International Journal of Clinical Pharmacy

, Volume 40, Issue 6, pp 1420–1429 | Cite as

The effect of online versus hospital warfarin management on patient outcomes: a systematic review and meta-analysis

  • Xiaotong Xia
  • Jianmei Wu
  • Jinhua ZhangEmail author
Review Article


Background Patients using oral anticoagulants are prone both to thrombus from insufficient anticoagulant therapy and to bleeding by overmedication, so there is a need for further exploring. Aim of the review To assess the effect of online management (using electronic communication such as smartphone), and hospital management on the outcome of patients on long-term anticoagulant therapy, and to explore an appropriate anticoagulation management model. Method Studies published in English prior to July 2017 were retrieved from PubMed, EMBASE, Web of Science, and the Cochrane Library. Two researchers screened the literature independently, extracted the data and evaluated the methodological quality of the included studies. Meta-analysis was conducted using RevMan 5.3 software. The publication bias analysis was evaluated. Results A total of ten studies met the inclusion criteria, covering 16,915 patients. Of these, 8260 cases formed the online anticoagulation management group, and the other 8655 cases the hospital anticoagulant management group. There were no significant differences between the management models for time in therapeutic range, incidence of major or minor bleeding events, thromboembolic events, or warfarin-related emergency department visits. However, online management was associated with fewer warfarin-related hospital admissions than hospital management (odds ratio: 0.47, 95% confidence interval [0.30, 0.73]; P = 0.0009). Conclusion The online management of anticoagulant therapy was not inferior to hospital management, and may provide more convenient, higher quality anticoagulant therapy services for patients.


Anticoagulation Hospital management Meta-Analysis Online management Systematic review 



This research was funded by the Natural Science Foundation of Fujian Province of China [grant number 2018Y0037].

