Patients' Priorities for Oral Anticoagulation Therapy in Non-valvular Atrial Fibrillation: a Multi-criteria Decision Analysis

Physician and Patient Preferences for Oral Anticoagulation Therapy Decision Making in Atrial Fibrillation: Results From a National Best-Worst Scaling Survey in Türkiye

Atrial fibrillation (AF) is the most common cardiac dysrhythmia and a common cause of ischemic stroke. Stroke prevention with oral anticoagulation (OAC) is the cornerstone of AF management. Patients and their treating physicians may have different views on different attributes of OACs. The objective of this study was to quantify the relative importance that patients and physicians in Turkey place on different OAC attributes when making treatment decisions in AF. A cross-sectional survey was administered to AF patients (≥ 50 years) receiving OAC and practising cardiologists, including residents with ≥ 2 years of experience in Turkey. For both patients (N = 230; 50% male) and physicians (N = 194; 74% male), the most important attributes for OAC treatment decision making in AF were "success in preventing stroke" (57% and 73.9% or overall importance, respectively) and "risk of major bleeding" (20% and 23.4%, respectively). For patients, other attributes were much less important, but not altogether unimportant: reversal agent availability (7%), monitoring (5%), food or drug interactions (3%), minor bleeding (3%), and ease of swallowing (2%). For physicians, among the other attributes, only the need for monitoring (1.3%) had a relative importance of > 1%. For all Turkish participants, efficacy and safety were found to be the most important attributes influencing OAC choice in AF with these two attributes accounting for 77% and 97.3% of overall importance for patients and physicians, respectively. Certain considerations, especially reversal agent availability and monitoring appear to be more important to patients than to physicians This is the first study to use BWS to quantify patient and physician preferences for OAC treatments in AF in Turkey.

Trends in direct oral anticoagulant (DOAC) prescribing in English primary care (2014-2019)

BACKGROUND

In England, most prescribing of direct-acting oral anticoagulants for atrial fibrillation (AF) is in primary care. However, there remain gaps in our understanding of dosage and disparities in use. We aimed to describe trends in direct oral anticoagulant (DOAC) prescribing, including dose reduction in people with renal impairment and other criteria, and adherence.

METHODS

Using English primary care sentinel network data from 2014 to 2019, we assessed appropriate DOAC dose adjustment with creatinine clearance (CrCl). Our primary care sentinel cohort was a subset of 722 general practices, with 6.46 million currently registered patients at the time of this study.

RESULTS

Of 6 464 129 people in the cohort, 2.3% were aged ≥18 years with a diagnosis of AF, and 30.8% of these were prescribed vitamin K antagonist and 69.1% DOACs. Appropriate DOAC prescribing following CrCl measures improved between 2014 and 2019; dabigatran from 21.3% (95% CI 15.1% to 28.8%) to 48.7% (95% CI 45.0% to 52.4%); rivaroxaban from 22.1% (95% CI 16.7% to 28.4%) to 49.9% (95% CI 48.5% to 53.3%); edoxaban from 10.0% (95% CI 0.3% to 44.5%) in 2016 to 57.6% (95% CI 54.5% to 60.7%) in 2019; apixaban from 30.8% (95% CI 9.1% to 61.4%) in 2015 to 60.5% (95% CI 57.8% to 63.2%) in 2019.Adherence was highest for factor Xa inhibitors, increasing from 50.1% (95% CI 47.7% to 52.4%) in 2014 to 57.8% (95% CI 57.4% to 58.2%) in 2019. Asian and black/mixed ethnicity was associated with non-adherence (OR 1.81, 95% CI 1.56 to 2.09) as was male gender (OR 1.19, 95% CI 1.15 to 1.22), higher socioeconomic status (OR 1.60, 95% CI 1.52 to 1.68), being an ex-smoker (OR 1.12, 95% CI 1.06 to 1.19) and hypertension (OR 1.07, 95% CI 1.03 to 1.17).

CONCLUSIONS

The volume and quality of DOAC prescribing has increased yearly. Future interventions to augment quality of anticoagulant management should target disparities in adherence.

Assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A Position Paper from the ESC Working Group on Thrombosis, in collaboration with the European Heart Rhythm Association, the Association for Acute CardioVascular Care and the Asia-Pacific Heart Rhythm Society

Whilst there is a clear clinical benefit of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision to initiate and continue anticoagulation is often based on a careful assessment of both the thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static 'one off' assessment based on baseline factors but is dynamic, being influenced by ageing, incident comorbidities, and drug therapies. In this Consensus Document, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with the view to summarizing 'best practice' when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, review established bleeding risk factors, and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.

