Telemedicine-Based Management of Oral Anticoagulation Therapy: Systematic Review and Meta-analysis

Abstract

Background: Oral anticoagulation is the cornerstone treatment of several diseases. Its management is often challenging, and different telemedicine strategies have been implemented to support it.

Objective: The aim of the study is to systematically review the evidence on the impact of telemedicine-based oral anticoagulation management compared to usual care on thromboembolic and bleeding events.

Methods: Randomized controlled trials were searched in 5 databases from inception to September 2021. Two independent reviewers performed study selection and data extraction. Total thromboembolic events, major bleeding, mortality, and time in therapeutic range were assessed. Results were pooled using random effect models.

Results: In total, 25 randomized controlled trials were included (n=25,746 patients) and classified as moderate to high risk of bias by the Cochrane tool. Telemedicine resulted in lower rates of thromboembolic events, though not statistically significant (n=13 studies, relative risk [RR] 0.75, 95% CI 0.53-1.07; I²=42%), comparable rates of major bleeding (n=11 studies, RR 0.94, 95% CI 0.82-1.07; I²=0%) and mortality (n=12 studies, RR 0.96, 95% CI 0.78-1.20; I²=11%), and an improved time in therapeutic range (n=16 studies, mean difference 3.38, 95% CI 1.12-5.65; I²=90%). In the subgroup of the multitasking intervention, telemedicine resulted in an important reduction of thromboembolic events (RR 0.20, 95% CI 0.08-0.48).

Conclusions: Telemedicine-based oral anticoagulation management resulted in similar rates of major bleeding and mortality, a trend for fewer thromboembolic events, and better anticoagulation quality compared to standard care. Given the potential benefits of telemedicine-based care, such as greater access to remote populations or people with ambulatory restrictions, these findings may encourage further implementation of eHealth strategies for anticoagulation management, particularly as part of multifaceted interventions for integrated care of chronic diseases. Meanwhile, researchers should develop higher-quality evidence focusing on hard clinical outcomes, cost-effectiveness, and quality of life.

Trial registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020159208; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=159208.

Keywords: DOACs; anticoagulation; atrial fibrillation; eHealth; telemedicine; warfarin.

Figure 1

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. RCT: randomized controlled trial.

Figure 2

Risk of bias in individual randomized studies [7-9,20-38]. Green: low risk of bias; Red: high risk of bias; Yellow: unclear risk of bias.

Figure 3

Risk of bias in cluster randomized studies [17,19,41]. Green: low risk of bias; Yellow: unclear risk of bias.

Figure 4

Forest plot of the comparison: telemedicine interventions versus usual care. Outcome: total thromboembolic events.

Figure 5

Forest plot of the comparison: telemedicine interventions versus usual care. Outcome: major bleeding.

Figure 6

Forest plot of the comparison: telemedicine interventions versus usual care. Outcome: all-cause death.

Figure 7

Forest plot of the comparison: telemedicine interventions versus usual care. Outcome: time in therapeutic range.