Conflicts of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Zhang J, Liu M, Guan C, Tian H. Establishment and practice of online anticoagulation clinic. Chin Pharm J. 2014;49(16):1476–80.Google Scholar
  2. 2.
    Zang XZ, Liu DP. The significance and status of anticoagulation clinic. Chin J Cardiovasc Med. 2011;16(2):96.Google Scholar
  3. 3.
    Witt DM, Clark NP, Kaatz S, Schnurr T, Ansell JE. Guidance for the practical management of warfarin therapy in the treatment of venous thromboembolism. J Thromb Thrombolysis. 2016;41(1):187–205.CrossRefGoogle Scholar
  4. 4.
    Burkiewicz JS. Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation. Pharmacotherapy. 2005;25(8):1062–7.CrossRefGoogle Scholar
  5. 5.
    Ozkaynak M, Johnson SA, Tulu B, Donovan JL, Kanaan AO, Rose A. Exploring the effect of complex patients on care delivery tasks. Int J Health Care Qual Assur. 2015;28(5):494–509.CrossRefGoogle Scholar
  6. 6.
    Meade M, Borchert J, Griffin B, Kliethermes MA, Komperda K. Impact of health disparities on staff workload in pharmacistmanaged anticoagulation clinics. Am J Health Syst Pharm. 2011;68(15):1430.CrossRefGoogle Scholar
  7. 7.
    Cryder BT, Felczak MA, Darkwa A, Patel H, Janociak JD, Rihani R. Transition of stable patients from hospital anticoagulation clinic services to telephonic management. Int J Clin Pharm. 2017;39(3):569–72.CrossRefGoogle Scholar
  8. 8.
    Chiquette E, Amato MG, Bussey HI. Comparison of an anticoagulation clinic with usual medical care. Anticoagulation control, patient outcomes, and health care costs. Arch Intern Med. 1998;158(15):1641–7.CrossRefGoogle Scholar
  9. 9.
    Koertke H, Minami K, Bairaktaris A, Wagner O, Koerfer R. INR self-management following mechanical heart valve replacement. J Thromb Thrombolysis. 2000;9(Suppl 1):S41–5.CrossRefGoogle Scholar
  10. 10.
    Watzke HH, Forberg E, Svolba G, Jimenez-Boj E, Krinninger B. A prospective controlled trial comparing weekly self-testing and self-dosing with the standard management of patients on stable oral anticoagulation. Thromb Haemost. 2000;83(05):661–5.CrossRefGoogle Scholar
  11. 11.
    Taborski U, Muller-Berghaus G. State-of-the-art patient self-management for control of oral anticoagulation. Semin Thromb Hemost. 1999;25(01):43–7.CrossRefGoogle Scholar
  12. 12.
    Lafata JE, Martin SA, Kaatz S, Ward RE. Anticoagulation clinics and patient self-testing for patients on chronic warfarin therapy: a cost-effectiveness analysis. J Thromb Thrombolysis. 2000;9(1):13–9.CrossRefGoogle Scholar
  13. 13.
    Cromheecke ME, Levi M, Colly LP, de Mol BJ, Prins MH, Hutten BA, Mak R, Keyzers KC, Buller HR. Oral anticoagulation self-management and management by a specialist anticoagulation clinic: a randomised cross-over comparison. Lancet. 2000;356(9224):97–102.CrossRefGoogle Scholar
  14. 14.
    Wittkowsky AK, Nutescu EA, Blackburn J, Mullins J, Hardman J, Mitchell J, Vats V. Outcomes of oral anticoagulant therapy managed by telephone versus in-office visits in an anticoagulation clinic setting. Chest. 2006;130(5):1385.CrossRefGoogle Scholar
  15. 15.
    Stang A. Critical evaluation of the Newcastle–Ottawa Scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–5.CrossRefGoogle Scholar
  16. 16.
    Stoudenmire LG, DeRemer CE, Elewa H. Telephone versus office-based management of warfarin: impact on international normalized ratios and outcomes. Int J Hematol. 2014;100(2):119–24.CrossRefGoogle Scholar
  17. 17.
    Prochaska JH, Göbel S, Keller K, Coldewey M, Ullmann A, Lamparter H, Jünger C, Al-Bayati Z, Baer C, Walter U, Bickel C, ten Cate H, Münzel T, Wild PS. Quality of oral anticoagulation with phenprocoumon in regular medical care and its potential for improvement in a telemedicine-based coagulation service–results from the prospective, multi-center, observational cohort study thrombEVAL. BMC Med. 2015;13(1):14.CrossRefGoogle Scholar
  18. 18.
    Lee JC, Horner KE, Krummel ML, McDanel DL. Clinical and financial outcomes evaluation of multimodal pharmacist warfarin management of a statewide urban and rural population. J Pharm Pract. 2017;31(4):1–7.Google Scholar
  19. 19.
    Lin SW, Kang WY, Lin DT, Lee J, Wu FL, Chen CL, Tseng YJ. Comparison of warfarin therapy clinical outcomes following implementation of an automated mobile phone-based critical laboratory value text alert system. BMC Med Genomics. 2014;7(1):1–10.CrossRefGoogle Scholar
  20. 20.
    Staresinic AG, Sorkness CA, Goodman BM, Pigarelli DW. Comparison of outcomes using 2 delivery models of anticoagulation care. Arch Intern Med. 2006;166(9):997–1002.CrossRefGoogle Scholar
  21. 21.
    Blissit KT, Pharm D, Mullenix ML, Pharm D, Brittain KG, Pharm D, et al. Evaluation of time in therapeutic range on warfarin therapy between face-to-face and telephone follow-up in a VA medical center. J Pharm Technol. 2014;31(2):78–83.CrossRefGoogle Scholar
  22. 22.
    Salvador CH, Ruiz-Sanchez A, González de Mingo MA, Carmona Rodríguez M, Carrasco MP, Sagredo PG, et al. Evaluation of a telemedicine-based service for the follow-up and monitoring of patients treated with oral anticoagulant therapy. IEEE Trans Inf Technol Biomed. 2008;12(6):696–706.CrossRefGoogle Scholar
  23. 23.
    Witt DM, Sadler MA, Shanahan RL, Mazzoli G, Tillman DJ. Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy. Chest. 2005;127(5):1515–22.CrossRefGoogle Scholar
  24. 24.
    Wasson J, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch HG. Telephone care as a substitute for routine clinic follow-up. JAMA. 1992;267(13):1788–93.CrossRefGoogle Scholar
  25. 25.
    Waterman AD, Milligan PE, Banet GA, Gatchel SK, Gage BF. Establishing and running an effective telephone-based anticoagulation service. J Vasc Nurs. 2001;19(4):126–33.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Fujian Medical University Union HospitalFuzhouChina

Personalised recommendations