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Barbati S, Baumgartner PC, Dietrich F, Allemann SS, Arnet I. Concordance between pharmacy dispensing and electronic monitoring data of direct oral anticoagulants - A secondary analysis of the MAAESTRO study. Res Social Adm Pharm 2024:S1551-7411(24)00332-2. [PMID: 39209562 DOI: 10.1016/j.sapharm.2024.08.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 08/22/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Direct oral anticoagulants are the preferred treatment for stroke patients with atrial fibrillation. Pharmacy dispensing data represent a practical method to identify suboptimal medication adherence. OBJECTIVE This study investigates whether pharmacy dispensing data are indicative of real-life adherence behavior, using data from 130 patients in the MAAESTRO study (2018-2022) in Basel, Switzerland. METHODS This secondary data analysis of the MAAESTRO study (Dietrich, 2024) included patients with electronic monitoring (EM) and dispensing data for 12 months. Patients with at least two refills were included in the analysis. We categorized refill series into three adherence patterns using the Delta T method (Baumgartner, 2022): all refills on time, erratic refills, end-gaps ≥10 days. EM-adherence was assessed through "taking adherence" and "missing days" (24h without intake). We analyzed: i) all dispensing data ("all refills"); ii) all data independently of the MAAESTRO phase ("all phases"); iii) the last two dispensing data ("last"), and iv) EM data from the MAAESTRO phase that match the date of the last refill ("matched"). Associations between refill patterns and adherence were examined using Spearman correlation and Fisher's exact test. RESULTS Data analyzed from 50 patients (mean age 76.4 ± 9.1 years, 56.0 % male) included 252 refills with a median of 4 refills per patient. Refill patterns were: all refills on time (40.0 %), erratic refills (36.0 %), and end-gaps >10 days (24.0 %). Mean taking adherence was 89.3 ± 13.7 %. EM data revealed missing days in 82.0 % of patients, with 61.0 % having irregular refill patterns. Matched taking adherence was moderately associated with Delta T over all refills (p = 0.034) and the last refill (p = 0.013). CONCLUSIONS Dispensing data processed with the Delta T method correlate moderately with EM data. The Delta T value for the last two refills shows promise for estimating irregular adherence, suggesting potential for targeted interventions in pharmacy practice.
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Affiliation(s)
- Selina Barbati
- University of Basel, Department of Pharmaceutical Sciences, Klingelbergstrasse 50, 4056, Basel, Switzerland.
| | | | - Fine Dietrich
- Leipzig University, Clinical Trial Center, Härtelstrasse 16-18, 04107, Leipzig, Germany
| | - Samuel S Allemann
- University of Basel, Department of Pharmaceutical Sciences, Klingelbergstrasse 50, 4056, Basel, Switzerland
| | - Isabelle Arnet
- University of Basel, Department of Pharmaceutical Sciences, Klingelbergstrasse 50, 4056, Basel, Switzerland
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Dietrich F, Polymeris AA, Albert V, Engelter ST, Hersberger KE, Schaedelin S, Lyrer PA, Arnet I. Intake reminders are effective in enhancing adherence to direct oral anticoagulants in stroke patients: a randomised cross-over trial (MAAESTRO study). J Neurol 2024; 271:841-851. [PMID: 37831125 PMCID: PMC10827905 DOI: 10.1007/s00415-023-12035-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) effectively prevent recurrent ischaemic events in atrial fibrillation (AF) patients with recent stroke. However, excellent adherence to DOAC is mandatory to guarantee sufficient anticoagulation as the effect quickly subsides. AIM To investigate the effect of intake reminders on adherence to DOAC. METHODS MAAESTRO was a randomised, cross-over study in DOAC-treated AF patients hospitalised for ischaemic stroke. Adherence was measured by electronic monitoring for 12 months. After an observational phase, patients were randomised to obtain an intake reminder either in the first or the second half of the subsequent 6-month interventional phase. The primary outcome was 100%-timing adherence. Secondary outcomes were 100%-taking adherence, and overall timing and taking adherence. We analysed adherence outcomes using McNemar's test or mixed-effects logistic models. RESULTS Between January 2018 and March 2022, 130 stroke patients were included, of whom 42 dropped out before randomisation. Analysis was performed with 84 patients (mean age: 76.5 years, 39.3% women). A 100%-timing adherence was observed in 10 patients who were using the reminder, and in zero patients without reminder (p = 0.002). The reminder significantly improved adherence to DOAC, with study participants having 2.7-fold increased odds to achieve an alternative threshold of 90%-timing adherence (OR 2.65; 95% CI 1.05-6.69; p = 0.039). A similar effect was observed for 90%-taking adherence (OR 3.06; 95% CI 1.20-7.80; p = 0.019). Overall timing and taking adherence increased significantly when using the reminder (OR 1.70; 95% CI 1.55-1.86, p < 0.01; and OR 1.67; 95% CI 1.52-1.84; p < 0.01). CONCLUSION Intake reminders increased adherence to DOAC in patients with stroke attributable to atrial fibrillation. TRIAL REGISTRATION ClinicalTrials.gov: NCT03344146.
