Abstract 176: Technology Use Among Patients Undergoing Warfarin Therapy: A Report from the Michigan Anticoagulation Quality Improvement Initiative (MAQI2)
Ikponmwosa O OlomuGeoffrey D. BarnesScott KaatzBrian HaymartXiaokui GuEva Kline‐RogersTina Alexandris-SouphisJ KozłowskiSyed AhsanDennis BesleyThomas LeydenJames B. Froehlich
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Background: Anticoagulation therapy with warfarin often requires frequent communication between patients and their anticoagulation providers. Providers communicate the current dose schedule, INR/PT lab results, schedule the next blood draws, and ask for updates in patient status such as new medications, changes in health, diet, or activity. Currently, these interactions take place mostly in the form of phone calls and voicemails from anticoagulation nurses to their patients. With the widespread adoption of new telecommunications technology, there is an opportunity to leverage the capabilities of mobile devices to facilitate communication between patients and their providers in order to enhance patient engagement and support clinical care goals. Methods: To assess the current use of technology among warfarin patients and the potential utilization of mobile devices in anticoagulant therapy, we surveyed 136 patients from two sites of the MAQI2 consortium. Survey questions investigated the use of technology for health information and comfort using mobile devices in this cohort of patients. The survey asked whether patients undergoing warfarin therapy believe a mobile device, a smartphone/tablet, would be useful to support instructions. Responses were linked to each patient’s health record by their MAQI2 ID to characterize them based on demographics and indicators of quality of care such as time in therapeutic range (TTR) and the number of out of range INRs. Results: The survey results show that 84% of patients who responded to the survey have internet connectivity at their home. In addition, 66% reported that they always or sometimes use a computer to find health information compared with 34% who rarely or never go online seeking health information (p<0.01). Patients who are comfortable with mobile devices are on average 14 years younger, 57 vs. 71 years old (p<0.01). About 70% of patients responded that a mobile device would be useful to support warfarin instruction and 44% of these patients responded that they would be capable of using a device to support their warfarin therapy. These patients that responded favorably to mobile devices have a lower TTR 40.6% vs. 64.2% (p<0.01), and almost twice the rate of out of range INRs with known reasons (p>0.05) for example such as a change in medication, diet, or because the patient took more/less warfarin than prescribed. Conclusion: A majority of warfarin patients surveyed have internet connectivity at home, and they currently use a computer for health-related purposes. Patients who are most likely to use a mobile device to support instructions and communicate with their providers are younger and spend less time in therapeutic range. Quality of care may be improved in this population through an online/mobile application as a resource to communicate dose changes, remind patients of scheduled blood draws, and collect changes in patient status.Keywords:
Demographics
Mobile phone
Health information technology
I have been promising (or threatening, depending on your point of view) for some time to write on the subject of SEG's demographics and now is the time. One could say that it is SEG's most important issue because our demographic profile says a lot about our society and deeply influences our future. Yet, I have been slow to bring the issue to the fore because I have been puzzled by some aspects of our demographics and also needed to collect some hard data. I think you may find the results interesting.
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Because of its drug interaction with warfarin K, bucolome is used to reduce the dose of warfarin K. We retrospectively investigated the prescription of warfarin K and bucolome in our hospital from January 2000 to June 2002, based on data from the thrombo test as an indicator of the effects. The total number of patients who were prescribed warfarin K was 654 (mean age, 62.7), and 55 (mean age, 62.8) of those were prescribed both warfarin K and bucolome during the period under investigation. All patients given bucolome were administered warfarin K. Bucolome was discontinued in nine patients, while it was added in five patients. The dose of warfarin K was changed when the bucolome therapy started or stopped in 11 patients, and the same dose of warfarin K was prescribed in three patients upon the discontinuation of bucolome. The doses of warfarin K in the 11 patients who started or stopped bucolome were reduced by more than 50% without any significant change in the thrombo test findings. However, the thrombo level increased in the other three patients and several thrombo tests were subsequently necessary to determine the proper dosage of warfarin K. Pharmacists must therefore monitor not only the dose of warfarin K but also that of any concurrently administered drugs interacting with warfarin K, as well as any previously prescribed medications. Pharmaceutical instruction to the patients, especially in clinical departments unfamiliar with warfarin use, is also essential.
