Table 1 Summary of results for all research questions
Research question | Summary of findings | Risk of bias in the primary evidencea |
|---|---|---|
RQ1 (a) Efficacy of warfarin versus direct OACs in different patient cohorts? | For AF, direct OACs were more effective and safer than usual care, and apixaban 5Â mg twice daily had the best profile. For VTE, overall, direct OACs were no better than low-molecular-weight heparin (prevention in hip or knee surgery), warfarin (treatment), and warfarin or aspirin (secondary prevention) | Overall, low risk of bias. Some outcomes had low, high, or unclear risks Few direct comparisons |
RQ2 (b) Complications associated with warfarin and direct OACs, including bleeding and stroke risk? | ||
RQ1 (b) The evidence for an optimised pathway on genotyping? | One review found no difference between genotype-guided warfarin dosing and direct OACs for stroke prevention in patients with AF. Systematic reviews of genotype-guided dosing for direct OACs, in patients with AF or VTE are needed | Very low to moderate quality (GRADE). The most common flaw was a lack of blinding |
RQ1 (c) The evidence for an optimised pathway on self-monitoring? | In patients with AF, education with or without a decision aid improved time in therapeutic range, while self-monitoring and self-testing made little difference. Evidence was lacking for patients with VTE | Low-to-moderate or uncertain quality |
RQ2 (a) Safety relating to renal function and the long-term use of direct OACs? | Several reviews were identified and are listed in Additional file 5 | Not applicable |
RQ3 (a) The impact of direct OACs and warfarin on patient lifestyle? | Patients were more satisfied with pharmacist management, and with direct OACs, than with usual care | The quality of the primary studies varied |
RQ3 (b) Medicines adherence and compliance of direct OACs and warfarin? | For patients, it seems that knowledge, past experience, disease-related issues, and support needs influence OAC choices and adherence. Adherence was better with direct OACs than with warfarin | |
RQ3 (c) Clinician perceptions of direct OACs and warfarin? | Efficacy was the main driver of the choice of OAC, followed by safety, except for geriatricians, where safety was more important than efficacy | |
RQ3 (d) Monitoring INRs in patients receiving vitamin K antagonists and the effect on patient adherence? | Pharmacist management could improve time in therapeutic range, compared with usual primary care | Low-, uncertain-, and high-quality evidence |