Assessment and Mitigation of Bleeding Risk in Atrial Fibrillation and Venous Thromboembolism: Executive Summary of a European and Asia-Pacific Expert Consensus Paper

While there is a clear clinical benefit of oral anticoagulation in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision for initiating and continuing anticoagulation is often based on a careful assessment of both thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static "one-off" assessment based on baseline factors but is dynamic, being influenced by aging, incident comorbidities, and drug therapies. In this executive summary of a European and Asia-Pacific Expert Consensus Paper, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with a view to summarizing "best practice" when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, and review established bleeding risk factors and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism, are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.

The Influence of Frailty Syndrome and Dementia on the Convenience and Satisfaction with Oral Anticoagulation Treatment in Elderly Patients with Atrial Fibrillation

Background: The impact of frailty syndrome (FS) and dementia on the convenience and satisfaction with oral anticoagulation (OAC) treatment in atrial fibrillation (AF) patients is not well-known. Aim: Assessment the impact of FS and dementia on the convenience and satisfaction with OAC treatment in 116 elderly (mean age 75.2, SD = 8.2) patients with AF. Methodology: A self-administered questionnaire was used in the study to collect basic socio-demographic and clinical data. Tilburg Frailty Indicator (TFI) questionnaire was used to assess the presence of FS, Mini Mental State Examination (MMSE) to assess cognitive impairment (CI), The Perception of Anticoagulant Treatment Questionnaire Part 2 (PACT-Q2) to assess convenience and satisfaction with OAC treatment, and the Arrhythmia-Specific Questionnaire in Tachycardia and Arrhythmia (ASTA) to assess quality of life (QoL). Results: Multivariable analysis as a significant, negative predictor of the convenience and satisfaction domain showed the occurrence of dementia (β = −0.34; p < 0.001, β = −0.41; p < 0.001, respectively) and prior major bleeding (β = −0.30; p < 0.001, β = −0.33; p < 0.001, respectively). Analysis showed a significant relationship between convenience and satisfaction and the overall result of the ASTA (r = −0.329; p < 0.001, r = −0.372; p < 0.001, respectively). Conclusions: Elements of geriatric syndrome, such as FS and dementia, adversely affect treatment convenience and satisfaction with OAC treatment in AF. It has been shown that better convenience and satisfaction with OAC treatment translates into better QoL. There were no differences between satisfaction and convenience and the type of OAC treatment (vitamin K antagonists (VKA) vs. novel oral anticoagulants (NOAC).

Development of a New Patient-Reported Medication Adherence Instrument: Concerns Influencing Medication Adherence

PURPOSE

The purpose of this research was to conceptualize and develop a tool for identifying persons who are, or are likely to be, non-adherent to medications prescribed by their healthcare provider(s) by identifying concerns that patients have regarding their treatments.

PATIENTS AND METHODS

The target populations were persons diagnosed with atrial fibrillation or osteoarthritis, who were prescribed anticoagulants or over-the-counter or prescription pain medications, respectively. In this two-stage, multi-year, qualitative research study, relevant concepts were explored, confirmed and refined. The focus was on non-adherence due to active (thus potentially modifiable) patient decisions to forego taking medications as prescribed.

RESULTS

The most common concerns among participants with atrial fibrillation were medication-related side effects and fear of bleeding. Participants with osteoarthritis were most concerned about short-term stomach problems and long-term kidney and liver side effects. The Concerns Influencing Medication Adherence (CIMA) instrument was developed based on these concerns and those identified in the literature. It is comprised of 16 items: a core set of 11 items potentially applicable to multiple disease states, 3 items specific to atrial fibrillation, and 2 items unique to osteoarthritis. The instrument is intended to be completed electronically, and publicly available for use in direct patient care in the United States or in population health management.

CONCLUSION

To our knowledge, this is the first instrument focused on medication adherence that includes documented details of patient input as recommended by the United States Food and Drug Administration guidance. Patient input is considered a key component of content validity. In this research, for example, the concerns that patients have regarding their treatments can be expected to have affected past medication adherence and can potentially impact future adherence. Although applicability outside atrial fibrillation or osteoarthritis was not assessed, the general items may be useful in assessing adherence in other chronic diseases.

Convenience and satisfaction in direct oral anticoagulant-treated patients with atrial fibrillation

BACKGROUND

Direct oral anticoagulants (DOACs) are the preferred anticoagulants for thromboprophylaxis in atrial fibrillation. We aimed to identify determinants of quality of life related to DOAC treatment to optimize DOAC treatment convenience and satisfaction.

