Overcoming Barriers to Warfarin Patient Self-Management (PSM) in the US Healthcare System: Implementation Trial Study Protocol.

Introduction: Warfarin is a narrow therapeutic index drug that requires frequent monitoring using the international normalized ratio (INR). Current clinic-based INR monitoring models lead to suboptimal warfarin management. Warfarin patient self-management (PSM) has consistently demonstrated superior efficacy compared to clinic-based management but is virtually unused in the US healthcare system.

Assessing the sex-based enrollment gap in urologic oncology clinical trials.

Introduction: Clinical trials should reflect the population affected by the disease under study. While urologic cancers occur more frequently in men, there is still a substantial incidence in women. Ensuring representative enrollment by sex is crucial for trial generalizability, as treatment efficacy and safety may vary between men and women.

Outcomes of Oral Anticoagulation with Concomitant NSAID Use: A Registry Based Cohort Study.

Background: Concomitant use of oral anticoagulants (OACs) and nonsteroidal anti-inflammatory drugs (NSAIDs) is common despite concerns about increased bleeding risk. We sought to assess the frequency of co-administering NSAIDs for patients on OAC and the impact on clinical outcomes.

Methods: We conducted a multicenter registry-based cohort study, utilizing 4:1 propensity score matching to compare patients on OAC monotherapy to those on OAC+NSAIDs therapy between 2011 and 2023 at six anticoagulation clinics of the Michigan Anticoagulation Quality Improvement Initiative.

Identifying and addressing underuse in hematologic care through systems-based hematology.

Underuse of high-value hematologic care receives comparatively less attention than the overuse of unnecessary tests and treatments. In this review, we analyze examples of underutilized care in several domains: procedural (inferior vena cava filter retrieval), medical (hydroxyurea use in sickle cell anemia), and patient-facing (education prior to anticoagulation). For each, we justify the need for increased uptake and highlight examples of systems-based hematology interventions to accomplish this.

Pulmonary Embolism Response Teams.

Pulmonary embolism response teams (PERT) were developed to facilitate pulmonary embolism risk stratification and management through a multidisciplinary and structured approach focused on rapid and effective decision-making. The PERT model involves multiple specialties and incorporates various available therapies. While there are mixed outcomes reported in the literature, major cardiovascular guidelines recommend the implementation of PERT for intermediate to high-risk patients.

A qualitative evaluation of barriers and facilitators to a large-scale antithrombotic stewardship intervention in the United States Veterans Healthcare system.

Background: The combined use of antiplatelet medications with direct oral anticoagulants increases patients' risk of hemorrhage. In 2021, a multistate network of Veterans Affairs medical centers in the United States deployed a successful multicomponent stewardship initiative to reduce inappropriate anticoagulant-antiplatelet therapy.

Aim: Identify barriers, facilitators, and potential adaptations of the initiative to guide broader dissemination.

Review of venous thromboembolism (VTE) risk, evaluation, and treatment in individuals on estrogen-based gender-affirming hormone therapy.

Epidemiological studies of transgender women suggest that these individuals experience higher rates of venous thromboembolism than their cisgender peers. Several factors likely increase this risk, including medication use, comorbidities, and social determinants of health. Estrogen-based gender-affirming hormone therapy is critical for helping patients address unwanted secondary sexual characteristics and induce physical changes in accordance with their gender identity.

An Intervention to Reduce Antiplatelet Use without Gastroprotection in Patients Using Warfarin: The AEGIS Cluster Randomized Trial.

Many patients receiving anticoagulants take antiplatelet medications unnecessarily and without gastroprotection, increasing the risk of gastrointestinal bleeding.To evaluate the effectiveness of a multicomponent intervention-clinician notification with nurse facilitation (CNNF)-in reducing high-risk use of antiplatelet medications in patients taking warfarin without a proton pump inhibitor (PPI).For patients in the CNNF group, nurses sent electronic messages to clinicians identifying patients with high-risk antiplatelet use, recommending consideration of either antiplatelet discontinuation or PPI initiation, and offering to facilitate any medication changes.

A Comparison of Outcomes With Apixaban, Rivaroxaban, and Warfarin for Atrial Fibrillation and/or Venous Thromboembolism.

Background: Apixaban and rivaroxaban are commonly used direct oral anticoagulants for atrial fibrillation (AF) and venous thromboembolism (VTE). Both have been compared to warfarin, but there are insufficient comparative outcome data.

Objectives: The purpose of this study was to assess outcomes of apixaban, rivaroxaban, and warfarin.

A Web-Based Tool to Perform a Values Clarification for Stroke Prevention in Patients With Atrial Fibrillation: Design and Preliminary Testing Study.

Background: Atrial fibrillation (AF) is associated with an increased risk of stroke. Oral anticoagulation (OAC) is used for stroke prevention in AF, but it also increases bleeding risk. Clinical guidelines do not definitively recommend for or against OAC for patients with borderline stroke risk.

