| Disparities in anticoagulation care across the spectrum Sara Vasquez. |
Abstract
A disparity is a "noticeable and usually significant difference or dissimilarity," and these can occur across the spectrum of anticoagulation care. There are known differences in the epidemiology of venous thromboembolism (VTE), such as higher risk of VTE with age, and with women earlier in life, men later in life, and higher risk of VTE in patients identifying as Black race. The goal of the 2014 National Action Plan for Adverse Drug Event (ADE) prevention, targeting anticoagulants, was to identify patients at higher risk of anticoagulant-induced ADEs so that targeted strategies can be developed to improve safety. The spectrum of anticoagulation care includes access to therapy, quality of therapy, and the humanistic outcome of therapy. Patients identifying with non-White racial groups may receive direct oral anticoagulants (DOACs) as first-line therapy less often than other groups. Education and patient satisfaction with service may improve anticoagulation treatment persistence. At-risk groups for receiving off-label DOAC dosing include patients of advanced age, Black race, and extremes of body weight. At-risk groups for poorer quality of INR control with warfarin include women and Black race. It is well-established that patients performing patient self-testing and/or self-management of the INR have better clinical outcomes compared to standard management. However, uptake of patient self-testing is generally poor. Groups of anticoagulated patients at-risk for lower quality of life and lower treatment satisfaction include women and older age. Limited health literacy correlates with a higher anticoagulation treatment burden. DOACs improve quality of life and treatment satisfaction for most patients, especially those in rural geographic regions. Strategies to eliminate disparities include assessing one's own practice for anticoagulation care disparities, using education as a foundation for improved adherence and persistence, which then can improve the quality of care, satisfaction, and quality of life. Additionally, creating processes and care pathways and systematically implementing them can ensure equitable treatment. Finally, a population health approach can be utilized to target at-risk groups for intervention to ensure optimal quality of care.
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