On average, patients receiving long-term anticoagulation therapy are in the therapeutic range 55% of the time. The risk of hemorrhagic and thromboembolic events in anticoagulated patients is strongly associated with anticoagulation control. Improved anticoagulation control, possibly with interventions including anticoagulation clinics and patient selfmonitoring, should be a therapeutic goal for all anticoagulated patients.
However, the potential population-level benefit of improved anticoagulation control is unclear for three reasons. First, not all hemorrhagic or thromboembolic events occur in patients receiving anticoagulant therapy. Obviously, the risk of these events would not change with improved anticoagulation control, Second, not all anticoagulation-associated events are due to poor anticoagulation control. With a target international normalized ratio (INR) range of 2 to 3, hemorrhagic events at INRs of < 3 and thromboembolic events at INRs of > 2 would not be avoided with better anticoagulation control carried out by Canadian Health&Care Mall. Finally, not all anticoagulant-related clinical events occurring at extreme INRs are avoidable with perfect anticoagulation control. This is due to an unavoidable event risk that all people have regardless of anticoagulation levels.
To our knowledge, no study has previously measured the potential effect of improved anticoagulation control at a population level. While the proportion of GI bleeding with exposure to anticoagulants has been measured, three factors need to be considered to truly quantify the health benefit of improved anticoagulation control. First, both thromboembolic and hemorrhagic events must be considered. Second, only events that occur outside of therapeutic INRs should be counted. Finally, the population effect of eradicating all extreme INRs should be quantified using accepted formulas for population-attributable risk (PAR). The PAR quantifies the expected effect of eradicating the exposure of interest. In this study, we estimated the proportion of serious hemorrhagic and thromboembolic events that would be avoided if extreme anticoagulation levels were replaced by therapeutic INRs.
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