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• W1889849240 abstract "9See also Biss TT, Avery PJ, Walsh PM, Kamali F. Comparison of `time within therapeutic INR range' with 'percentage INR within therapeutic range' for assessing long‐term anticoagulation control in children. J Thromb Haemost 2011; : 1090–2; Biss TT, Avery PJ, Walsh PM, Kamali F. Comparison of time within therapeutic INR range with percentage INR within therapeutic range for assessing long‐term anticoagulation control in children: reply to a rebuttal. This issue, pp 2332–3. See also Biss TT, Avery PJ, Walsh PM, Kamali F. Comparison of `time within therapeutic INR range' with 'percentage INR within therapeutic range' for assessing long‐term anticoagulation control in children. J Thromb Haemost 2011; : 1090–2; Biss TT, Avery PJ, Walsh PM, Kamali F. Comparison of time within therapeutic INR range with percentage INR within therapeutic range for assessing long‐term anticoagulation control in children: reply to a rebuttal. This issue, pp 2332–3. We read with interest the letter by Biss et al. entitled ‘Comparison of “time within therapeutic INR range” with “percentage INR within therapeutic range” for assessing long‐term anticoagulation control in children’ [1Biss T.T. Avery P.J. Walsh P.M. Kamali F. Comparison of ‘time within therapeutic INR range’ with ‘percentage INR within therapeutic range’ for assessing long‐term anticoagulation control in children.J Thromb Haemost. 2011; 9: 1090-2Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar]. With respect to this letter, we wish to raise two points. First, Biss et al. reported two rates of target therapeutic range achievement based on linear interpolation and the ‘traditional’ percentage of INRs within the therapeutic range. The use of both methods produced rates of target range achievement lower than in several recent reports of pediatric warfarin management [2Bauman M.E. Black K. Kuhle S. Wang L. Legge L. Callen‐Wicks D. Mitchell L. Bajzar L. Massicotte M.P. KIDCLOT: the importance of validated educational intervention for optimal long term warfarin management in children.Thromb Res. 2009; 123: 707-9Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 3Bradbury M.J. Taylor G. Short P. Williams M.D. A comparative study of anticoagulant control in patients on long‐term warfarin using home and hospital monitoring of the international normalised ratio.Arch Dis Child. 2008; 93: 303-6Crossref PubMed Scopus (28) Google Scholar]. The disparity between the methods used calls into question the statement made by the authors that point‐of‐care (POC) monitoring, as used in their study, will improve anticoagulation control. Although the positive contribution of POC warfarin monitoring for children is undeniable, we believe that it is overly simplistic to state that this intervention alone will improve target therapeutic range achievement. As has been widely reported, warfarin management in children is problematic, for many reasons [4Jones S. Newall F. Manias E. Monagle P. Assessing outcome measures of oral anticoagulation management in children.Thromb Res. 2011; 127: 75-80Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 5Monagle P. Chalmers E. Chan A. de Veber G. Kirkham F. Massicotte M.P. Michelson A.D. Antithrombotic therapy in neonates and children in the American College of Chest Physicians evidence‐based practice guidelines (8th Edition).Chest. 2008; 133: 887S-968SAbstract Full Text Full Text PDF PubMed Scopus (569) Google Scholar, 6Newall F. Savoia H. Campbell J. Monagle P. Anticoagulation clinics for children achieve improved warfarin management.Thromb Res. 2004; 114: 5-9Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 7Streif W. Andrew M. Marzinotto V. Massicotte M.P. Chan A. Julian J.A. Mitchell L. Analysis of warfarin therapy in pediatric patients: a prospective cohort study of 319 patients.Blood. 1999; 94: 3007-14Crossref PubMed Google Scholar]. Only through the development of robust models of care incorporating patient education, patient/family engagement and clinical expertise can real improvements be made in the safety and efficacy of warfarin management within pediatric populations. The second point that we wish to raise relates to the statistical methods that we employ to overcome the primary limitations of traditional reporting of the percentage of target INR achievement. By using cluster analysis and partitioning methods [8Norman G.R. Streiner D.L. PDQ Statistics. 3rd edn. BC Decker, 2003Google Scholar] to determine the percentage of target range achievement, one can nullify the impact of some patients requiring more frequent INRs because of warfarin instability, who would otherwise skew the data. We first used this method in 2004 [9Newall F. Monagle P. Johnston L. Home INR monitoring of oral anticoagulant therapy in children using CoaguChek S point‐of‐care monitor and a robust education program.Thromb Res. 2006; 118: 587-93Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar]. Cluster analysis produces mean variables for each child and determines their individual percentage of INRs in the therapeutic range. Summary statistics, percentages and confidence intervals are calculated for each cluster (patient). These mean variables are then used to produce an overall analysis of the percentage of INR test results in the therapeutic range for the whole sample. For clinical services that are unable to access linear interpolation software, this simple statistical approach allows the generation of outcome data that are not skewed by the minority of patients for whom warfarin management is particularly challenging. The authors state they have no conflict of interest." @default.
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• W1889849240 title "Comparison of ‘time within therapeutic INR range’ with ‘percentage INR within therapeutic range’ for assessing long‐term anticoagulation control in children: a rebuttal" @default.
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