METHODS

We conducted a cross-sectional study in DOAC users. DOAC treatment-related convenience and satisfaction were measured by Perception of Anticoagulant Treatment Questionnaire. Higher scores are more favorable (range, 0-100). Patient-reported outcome measures and drug- and organization-related factors were collected. Multiple regression analyses were used to evaluate the association between these factors (ie, exposure variables) and DOAC treatment-related convenience and treatment satisfaction (ie, outcome variables).

RESULTS

Of 1598 patients invited, 1035 responded, and 962 were included. The median convenience score was 98.1 (94.2-100.0), mean satisfaction score 66.5± 14.9. Twenty-four percent felt not well informed at the start of DOAC; 6.9% did not know who to turn to with questions. Multiple regression analyses showed that lacking sense of security, the predefined composite of receiving insufficient information at start of DOAC and/or not knowing who to turn to with questions was associated with lower convenience (regression coefficient, -1.29; 95% confidence interval [CI], -2.16 to -0.41). Bleeding, gastrointestinal complaints, and lower medication adherence were also associated with lower convenience. Missing sense of security (regression coefficient -6.59; 95% CI, -8.94 to -4.24) and bleeding without consultation were associated with lower treatment satisfaction.

CONCLUSIONS

Accessible interventions to improve DOAC care could be providing more instruction at treatment initiation and ensuring that patients know who to contact in case of problems.

A Multiple Stakeholder Multicriteria Decision Analysis in Diabetic Macular Edema Management: The MULTIDEX-EMD Study

BACKGROUND

The clinical and economic management of retinal diseases has become more complex following the introduction of new intravitreal treatments. Multicriteria decision analysis (MCDA) offers the potential to overcome the challenges associated with traditional decision-making tools.

OBJECTIVES

A MCDA to determine the most relevant criteria to decision-making in the management of diabetic macular edema (DME) based on the perspectives of multiple stakeholders in Spain was developed. This MCDA was termed the MULTIDEX-EMD study.

METHODS

Nineteen stakeholders (7 physicians, 4 pharmacists, 5 health authorities and health management experts, 1 psychologist, and 2 patient representatives) participated in this three-phase project. In phase A, an advisory board defined all of the criteria that could influence DME treatment decision-making. These criteria were then screened using a discrete choice experiment (DCE) (phase B). Next, a multinomial logit model was fitted by applying the backward elimination algorithm (relevant criteria: p value < 0.05). Finally, the results were discussed in a deliberative process (phase C).

RESULTS

Thirty-one criteria were initially defined (phase A) and grouped into 5 categories: efficacy/effectiveness, safety, organizational and economic impact, patient-reported outcomes, and other therapeutic features. The DCE results (phase B) showed that 10 criteria were relevant to the decision-making process for a 50- to 65-year-old DME patient: mean change in best corrected visual acuity (p value < 0.001), percentage of patients with an improvement of ≥ 15 letters (p value < 0.001), effect duration per administration (p value = 0.008), retinal detachment (p value < 0.001), endophthalmitis (p value = 0.012), myocardial infarction (p value < 0.001), intravitreal hemorrhage (p value = 0.021), annual treatment cost per patient (p value = 0.001), health-related quality of life (HRQoL) (p value = 0.004), and disability level (p value = 0.021).

CONCLUSIONS

From a multi-stakeholder perspective, the selection of an appropriate treatment for DME patients should guarantee patient safety and maximize the visual acuity improvement and treatment effect duration. It should also contribute to system sustainability by being affordable, it should have a positive impact on HRQoL, and it should prevent disability.

Treatment preferences as basis for decision making in patients using direct oral anticoagulants in Spain

Treatment preferences are considered a relevant decision-making driver by the main atrial fibrillation (AF) guidelines. Direct Oral Anticoagulants (DOACs), considered as similar clinically, have administration differences useful for treatment individualization. Preferences, priorities and satisfaction of DOAC users were assessed through an observational, multicentric (25 hospitals), cross-sectional study including adult AF-patients (and/or caregivers) in Spain. Three study groups were considered according to DOAC posology preferences: (A) once-daily, with water; (B) once-daily, with food; (C) twice-daily. Overall, 332 patients and 55 caregivers were included. Mean (SD) age was 73.7 (10.7) years [58.7 (13.9) for caregivers]; 51.5% women [69.1% for caregivers]; 80.7% showed comorbidities and poly-pharmacy [6.6 (3.3) drugs/day]. No statistically significant differences were shown among study groups. Once-daily administration was preferred by 274 patients (82.5%) [60.8% (Group A); 21.7% (Group B); 17.5% (Group C)], and 47 caregivers (85.5%) [58.2% (Group A); 27.3% (Group B); 14.5% (Group C)]. Once-daily DOACs were prescribed in 42.8% of the patients. Bleeding risk was the main concern for both, patients and caregivers, followed by DOAC posology and interactions. Although treatment satisfaction (patients and caregivers) was high (9.0 and 9.1 points, respectively), match between individual treatment preferences and real prescriptions was only shown in 41.0% of AF-patients, evidencing a need for patient involvement on treatment decision-making. There is not a patient profile linked to treatment preferences, and clinical criteria must be the main driver for decision-making. However, for most AF-patients (elderly patients), aged, with comorbidity, poly-pharmacy and high cardiovascular risk, once-daily DOACs would be the preferred option.