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Affiliation(s)
- Fine Dietrich
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland.
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Petersgraben 4, 4051, Basel, Switzerland
| | - Valerie Albert
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Petersgraben 4, 4051, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Burgfelderstrasse 101, 4055, Basel, Switzerland
| | - Kurt E Hersberger
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel and University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Petersgraben 4, 4051, Basel, Switzerland
| | - Isabelle Arnet
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland
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Mihas P, Rosman L, Armbruster T, Walker J, Deyo Z, Gehi A. Assessing a Virtual Education Intervention for Patients With Atrial Fibrillation: A Qualitative Study of Patient Perceptions. J Cardiovasc Nurs 2024; 39:E1-E11. [PMID: 37088903 DOI: 10.1097/jcn.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND Authors of studies of patients with atrial fibrillation (AF) have identified several knowledge gaps and misconceptions regarding the condition and its management. The COVID-19 pandemic heightened isolation of patients and underscored the need for education and knowledge building in order for patients to effectively manage AF during times of increased health risk. OBJECTIVE The aim of this study was to assess, using a qualitative approach, the experiences and perceived benefits of patients with AF regarding an 8-session virtual education intervention (AF-at-Home) during the early months of the COVID-19 pandemic. METHODS A qualitative study with 3 focus groups using a semistructured focus group guide was conducted and recorded online with the same trained moderator. RESULTS We identified 7 primary themes emerging from patients' experiences: (1) building knowledge beyond information available in clinic visits, (2) managing anxiety, (3) generating self-efficacy, (4) providing social comparison, (5) perceived benefits of both experiential and informational content, (6) facilitating self-management behaviors, and (7) facilitating communication with providers. CONCLUSIONS The analysis of the focus groups shows the benefits of a virtual education program in building knowledge, skills, and self-efficacy as well as reducing anxiety and normalizing one's experience by attending a program alongside other patients with AF.
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Knaepen L, Delesie M, Vijgen J, Dendale P, Ector J, Desteghe L, Heidbuchel H. Adherence to oral anticoagulation measured by electronic monitoring in a Belgian atrial fibrillation population. Clin Res Cardiol 2023; 112:1812-1823. [PMID: 37498363 PMCID: PMC10698080 DOI: 10.1007/s00392-023-02261-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Stroke prevention using oral anticoagulation (OAC) is the first management priority in atrial fibrillation (AF). Despite the importance of good therapy adherence, real-world adherence is still suboptimal. Patient education and adherence monitoring with new technologies are recommended. The main purpose of this sub-analysis of the AF-EduCare trial was to evaluate the effect of personalized follow-up strategies on adherence to OAC. METHODS Regimen adherence was monitored by the electronic Medication Event Monitoring System cap at the start of the trial (M1) and after 12 months (M2), each for three months. Patients were part of one of three education groups (In-person, Online or App-based) or the standard care (SC) group. All are qualified for OAC therapy. RESULTS A total of 768 patients were evaluated (11.8% SC vs. 86.8% any education group, mean age: 70.1 ± 7.9 years). Patients were taking non-vitamin K OAC (once daily 53.8%; twice daily 35.9%) or vitamin K antagonists (9.4%), equally distributed over the different study arms (p = 0.457). Mean therapy adherence was high (M1:93.8 ± 10.8%; M2:94.1 ± 10.1%). During both monitoring periods, the education group scored significantly higher than SC (M1:94.2 ± 10.0% vs. 91.3 ± 15.0%; p = 0.027; M2:94.4 ± 9.3% vs. 91.6 ± 14.0%; p = 0.006). More patients in the In-person and Online groups were able to keep or improve their adherence to > 90% compared to the SC. CONCLUSION Overall adherence to OAC in all study groups, even in SC, was very high, without attrition over time. Nevertheless, targeted education led to a small but significantly improved adherence compared to SC.
