A regional anticoagulation program improves safety and outcomes for both children and adults

J Thromb Thrombolysis. 2023 Jul;56(1):27-36. doi: 10.1007/s11239-023-02806-w. Epub 2023 Apr 24.

Abstract

Background: Evidence-based anticoagulation programs usually serve a local, adult patient population. Here we report outcomes for a regional combined pediatric-adult program.

Aims: The aims of this study were: (1) Compare the pre- vs. post-implementation quality of therapy (% time in therapeutic range (%TTR) and compliance). (2) Assess anticoagulant-relevant outcomes (bleeding and thrombotic complications).

Methods: Data were collected for the years 2014-2019. Rosendaal linear interpolation was used to calculate %TTR. Bleeding complications were categorized using ISTH-SSC standard nomenclature and new thrombotic events were reviewed.

Results: The patients were divided into a long-term warfarin group (N = 308), 80.2% of whom had cardiac-related therapeutic indications (median age 24y), and a second group (N = 114) comprised of short-term and non-warfarin long-term anticoagulation (median age 16y). Median %TTR for those on long-term warfarin was 78.9%. The incidence of major and clinically relevant non-major bleeding events was 1.65 and 2.43 /100 person-years of warfarin use, respectively. Thromboembolism (TE) incidence was 0.78/100 patient-years of warfarin use. Neither bleeding nor thrombosis was associated with %TTR (p = 0.48). Anticoagulant indication was the only variable associated with bleeding risk (p = 0.005). The second group had no on-therapy TE events but 7.9% experienced bleeding. Complete data were available for a randomly sampled pre-program warfarin group (N = 26). Median %TTR improved from 17.5 to 87% pre- vs. post-implementation. Similarly, compliance (defined as ≥ 1 INR/month) improved by 34.3%.

Conclusions: In conclusion, this program significantly improved and sustained %TTR and compliance. The lack of association between bleeding and thrombosis events and %TTR may be related to the high median %TTR (> 70%) achieved by this approach.

Keywords: Anticoagulation; Bleeding; Outcomes; Thrombosis; Time in therapeutic range.

MeSH terms

  • Adolescent
  • Adult
  • Anticoagulants / adverse effects
  • Blood Coagulation
  • Child
  • Hemorrhage / chemically induced
  • Hemorrhage / drug therapy
  • Humans
  • International Normalized Ratio
  • Thromboembolism* / drug therapy
  • Thrombosis* / drug therapy
  • Treatment Outcome
  • Warfarin / adverse effects
  • Young Adult

Substances

  • Warfarin
  • Anticoagulants