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Meta-Analysis
. 2023 Jul 10:25:e45922.
doi: 10.2196/45922.

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

Letícia Braga Ferreira  1   2 , Rodrigo Lanna de Almeida  3 , Alair Arantes  1 , Hebatullah Abdulazeem  4 , Ishanka Weerasekara  5   6 , Leticia Santos Dias Norberto Ferreira  2 , Luana Fonseca de Almeida Messias  1 , Luciana Siuves Ferreira Couto  7 , Maria Auxiliadora Parreiras Martins  8 , Núbia Suelen Antunes  9 , Raissa Carolina Fonseca Cândido  1   8 , Samuel Rosa Ferreira  1 , Tati Guerra Pezzini Assis  10 , Thais Marques Pedroso  1 , Eric Boersma  11 , Antonio Ribeiro  1   12 , Milena Soriano Marcolino  1   12
Affiliations
Meta-Analysis

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

Letícia Braga Ferreira et al. J Med Internet Res. .

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.

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Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1
Figure 1
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. RCT: randomized controlled trial.
Figure 2
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
Figure 3
Risk of bias in cluster randomized studies [17,19,41]. Green: low risk of bias; Yellow: unclear risk of bias.
Figure 4
Figure 4
Forest plot of the comparison: telemedicine interventions versus usual care. Outcome: total thromboembolic events.
Figure 5
Figure 5
Forest plot of the comparison: telemedicine interventions versus usual care. Outcome: major bleeding.
Figure 6
Figure 6
Forest plot of the comparison: telemedicine interventions versus usual care. Outcome: all-cause death.
Figure 7
Figure 7
Forest plot of the comparison: telemedicine interventions versus usual care. Outcome: time in therapeutic range.
See this image and copyright information in PMC

References

    1. Kornej J, Börschel CS, Benjamin EJ, Schnabel RB. Epidemiology of atrial fibrillation in the 21st century: novel methods and new insights. Circ Res. 2020;127(1):4–20. doi: 10.1161/CIRCRESAHA.120.316340. https://europepmc.org/abstract/MED/32716709 - DOI - PMC - PubMed
    1. Wendelboe AM, Raskob GE. Global burden of thrombosis: epidemiologic aspects. Circ Res. 2016;118(9):1340–1347. doi: 10.1161/CIRCRESAHA.115.306841.CIRCRESAHA.115.306841 - DOI - PubMed
    1. Yu AYX, Malo S, Svenson LW, Wilton SB, Hill MD. Temporal trends in the use and comparative effectiveness of direct oral anticoagulant agents versus warfarin for nonvalvular atrial fibrillation: a Canadian population-based study. J Am Heart Assoc. 2017;6(11):e007129. doi: 10.1161/JAHA.117.007129. https://www.ahajournals.org/doi/10.1161/JAHA.117.007129?url_ver=Z39.88-2... JAHA.117.007129 - DOI - PMC - PubMed
    1. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W, ESC/EACTS Scientific Document Group 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2022;43(7):561–632. doi: 10.1093/eurheartj/ehab395. https://hdl.handle.net/2268/291297 6358470 - DOI - PubMed
    1. Connolly SJ, Karthikeyan G, Ntsekhe M, Haileamlak A, El Sayed A, El Ghamrawy A, Damasceno A, Avezum A, Dans AML, Gitura B, Hu D, Kamanzi ER, Maklady F, Fana G, Gonzalez-Hermosillo JA, Musuku J, Kazmi K, Zühlke L, Gondwe L, Ma C, Paniagua M, Ogah OS, Molefe-Baikai OJ, Lwabi P, Chillo P, Sharma SK, Cabral TTJ, Tarhuni WM, Benz A, van Eikels M, Krol A, Pattath D, Balasubramanian K, Rangarajan S, Ramasundarahettige C, Mayosi B, Yusuf S, INVICTUS Investigators Rivaroxaban in rheumatic heart disease-associated atrial fibrillation. N Engl J Med. 2022;387(11):978–988. doi: 10.1056/NEJMoa2209051. - DOI - PubMed

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