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Affiliation(s)
- Lieselotte Knaepen
- Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium.
- Research Group Cardiovascular Diseases, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium.
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium.
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium.
| | - Michiel Delesie
- Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
| | - Johan Vijgen
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Paul Dendale
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Joris Ector
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Lien Desteghe
- Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Hein Heidbuchel
- Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
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Capiau A, Grymonprez M, Scheire S, Faute Y, Lahousse L, Mehuys E, De Backer T, Boussery K. Barriers and facilitators for adherence to direct oral anticoagulants in patients with atrial fibrillation: A qualitative approach. Thromb Res 2023; 229:164-169. [PMID: 37515981 DOI: 10.1016/j.thromres.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 07/31/2023]
Affiliation(s)
- Andreas Capiau
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium.
| | - Maxim Grymonprez
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Sophie Scheire
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Yenna Faute
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Lies Lahousse
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium; Department of Epidemiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 Rotterdam, the Netherlands
| | - Els Mehuys
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Tine De Backer
- Department of Cardiology, Heart Centre, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Koen Boussery
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
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Effects of a Pharmacist-Led Educational Interventional Program on Electronic Monitoring–Assessed Adherence to Direct Oral Anticoagulants: A Randomized, Controlled Trial in Patients with Nonvalvular Atrial Fibrillation. Clin Ther 2022; 44:1494-1505. [DOI: 10.1016/j.clinthera.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 08/28/2022] [Accepted: 09/20/2022] [Indexed: 11/22/2022]
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Pokorney SD, Cocoros N, Al-Khalidi HR, Haynes K, Li S, Al-Khatib SM, Corrigan-Curay J, Driscoll MR, Garcia C, Calvert SB, Harkins T, Jin R, Knecht D, Levenson M, Lin ND, Martin D, McCall D, McMahill-Walraven C, Nair V, Parlett L, Petrone A, Temple R, Zhang R, Zhou Y, Platt R, Granger CB. Effect of Mailing Educational Material to Patients With Atrial Fibrillation and Their Clinicians on Use of Oral Anticoagulants: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2214321. [PMID: 35639381 PMCID: PMC9157265 DOI: 10.1001/jamanetworkopen.2022.14321] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
IMPORTANCE Only about half of patients with atrial fibrillation (AF) who are at increased risk for stroke are treated with an oral anticoagulant (OAC), despite guideline recommendations for their use. Educating patients with AF about prevention of stroke with OACs may enable them as agents of change to initiate OAC treatment. OBJECTIVE To determine whether an educational intervention directed to patients and their clinicians stimulates the use of OACs in patients with AF who are not receiving OACs. DESIGN, SETTING, AND PARTICIPANTS The Implementation of a Randomized Controlled Trial to Improve Treatment With Oral Anticoagulants in Patients With Atrial Fibrillation (IMPACT-AFib) trial was a prospective, multicenter, open-label, pragmatic randomized clinical trial conducted from September 25, 2017, to May 1, 2019, embedded in health plans that participate in the US Food and Drug Administration's Sentinel System. It used the distributed database comprising health plan members to identify eligible patients, their clinicians, and outcomes. IMPACT-AFib enrolled patients with AF, a CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age 65-74 [1 point] or ≥75 years [2 points], diabetes, and stroke, transient ischemic attack or thromboembolism [2 points]-vascular disease, and sex