 0.2%, P = .01). Following other hospitalization types, the proportion of patients with INR < 1.5 was significantly increased (daily increase 0.19%, P = .02). Patients admitted to the hospital for a variety of indications have significantly worse anticoagulation control in the peri-hospitalization period. Anticoagulated patients discharged after medical hospitalizations could be targeted for improved anticoagulation control.

SUBMITTER: van Walraven C

PROVIDER: S-EPMC2219864 | biostudies-other | 2007 Jun

REPOSITORIES: biostudies-other

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Project description:BackgroundChronic anticoagulation has been demonstrated to be a risk factor for GI bleeding (GIB) in patients undergoing endoscopic procedures.ObjectiveThe aim of this study was to determine the incidence of GIB prospectively in a large cohort of patients enrolled in the Clinical Outcomes Research Initiative (CORI) database.DesignAnticoagulated patients undergoing endoscopic procedures were interviewed by phone 30 to 45 days after the procedure to determine potential adverse events and management of warfarin therapy in the periendoscopic period.SettingParticipating CORI sites, Stanford University Hospital, Veterans Administration Palo Alto Health Care System.Main outcome measurementPostprocedural hemorrhagic or thrombotic events.ResultsThirteen CORI sites agreed to participate, including 120,886 procedures in 95,807 patients. We contacted 929 patients on warfarin therapy and enrolled 483 patients (52%). The majority of the patients were men with atrial fibrillation undergoing colonoscopy. Warfarin was temporarily suspended in 437 (90%) of the patients before the procedure, and 114 (22%) received periprocedural heparin therapy. There were 10 major hemorrhagic events (2%), and the rate of hemorrhage was not higher in the patients receiving periprocedural heparin therapy (P = .1). However, polypectomy was a risk factor for postprocedural hemorrhage (P = .02). One fatal stroke (0.2%) occurred in a patient 2 weeks after endoscopy; however, information regarding warfarin management was not available.LimitationsSmall number of enrolled patients and lack of control group. Lack of information regarding prothrombin time before procedure, concurrent antiplatelet agents, and timing of bleeding in 50% of the cases. The study was underpowered to definitively conclude benefits of current guidelines regarding thrombosis or bleeding.ConclusionsPostprocedural hemorrhagic events were not increased in anticoagulated patients. Most patients receiving bridging therapy were managed according to current society guidelines.

Project description:BackgroundAnticoagulants are major contributors to preventable adverse drug events, and their optimal management in the periprocedural period is particularly challenging. Traditional methods of disseminating clinical guidelines and tools cannot keep pace with the rapid expansion of available therapeutic agents, approved indications for use, and published medical evidence, so a mobile app, Management of Anticoagulation in the Periprocedural Period (MAPPP), was developed and disseminated to provide clinicians with guidance that reflects the most current medical evidence.ObjectiveThe objective of this study was to assess the global, national, and state-level acquisition of a mobile app since its initial release and characterize individual episodes of use based on drug selection, procedural bleeding risk, and patient thromboembolic risk.MethodsData were extracted from a mobile app usage tracker (Google Analytics) to characterize new users and completed episodes temporally (by calendar quarter) and geographically (globally, nationally, and in the targeted US state of New York) for the period between April 1, 2016 and September 30, 2017.ResultsThe app was acquired by 2866 new users in the measurement period, and the users completed nearly 10,000 individual episodes of use. Acquisition and utilization spanned 51 countries globally, predominantly in the United States and particularly in New York State. Warfarin and rivaroxaban were the most frequently selected drugs, and completed episodes most frequently included the selection of high bleeding risk (4888/9963, 49.06%) and high thromboembolic risk categories (4500/9963, 45.17%).ConclusionsThe MAPPP app is a successful means of disseminating current guidance on periprocedural anticoagulant use, as indicated by broad global uptake and upward trends in utilization. Limitations in access to provider and patient-specific data preclude objective evaluation of the clinical impact of the app. An ongoing study incorporating app logic into electronic health record systems at participant health systems will provide a more definitive evaluation of the clinical impact of the app logic.

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Anticoagulation control in the peri-hospitalization period.

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