Meta-Analysis to Assess the Quality of Warfarin Control in Atrial Fibrillation Patients in the United States
Meta-Analysis to Assess the Quality of Warfarin Control in Atrial Fibrillation Patients in the United States
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DOI：
10.18553/jmcp.2009.15.3.244
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发表时间：
2009-04-01
影响因子：
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通讯作者：
Coleman, Craig I.
中科院分区：
文献类型：
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作者：
Baker, William L.;Cios, Deborah A.;Coleman, Craig I.
背景：房颤（AF）影响了相当大比例的美国人群，使缺血性卒中风险增加4- 5倍。口服维生素K拮抗剂，如华法林，可以显著降低中风风险，但难以剂量和监测。以往关于环境（如随机对照试验、专科诊所的抗凝管理、社区医生的常规护理）对国际标准化比率（INR）治疗范围内时间比例的影响的研究没有专门研究房颤患者的抗凝。目的：使用传统的荟萃分析和荟萃回归技术来评估专科诊所与社区医生的常规护理对抗凝控制的影响，以在治疗INR范围内花费的时间比例来衡量，在美国接受华法林抗凝治疗的房颤患者。方法：先前发表的荟萃分析（van Walraven et al., 2006）系统地检索了1987年至2005年之间的报告，其中包括的研究也被筛选纳入我们的分析。从2005年1月到2008年2月，对MEDLINE、EMBASE和Cochrane临床试验中心进行了系统的文献检索。纳入研究的条件是：(a)包含至少1个华法林治疗组，包括超过25名患者，其INR控制监测至少3周；(b)纳入在美国接受房颤治疗的患者；(c)采用患者-时间（患者-年）方法报告结果；(d)报告了在传统治疗INR范围内花费的时间比例的数据（即，下限INR在1.8至2.0之间，上限INR在3.0至3.5之间）。INR目标超出此范围的研究被排除在外)。每个研究组在治疗INR范围内花费的时间比例使用人-时间方法（以年为单位）表示为发病率密度。所有的研究都使用随机效应模型进行汇总，并以治疗范围内花费的时间比例方差的倒数进行加权。为了确定研究环境如何影响在治疗INR范围内花费的时间比例，进行了亚组和荟萃回归分析。结果：本分析纳入8项研究，共14个华法林治疗组；8项研究中有3项和4个华法林组未纳入先前的荟萃分析（van Walraven et al., 2006）。总体而言，患者在治疗INR范围内平均花费55% （95% CI = 51%-58%）的时间。荟萃回归表明，与抗凝诊所相比，在社区常规护理机构接受治疗的房颤患者在治疗范围内的时间缩短了11% （95% CI =2%-20%, n=6项研究，9个研究组）。结论：在美国，房颤患者在治疗性INR内的时间仅为一半左右。与标准社区护理相比，抗凝门诊服务与更好的INR控制相关。
BACKGROUND: Atrial fibrillation (AF) affects a significant proportion of the American population and increases ischemic stroke risk by 4- to 5-fold. Oral vitamin K antagonists, such as warfarin, can significantly reduce this stroke risk but can be difficult to dose and monitor. Previous research on the effects of setting (e.g., randomized controlled trials, anticoagulation management by specialty clinics, usual care by community physicians) on the proportion of time spent within therapeutic range for the international normalized ratio (INR) has not specifically examined anticoagulation in AF patients.OBJECTIVES: Use traditional meta-analytic and meta-regressive techniques to evaluate the effect of specialty clinic versus usual care by community physicians on anticoagulation control, measured as the proportion of time spent in therapeutic INR range, for AF patients that received warfarin anti coagulation in the United States.METHODS: Studies included in a previously published meta-analysis (van Walraven et al., 2006), which systematically searched reports between 1987 and 2005, were also screened for inclusion in our analysis. A subsequent systematic literature search of MEDLINE, EMBASE, and the Cochrane Central Register of Clinical Trials from January 2005 through February 2008 was conducted. Studies were included if they (a) contained at least 1 warfarin-treated group including more than 25 patients for whom INR control was monitored for at least 3 weeks; (b) included patients treated for AF in the United States; (c) used a patient-time approach (patient-year) to report outcomes; and (d) reported data on the proportion of time spent in traditional therapeutic INR ranges (i.e., a lower limit INR between 1.8 and 2.0 and an upper limit INR between 3.0 and 3.5. Studies with INR goals outside this range were excluded). The proportion of time spent within the therapeutic INR range for each study group was expressed as an incidence density using a person-time approach (in years). All studies were pooled using a random effects model and were weighted by the inverse of the variance of proportion of time spent in the therapeutic range. In order to determine how study setting influenced the proportion of time spent within a therapeutic INR range, both subgroup and meta-regression analyses were conducted.RESULTS: This analysis included 8 studies and a total of 14 unique warfarin-treated groups; 3 of the 8 studies and 4 of the warfarin groups were not included in the previous meta-analysis (van Walraven et al., 2006). Overall, patients spent a mean 55% (95% CI = 51%-58%) of their time in the therapeutic INR range. Meta-regression suggested that AF patients treated in a community usual care setting compared with an anticoagulation clinic spent 11% (95% CI =2%-20%, n=6 studies with 9 study groups) less time in range.CONCLUSIONS: In the United States, AF patients spend only about one-half the time within therapeutic INR. Anticoagulation clinic services are associated with somewhat better INR control compared with standard community care.