Evaluation of Information About Cardiovascular Implications of Gender-Affirming Care From Online Chat-based Artificial Intelligence Systems.

Because of restrictive laws in multiple states for gender-affirming care, patients might be prompted to get recommendations from contemporary online chatbots. This study explored the appropriateness of such recommendations using validated tools to assess patient education materials by a team of LGBTQ-affirming cardiologists. The study showed that although all systems emphasize the need for multidisciplinary care, there were notable differences in the comprehensiveness, cultural appropriateness, and presentation of their responses.

A stepped wedge cluster randomized implementation trial to increase outpatient management of low-risk pulmonary embolism from the emergency department - the MEDIC ALERT PE study.

Background: Home-based care for patients diagnosed in emergency departments (EDs) with low-risk pulmonary embolism (PE) is an evidence-based, guideline-recommended practice that is not widely adopted in the US. Few studies demonstrate how this care pathway can be implemented effectively or test whether implementation strategies can address known barriers. Further, prior studies have lacked diversity in population and health system type and did not integrate theory-informed implementation frameworks.

In adults treated with OACs after a first VTE, NSAID use was linked to increased risk for bleeding.

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Implementation of an enhanced medication access workflow within a health-system specialty pharmacy: Impact on patient and clinician experience.

Purpose: The initiation of specialty medications is associated with patient access challenges and clinician burden. This evaluation assessed the impact on patient and clinician experience of an intervention to improve medication access by investing resources upstream of the prescribing step.

Methods: The specialty pharmacy intervention was designed to improve medication access within 5 medical specialty clinics by utilizing an embedded medication access team assigned to patients and prescribers of targeted medications.

Experiences of Lesbian, Gay, Bisexual, Transgender, and Queer Cardiology Physicians and Fellows in Training.

Background: The number of practicing lesbian, gay, bisexual, transgender, and queer (LGBTQ+) cardiologists is unknown despite diversity initiatives focused on understanding workforce demographics.

Objectives: The aim of this study was to evaluate the prevalence, sources of mistreatment, and measures of wellness among the LGBTQ+ cardiology community.

Methods: An online survey was sent to the American College of Cardiology Fellow in Training and Early Career Professional Listservs and shared on social media sites.

Performance of an Electronic Health Record-Based Automated Pulmonary Embolism Severity Index Score Calculator: Cohort Study in the Emergency Department.

Background: Studies suggest that less than 4% of patients with pulmonary embolisms (PEs) are managed in the outpatient setting. Strong evidence and multiple guidelines support the use of the Pulmonary Embolism Severity Index (PESI) for the identification of acute PE patients appropriate for outpatient management. However, calculating the PESI score can be inconvenient in a busy emergency department (ED).

Disparities in 180-day infection rates following coronary artery bypass grafting and aortic valve replacement.

Objective: The study objective was to compare sex and racial differences in 180-day infection rates after coronary artery bypass grafting and aortic valve replacement.

Methods: A statewide Society of Thoracic Surgeons Adult Cardiac Surgery Database was linked to Medicare claims data to identify 8887 beneficiaries undergoing coronary artery bypass grafting and aortic valve replacement (surgical or transcatheter) between 2017 and 2021. The primary outcome was the incidence of 180-day infection.

Effectiveness of shared decision making strategies for stroke prevention among patients with atrial fibrillation: cluster randomized controlled trial.

Objective: To evaluate the effectiveness of multiple decision aid strategies in promoting high quality shared decision making for prevention of stroke in patients with non-valvular atrial fibrillation.

Design: Cluster randomized controlled trial.

Setting: Six academic medical centers in the United States.

A Practical Clinical Approach to Navigate Pulmonary Embolism Management: A Primer and Narrative Review of the Evolving Landscape.

Advances in imaging, pharmacological, and procedural technologies have rapidly expanded the care of pulmonary embolism. Earlier, more accurate identification and quantification has enhanced risk stratification across the spectrum of the disease process, with a number of clinical tools available to prognosticate outcomes and guide treatment. Direct oral anticoagulants have enabled a consistent and more convenient long-term therapeutic option, with a greater shift toward outpatient treatment for a select group of low-risk patients.

Factors in Initial Anticoagulation Choice in Hospitalized Patients With Pulmonary Embolism.

Importance: Despite guideline recommendations to use low-molecular-weight heparins (LMWHs) or direct oral anticoagulants in the treatment of most patients with acute pulmonary embolism (PE), US-based studies have found increasing use of unfractionated heparin (UFH) in hospitalized patients.

Objective: To identify barriers and facilitators of guideline-concordant anticoagulation in patients hospitalized with acute PE.

Design, Setting, And Participants: This qualitative study conducted semistructured interviews from February 1 to June 3, 2024, that were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis.