ABSTRACT
Background: Previous studies demonstrate a reduced risk of thrombosis and mortality with anticoagulant treatment in patients with COVID-19 than those without anticoagulation treatment. However, an open question regarding the efficacy and safety of therapeutic anticoagulation (T-AC) versus a lower dose, prophylaxis anticoagulation (P-AC) in COVID-19 patients is still controversial. Methods: We systematically reviewed currently available randomized clinical trials (RCTs) and observational studies (OBs) from January 8, 2019, to January 8, 2022, and compared prophylactic and therapeutic anticoagulant treatment in COVID-19 patients. The primary outcomes were risk of mortality, major bleeding, and the secondary outcomes included venous and arterial thromboembolism. Subgroup analysis was also performed between critically ill and non-critically ill patients with COVID-19 and between patients with higher and lower levels of D-dimer. Sensitive analysis was performed to decrease the bias and the impact of population heterogeneity.Results: We identified 11 RCTs and 17 OBs fulfilling our inclusion criteria. In the RCTs analyses, there was no statistically significant difference in the relative risk of mortality between COVID-19 patients with T-AC treatment and those treated with P-AC (RR 0.95, 95% CI, 0.78–1.16, P = 0.61). Similar results were also found in the OBs analyses (RR 1.21, 95% CI, 0.98-1.49, P = 0.08). The pooling meta-analysis using a random-effects model combined with effect sizes showed that in the RCTs and OBs analyses, patients with COVID-19 who received T-AC treatment had a significantly higher relative risk of the major bleeding event than those with P-AC treatment in COVID-19 patients (RCTs: RR 1.76, 95% CI, 1.19-2.62, P = 0.005; OBs: RR 2.39, 95% CI, 1.56-3.68, P < 0.0001). Compared with P-AC treatment in COVID-19 patients, patients with T-AC treatment significantly reduced the incidence of venous thromboembolism (RR 0.51, 95%, 0.39-0.67, P＜0.00001), but it is not associated with arterial thrombosis events (RR 0.97, 95%, 0.66-1.42, P = 0.88). The subgroup analysis of OBs shows that the mortality risk significantly reduces in critically ill COVID-19 patients treated with T-AC compared with those with P-AC treatment (RR 0.58, 95% CI, 0.39-0.86, P = 0.007), while the mortality risk significantly increases in non-critically ill COVID-19 patients treated with T-AC (RR 1.56, 95% CI, 1.34-1.80, P < 0.00001). In addition, T-AC treatment does not reduce the risk of mortality in COVID-19 patients with high d-dimer levels in RCTs. Finally, the overall sensitivity analysis after excluding two RCTs studies remains consistent with the previous results.Conclusions: A comprehensive meta-analysis of OBs demonstrated that T-AC treatment in critically ill patients with COVID-19 significantly increased survival compared with those treated with P-AC, which was not found in the RCTs analyses. Meanwhile, P-AC treatment showed survival superiority in non-critically ill patients with COVID-19. In both RCTs and OBs, T-AC treatment in COVID-19 patients significantly reduced the incidence of venous thromboembolism but showed a higher risk of bleeding than those with P-AC treatment. Protocol registration: PROSPERO (CRD42021293294). Registered 24 November 2021.
Subject(s)
COVID-19ABSTRACT
PurposeThis paper aims to reveal the factors patients consider when choosing a doctor for consultation on an online medical consultation (OMC) platform and how these factors influence doctors' consultation volumes.Design/methodology/approachIn Study 1, influencing factors reflected as service features were identified by applying a feature extraction method to physician reviews, and the importance of each feature was determined based on word frequencies and the PageRank algorithm. Sentiment analysis was used to analyze patient satisfaction with each service feature. In Study 2, regression models were used to analyze the relationships between the service features obtained from Study 1 and the doctor's consultation volume.FindingsThe study identified 14 service features of patients' concerns and found that patients mostly care about features such as trust, phraseology, overall service experience, word of mouth and personality traits, all of which describe a doctor's soft skills. These service features affect patients' trust in doctors, which, in turn, affects doctors' consultation volumes.Originality/valueThis research is important as it informs doctors about the features they should improve, to increase their consultation volume on OMC platforms. Furthermore, it not only enriches current trust-related research in the field of OMC, which has a certain reference significance for subsequent research on establishing trust in online doctor–patient relationships, but it also provides a reference for research concerning the antecedents of trust in general.