Patients' perceptions with dabigatran in patients with atrial fibrillation previously treated with vitamin K antagonists

Aim: To analyze the perception of anticoagulation with dabigatran in patients with nonvalvular atrial fibrillation previously treated with vitamin K antagonists over a 6-month period. Materials & methods: This is a prospective, noninterventional, noncontrolled, multicenter study. To assess patients' perceptions, PACT-Q2 questionnaire was completed. Results: Six hundred and fifty nine patients (73.1 ± 9.4 years, CHA₂DS₂-VASc 3.6 ± 1.6) were included. At baseline, the convenience and satisfaction scores were 60.9 ± 24.9 and 49.9 ± 17.7, respectively. The scores significantly increased along the study. Convenience score was higher in males and in patients with low-moderate thromboembolic risk. Satisfaction score was higher in females. Only 8.0% of patients discontinued dabigatran (3.7% due to side effects). Conclusion: Convenience and satisfaction scores for nonvalvular atrial fibrillation patients treated with dabigatran at 6 months were significantly better than with previous vitamin K antagonists.

Heterogeneity in Preferences for Anti-coagulant Use in Atrial Fibrillation: A Latent Class Analysis

Introduction

Recent reviews on patients’ preferences towards attributes of oral anti-coagulant therapy have shown that preference for convenience of therapy is heterogeneous. In this study, we used a novel approach—latent class analysis (LCA)—to assess heterogeneity.

Methods

We developed a health preference survey that consisted of 12 discrete choice questions. The following attributes of convenience were included: intake frequency; need for regular coagulation monitoring; diet or drug interactions; relation between medication and food intake; and pill type. Background questions about gender, age, current therapy [i.e., direct-acting oral anti-coagulant (DOAC) or vitamin K antagonist (VKA)], self-reported medication adherence, and pill burden were included. Mixed logit analysis (MLA) and LCA were performed. The scale-adjusted LCA model with two scale classes and four preference classes emerged as the model with the best fit and interpretability.

Results

A total of 508 patients with non-valvular atrial fibrillation from five European countries (Germany, Italy, Spain, France, and the UK) were surveyed in August 2017. The most important attributes were need for monitoring (37%) and intake frequency (27%). Patient preferences were significantly influenced by country, gender, and current anti-coagulant therapy. Four different preference classes of patients were identified in the LCA. First, most patients (57%) were in the “no need for regular coagulation monitoring” class. Current DOAC users and patients who were the least adherent to therapy were more likely to prefer no coagulation monitoring. Second, 20% of patients were in the “balanced” class of patients. Current VKA users with moderate adherence were more likely to be in this class. Patients who reported the lowest adherence were most likely in the “once daily, interactions likely” class (16%). Fourth, current VKA users and highly adherent patients were most likely to prefer therapies with a need for regular coagulation monitoring (7%).

Conclusions

This study demonstrated significant preference heterogeneity among patients with atrial fibrillation and linked these preferences to differences in background characteristics. Country of residence and currently prescribed therapy influenced patient preferences in both the MLA and LCA models.

Electronic supplementary material

The online version of this article (10.1007/s40271-020-00420-z) contains supplementary material, which is available to authorized users.

Evaluation of a program of pharmaceutical counseling for French patients on oral anticoagulant therapy