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For most warfarin indications, the target maintenance international normalised ratio (INR) is 2–3. Risk factors for bleeding complications with warfarin use include age, history of past bleeding and specific comorbid conditions. To reverse the effects of warfarin, vitamin K1 can be given. Immediate reversal is achieved with a prothrombin complex concentrate (PCC) and fresh frozen plasma (FFP). Vitamin K1 is essential for sustaining the reversal achieved by PCC and FFP. When oral vitamin K1 is used for warfarin reversal, the injectable formulation of vitamin K1 is preferable to tablets because of its flexible dosing; this formulation can be given orally or injected. To temporarily reverse the effect of warfarin when there is a need to continue warfarin therapy, vitamin K1 should be given in a dose that will quickly lower the INR to a safe, but not subtherapeutic, range and will not cause resistance once warfarin is reinstated. Prothrombinex-HT is the only PCC approved in Australia and New Zealand for warfarin reversal. It contains factors II, IX and X, and low levels of factor VII. FFP should be added to Prothrombinex-HT as a source of factor VII when used for warfarin reversal. Simple dental or dermatological procedures may not require interruption to warfarin therapy. If necessary, warfarin therapy can be withheld 5 days before elective surgery, when the INR usually falls to below 1.5 and surgery can be conducted safely. Bridging anticoagulation therapy for patients at high risk for thromboembolism should be undertaken in consultation with the relevant experts.
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This paper examines the impact that demographics have on policy outcomes. The impact that aldermanic ward‐level demographics have on the number of liquor licenses is measured in two US cities. In one city there is a great deal of direct resident involvement in the issuance process, while in the other city, issuance decisions are handled by elected representatives. This research does find that demographics have a significant impact on policy outcomes. However, the paper does not find a significant difference in outcomes between decisions made by elected representatives and those made by the community.
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Azithromycin is considered unlikely to interact with warfarin. Unlike other macrolide antibiotics, it is not hepatically metabolized and did not produce an interaction with warfarin in a single‐dose study. A 71‐year‐old woman with a prosthetic heart valve, stabilized with warfarin, had international normalized ratios (INRs) maintained between 2.5 and 3.5. Six days after she received a prescription for a 5‐day course of azithromycin, her INR was 15.16. Phytonadione 10 mg was administered subcutaneously, and warfarin was held for 3 days until her INR fell to 2.10. She then was restabilized with warfarin. Until more information is known about the safety of warfarin and azithromycin, caution is advised when the agents are given together. Close monitoring of INR is recommended, and warfarin dosage adjustment may be necessary.
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Abstract Purpose To evaluate the frequency, severity and preventability of warfarin‐induced cerebral haemorrhages due to warfarin and warfarin–drug interactions in patients living in the county of Östergötland, Sweden. Methods All patients with a diagnosed cerebral haemorrhage at three hospitals during the period 2000–2002 were identified. Medical records were studied retrospectively to evaluate whether warfarin and warfarin–drug interactions could have caused the cerebral haemorrhage. The proportion of possibly avoidable cases due to drug interactions was estimated. Results Among 593 patients with cerebral haemorrhage, 59 (10%) were assessed as related to warfarin treatment. This imply an incidence of 1.7/100 000 treatment years. Of the 59 cases, 26 (44%) had a fatal outcome, compared to 136 (25%) among the non‐warfarin patients ( p < 0.01). A warfarin–drug interaction could have contributed to the haemorrhage in 24 (41%) of the warfarin patients and in 7 of these (12%) the bleeding complication was considered being possible to avoid. Conclusions Warfarin‐induced cerebral haemorrhages are a major clinical problem with a high fatality rate. Almost half of the cases was related to a warfarin–drug interaction. A significant proportion of warfarin‐related cerebral haemorrhages might have been prevented if greater caution had been taken when prescribing drugs known to interact with warfarin. Copyright © 2006 John Wiley & Sons, Ltd.
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Warfarin is an anticoagulant suppressing the synthesis of the specific vitamin K-dependent coagulation factors II, VII, IX and X as well as two vitamin K-dependent plasma proteins C and S. Warfarin therapy may bring about severe consequences including warfarin embryopathy associated with maternal warfarin ingestion, warfarin resistance, excessive anticoagulation and warfarin reversal. A 51-year-old female patient experienced warfarin resistance as well as subsequent excessive coagulation and warfarin reversal. With regulation of warfarin dosage and close monitoring of the international normalized ratio, she eventually obtained a proper target international normalized ratio with stable warfarin dose. The patient was more likely to have an acquired warfarin resistance. To regulate dietary habit might be a good solution for the resistance to this drug. In addition, individualized regimen for warfarin use should be established based on the conditions of individual patient including patient's age, gender, body surface area, dietary habit and target international normalized ratio, etc.
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The object of this study was to determine whether warfarin could be safely continued in patients with epistaxis if the International Normalized Ratio (INR) was within the suggested therapeutic range. Twenty patients on warfarin treatment were compared with controls, matched for age and sex. Local measures for the control of epistaxis were undertaken appropriately in all the patients. In the warfarin group 17 patients (85%) did not discontinue warfarin as the INR was within the suggested range. There were no additional bleeding complications or failure of epistaxis control due to continuation of warfarin. There was no significant difference in the mean hospital stay between the warfarin and non-warfarin groups. It is concluded that warfarin can be continued safely in patients with epistaxis, in appropriate circumstances, and that the policy of stopping warfarin routinely in all patients with epistaxis should be reconsidered.
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