Rubina Sunderji

Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data

BACKGROUND Uptake of self-testing and self-management of oral anticoagulation [corrected] has remained inconsistent, despite good evidence of their effectiveness. To clarify the value of self-monitoring of oral anticoagulation, we did a meta-analysis of individual patient data addressing several important gaps in the evidence, including an estimate of the effect on time to death, first major haemorrhage, and thromboembolism. METHODS We searched Ovid versions of Embase (1980-2009) and Medline (1966-2009), limiting searches to randomised trials with a maximally sensitive strategy. We approached all authors of included trials and requested individual patient data: primary outcomes were time to death, first major haemorrhage, and first thromboembolic event. We did prespecified subgroup analyses according to age, type of control-group care (anticoagulation-clinic care vs primary care), self-testing alone versus self-management, and sex. We analysed patients with mechanical heart valves or atrial fibrillation separately. We used a random-effect model method to calculate pooled hazard ratios and did tests for interaction and heterogeneity, and calculated a time-specific number needed to treat. FINDINGS Of 1357 abstracts, we included 11 trials with data for 6417 participants and 12,800 person-years of follow-up. We reported a significant reduction in thromboembolic events in the self-monitoring group (hazard ratio 0·51; 95% CI 0·31-0·85) but not for major haemorrhagic events (0·88, 0·74-1·06) or death (0·82, 0·62-1·09). Participants younger than 55 years showed a striking reduction in thrombotic events (hazard ratio 0·33, 95% CI 0·17-0·66), as did participants with mechanical heart valve (0·52, 0·35-0·77). Analysis of major outcomes in the very elderly (age ≥85 years, n=99) showed no significant adverse effects of the intervention for all outcomes. INTERPRETATION Our analysis showed that self-monitoring and self-management of oral coagulation is a safe option for suitable patients of all ages. Patients should also be offered the option to self-manage their disease with suitable health-care support as back-up. FUNDING UK National Institute for Health Research (NIHR) Technology Assessment Programme, UK NIHR National School for Primary Care Research.

Cost-effectiveness of self-managed versus physician-managed oral anticoagulation therapy

Background: Patient self-management of long-term oral anticoagulation therapy is an effective strategy in a number of clinical situations, but it is currently not a funded option in the Canadian health care system. We sought to compare the incremental cost and health benefits of self-management with those of physician management from the perspective of the Canadian health care payer over a 5-year period. Methods: We developed a Bayesian Markov model comparing the costs and quality-adjusted life years (QALYs) accrued to patients receiving oral anticoagulation therapy through self-management or physician management for atrial fibrillation or for a mechanical heart valve. Five health states were defined: no events, minor hemorrhagic events, major hemorrhagic events, thrombotic events and death. Data from published literature were used for transition probabilities. Canadian 2003 costs were used, and utility estimates were obtained from various published sources. Results: Self-management resulted in 3.50 fewer thrombotic events, 0.78 fewer major hemorrhagic events and 0.12 fewer deaths per 100 patients than physician management. The average discounted incremental cost of self-management over physician management was found to be

Cost-Utility Analysis of Tissue Plasminogen Activator Therapy for Acute Ischaemic Stroke A Canadian Healthcare Perspective

989 (95% confidence interval [CI]

Comparison of a Weight-Based Heparin Nomogram with Traditional Heparin Dosing to Achieve Therapeutic Anticoagulation

310–

Clinical Impact of Point-of-Care vs Laboratory Measurement of Anticoagulation

1655) per patient and the incremental QALYs gained was 0.07 (95% CI 0.06–0.08). The cost-effectiveness of self-management was

Outpatient Self-Management of Warfarin Therapy: A Pilot Study

14 129 per QALY gained. There was a 95% chance that self-management would be cost-effective at a willingness to pay of

Amiodarone-induced Pulmonary Toxicity

23 800 per QALY. Results were robust in probabilistic and deterministic sensitivity analyses. Interpretation: This model suggests that self-management is a cost-effective strategy for those receiving long-term oral anticoagulation therapy for atrial fibrillation or for a mechanical heart valve.

Glycoprotein IIb/IIIa Inhibitors in Patients with End-Stage Renal Disease

AbstractBackground: There are over 40 000 ischaemic strokes annually in Canada, which result in significant morbidity, mortality and burden to the healthcare system. A recent, large clinical trial has evaluated tissue plasminogen activator (t-PA) intravenously for the treatment of acute ischaemic stroke with promising outcomes but with an increased risk of symptomatic intracranial haemorrhage. Objective: To compare clinical and economic outcomes of intravenous t-PA therapy (0.9 mg/kg, to a maximum of 90mg, initiated within 3 hours of stroke onset) versus no t-PA for acute ischaemic stroke based on the outcomes achieved in the National Institute of Neurological Disorders and Stroke (NINDS) trial. Design: A Markov model depicting the natural lifetime course after an initial acute ischaemic stroke. On the basis of this model, a simulated trial compared no t-PA with t-PA. Patients: A hypothetical cohort of 1000 patients with acute ischaemic stroke. Study perspective: Canadian healthcare system. Outcome measures: Total acute stroke and post-stroke treatment costs and cumulative quality-adjusted life-years (QALYs). Results: For a hypothetical cohort of 1000 patients, the estimated lifetime stroke costs were 103 100 000 Canadian dollars (

Is oral sotalol effective in converting atrial fibrillation to sinus rhythm

Can) [1999 values) in the t-PA arm (

A randomized trial of patient self-managed versus physician-managed oral anticoagulation

Can103 100 per patient) compared with