Developing an anticoagulation composite measure: a stronger predictor for warfarin associated complications and a more comprehensive performance measure for anticoagulation clinics

Thesis (M.S.H.P.) PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at [email protected]. Thank you.BACKGROUND: Percent time in therapeutic range (TTR) and INR variability are both used to measure anticoagulation control with warfarin. TTR measures anticoagulation intensity, while INR variability measures anticoagulation stability; both predict definitive clinical outcomes such as stroke, major hemorrhage. Here, we examine whether an intermediate composite measure (ICOMO) predicts warfarin associated complications better than each measure separately. We also examine how the choice of measure changes the ranking order of anticoagulation clinics (ACCs) in the Veterans Health Administration (VHA) healthcare system. METHODS: We calculated TTR and INR variability for the study sample (N=130,897 patients) from 100 VHA ACCs. We constructed ICOMO using an equally weighted method, adding standardized TTR to standardized log-transformed INR variability. We used a subset of patients anticoagulated for atrial fibrillation (N=40,404) and divided them into quintiles based on their level of control, for each anticoagulation measure. We calculated the Hazard ratios for ischemic stroke and major bleeding and compared the ability of our independent variables (TTR, log INR variability, ICOMO) to predict each outcome. We measured mean observed value (O) and mean expected value (E) for each clinic, after adjusting for important clinical and demographic variables, for each anticoagulation measure. We identified outlier anticoagulation clinics if O was one standard deviation different from its corresponding E. We measured Kappa score and Pearson correlation coefficients when ranking sites according to each anticoagulation measure. RESULTS: ICOMO predicted ischemic stroke better than TTR and log INR variability in all quintiles. ICOMO and TTR predicted major bleeding similarly except in the second-best quintile; but both measures were better than log INR variability in all quintiles. Kappa scores identifying outlier and non-outlier clinics among our three profiling measures were moderate between ICOMO and its components (0.59 for TTR and 0.54 for log INR variability) but was weak between TTR and log INR variability (0.025) CONCLUSION: ICOMO predicts ischemic stroke better over TTR and log INR variability alone but it is only better than the latter in predicting major bleeding. The choice of which measure to use for clinic profiling changes clinic rankings considerably.2031-01-0

Clinical Factors Associated with Non-Obese Nonalcoholic Fatty Liver Disease Detected among US Adults in the NHANES 2017–2018

NAFLD can occur in non-obese individuals with BMI 2. Our goal was to examine the prevalence and clinical factors associated with non-obese NAFLD using vibration-controlled transient elastography (VCTE) with controlled attenuation parameter which estimates steatosis and fibrosis among US adults. We aggregated data from the 2017–2018 cycle of NHANES and included adults (age ≥ 20 years) with BMI 2 with complete data for the survey, medical examination, and VCTE along with controlled attenuation parameter (CAP). We excluded participants with risks of other liver diseases. We considered patients to have non-obese NAFLD if CAP was >285 dB/m, or non-obese NAFLD fibrosis if this CAP criteria was met and liver stiffness was >8.6 kPa. We calculated the adjusted OR and 95% CI for associations with non-obese NAFLD using multivariable logistic regression. The prevalence of non-obese NAFLD was 6.2% and Asian Americans (12.2%) had the highest non-obese NAFLD prevalence. Clinical factors associated with non-obese NAFLD were advanced age and metabolic syndrome (ORadjusted = 6.8, 95% CI 3.0–15.5). In a separate model, we found elevated glucose (ORadjusted = 4.1, 95% CI 2.1–7.9), triglycerides (ORadjusted = 3.8, 95% CI 1.7–8.5), and truncal fat (100-unit increase ORadjusted = 1.07, 95% CI: 1.04–1.10) were associated with higher odds of non-obese NAFLD. Meanwhile, low physical activity (ORadjusted = 2.9, 95% CI 1.2–7.1) was also positively associated with non-obese NAFLD. Non-obese NAFLD is prevalent in the US and is highly associated with metabolic conditions and syndrome. Our results support the importance of considering racial/ethnic differences when investigating NAFLD in a clinical setting

Anticoagulation reversal in vitamin K antagonist–associated intracerebral hemorrhage: a systematic review

The effect of rapid anticoagulation reversal on mortality and functional outcome in vitamin K antagonist–associated intracerebral hemorrhage (VKA–ICH) is uncertain. Given the approval of idarucizumab for dabigatran reversal and pending approval for andexanet alfa for reversal of factor Xa inhibitors, a systematic appraisal of the effectiveness of reversal for VKA–ICH would provide a bench mark for current practice. We performed PubMed searches and reviewed current guidelines. Using pre-specified inclusion and exclusion criteria, studies were reviewed by two physicians independently. Data elements abstracted included study design, sample size, inclusion and exclusion criteria; patient characteristics at presentation; time to presentation and therapy; dose and timing of warfarin reversal agents; functional outcome and mortality. Studies were assessed for risk of bias. Twenty-one studies met the selection criteria. The overall quality of the studies was poor with small sample size for the majority and all studies being either case series or retrospective observational in design. Inclusion criteria were not uniform. Interpretation of the effectiveness of vitamin K antagonist reversal on functional outcome was not feasible due to lack of standard protocols in the management of VKA–ICH including choice, dose, and timing of reversal agent, timing of subsequent INR monitoring, and decision for repeat imaging. Confounding by indication, lack of universal reporting of functional outcome, and use of varied scales for the endpoint further limited a summary interpretation. Despite availability of reversal agents, mortality and morbidity remain high following VKA–ICH. Evidence for improvement in neurological outcome is limited

Additional file 1: of Organizational factors associated with Health Care Provider (HCP) influenza campaigns in the Veterans health care system: a qualitative study

Interview guide for the key informants of the health care provider influenza vaccination project. (DOCX 18 kb