Background Oral anticoagulants are widely used for treatment and prevention of thromboembolic diseases. We set up a pharmaceutical counseling program for both direct oral anticoagulant and vitamin K antagonist drugs in our hospital in 2015. Objective Evaluate patient satisfaction and the evolution of their knowledge throughout the pharmaceutical counseling program on anticoagulants and identify knowledge variability factors. Setting Cardiology Inpatient Unit from the University Antoine Béclère Hospital, France. Methods Evaluation was based on data collection of patients surveyed between 2015 and 2018. Inpatients in the cardiology department on oral anticoagulants were eligible. The learning process was designed to enhance patient knowledge and understanding based on 10 cognitive or self-management skills, relating to the optimization of oral anticoagulant therapy management. It consisted in 2 face-to-face interviews during hospitalization and 2 additional phone interviews one and six months after discharge. The median patient score was evaluated at each step of the process as well as the mean score for each item from the global population. A sub-analysis was run on the less well-acquired skills in order to identify risk factors for limited knowledge. The association between those factors and the level of knowledge (score ≥ 7 or < 7) was assessed using Chi square test followed by multivariate analysis. Main outcome measure Patient knowledge of anticoagulation therapy depending on specific factors. Results Of the 880 patients eligible for pharmaceutical counseling, 319 entered the process and 102 completed it. Median knowledge scores were 8/10 and 9/10 after the first and the final interviews respectively with a significant improvement (p = 0.0003). The least well-acquired items at each step were surveillance and under-dosing management. The sub-analysis showed the use of vitamin K antagonist to be linked to an enhanced understanding related to treatment surveillance (p = 0.029). Patients suffering from atrial fibrillation were found to have a worse understanding of under-dosing management (p = 0.013). Finally, patients evaluated the process as helpful and suitable for their conditions. Conclusion Pharmaceutical counseling is appropriate for patients, improving and maintaining knowledge of oral anticoagulants. Our evaluation highlights the need to focus on patient-specific profiles to reach a satisfactory level of knowledge.

Treatment Expectations, Convenience, and Satisfaction with Anticoagulant Treatment: Perceptions of Patients in South-East Queensland, Australia

Background: Warfarin has long been the only oral anticoagulant (OAC) available, but options now include non-vitamin K antagonists. Prescribing an OAC may be influenced by patient factors and preferences influenced by dosing, monitoring, and adverse effects, which may ultimately impact patient satisfaction and convenience. The aim of this study was to explore the perception of OAC treatment by Australian patients in terms of treatment expectations, convenience, and satisfaction. Methods: The Perception of Anticoagulant Treatment Questionnaire was distributed to patients dispensed OAC medication from three pharmacies in South-East Queensland. Responses to questions using a five-point Likert scale were collated and mean results utilised to assess expectations, convenience, and satisfaction, including an analysis across demographic groups. Results: A total of 56 (26.8%) surveys were returned, with the majority of respondent’s male (58.2%). Highest mean scores for treatment expectation were for an OAC that was easy to take (4.85 ± 0.79) and that could be taken care of by the respondents themselves (4.11 ± 1.14). The mean overall score for convenience was 68.90 ± 11.44% and for satisfaction 69.43 ± 16.58%. Significantly higher mean convenience scores were found in females and patients with atrial fibrillation. Conclusions: Patients’ highest expectations were for an OAC that would be easy to take, and overall satisfaction and convenience was around 69%. Factors including demographics can influence perceptions of therapy, and addressing individual preferences for OAC therapy may increase ratings of satisfaction and convenience.

Reliability and validity of the Maltese version of the Perception of Anticoagulant Treatment Questionnaire (PACT-Q)

Purpose: Anticoagulant therapy has an impact on the health-related quality of life, as it is a chronic treatment for most clinical indications and also requires some lifestyle changes. Since there was no validated questionnaire available in the Maltese language, the aim of our study was to translate and validate the Perception of Anticoagulant Treatment Questionnaire (PACT-Q2). Patients and methods: The PACT-Q2 explores two dimensions (convenience and anticoagulant treatment satisfaction). Forward and backward translations were performed. The Maltese version of the PACT-Q2 was administered to 174 patients on warfarin treatment enrolled from different anticoagulation clinics in Malta. Reliability was assessed through internal consistency (Cronbach's alpha) and test-retest (intraclass correlation coefficient [ICC]). Validity was assessed through floor/ceiling effect, factor analysis (root mean square error of approximation [RMSEA], standardized root mean squared residual [SRMR], goodness-of-fit index [GFI], adjusted goodness-of-fit index [AGFI], comparative fit index [CFI]), subscales correlation and known-group validity. Results: Reliability was very good for the convenience subscale (Cronbach's alpha 0.86, ICC 0.87), but less good for the satisfaction subscale (Cronbach's alpha 0.62, ICC 0.40). Floor effect was 0%; ceiling effect was low (6.3% convenience, 1.2% satisfaction). Fit parameters were close to acceptable cut-offs (RMSEA =0.09, SRMR =0.10, GFI =0.82, AGFI =0.78, CFI =0.79). There was no correlation between the two subscales (r=0.01, p=0.83). Patients with history of bleeding showed lower convenience (r=-0.16, p=0.08) and lower satisfaction (r=-0.21, p=0.01). Conclusions: Our results support the finding that the Maltese translation of the PACT-Q2 is a valid and reliable instrument.