category [female]) score of 2 or more, no evidence of OAC prescription dispensing in the preceding 12 months, and no hospitalization-related bleeding event within the prior 6 months. INTERVENTIONS Randomization to a single mailing of patient and/or clinician educational materials vs control. MAIN OUTCOMES AND MEASURES Analysis was performed on a modified intention-to-treat basis. The primary end point was the proportion of patients with at least 1 OAC prescription dispensed or at least 4 international normalized ratio test results within 1 year of the intervention. RESULTS Among 47 333 patients, there were 24 909 men (52.6%), the mean (SD) age was 77.9 (9.7) years, mean (SD) CHA2DS2-VASc score was 4.5 (1.7), 22 404 patients (47.3%) had an ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) bleeding risk score of 5 or more, and 8890 patients (18.8%) had a history of hospitalization for bleeding. There were 2328 of 23 546 patients (9.9%) in the intervention group with initiation of OAC at 1 year compared with 2330 of 23 787 patients (9.8%) in the control group (adjusted OR, 1.01 [95% CI, 0.95-1.07]; P = .79). CONCLUSIONS AND RELEVANCE Among a large population with AF with a guideline indication for OACs for stroke prevention who were randomized to a mailed educational intervention or to usual care, there was no clinically meaningful, numerical, or statistically significant difference in rates of OAC initiation. More-intensive interventions are needed to try and address the public health issue of underuse of anticoagulation for stroke prevention among patients with AF. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03259373.
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Affiliation(s)
- Sean D. Pokorney
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Noelle Cocoros
- Harvard Pilgrim Health Care Institute, Harvard Medical School Department of Population Medicine, Boston, Massachusetts
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute and Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | | | - Shuang Li
- Duke Clinical Research Institute and Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Sana M. Al-Khatib
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | | | - Meighan Rogers Driscoll
- Harvard Pilgrim Health Care Institute, Harvard Medical School Department of Population Medicine, Boston, Massachusetts
| | - Crystal Garcia
- Harvard Pilgrim Health Care Institute, Harvard Medical School Department of Population Medicine, Boston, Massachusetts
| | - Sara B. Calvert
- Clinical Trials Transformation Initiative, Durham, North Carolina
| | | | - Robert Jin
- Harvard Pilgrim Health Care Institute, Harvard Medical School Department of Population Medicine, Boston, Massachusetts
| | | | - Mark Levenson
- Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration
| | - Nancy D. Lin
- OptumInsight Life Sciences Inc, Boston, Massachusetts
| | | | - Debbe McCall
- Rowan Tree Perspectives Consulting, Murrieta, California
| | | | - Vinit Nair
- Humana Healthcare Research Inc, Louisville, Kentucky
| | | | - Andrew Petrone
- Harvard Pilgrim Health Care Institute, Harvard Medical School Department of Population Medicine, Boston, Massachusetts
| | - Robert Temple
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Rongmei Zhang
- Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration
| | - Yunping Zhou
- Humana Healthcare Research Inc, Louisville, Kentucky
| | - Richard Platt
- Harvard Pilgrim Health Care Institute, Harvard Medical School Department of Population Medicine, Boston, Massachusetts
| | - Christopher B. Granger
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, North Carolina
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Farinha JM, Jones ID, Lip GYH. Optimizing adherence and persistence to non-vitamin K antagonist oral anticoagulant therapy in atrial fibrillation. Eur Heart J Suppl 2022; 24:A42-A55. [PMID: 35185408 PMCID: PMC8850710 DOI: 10.1093/eurheartj/suab152] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke, which can be prevented by the use of oral anticoagulation. Although non-vitamin K antagonist oral anticoagulants (NOACs) have become the first choice for stroke prevention in the majority of patients with non-valvular AF, adherence and persistence to these medications remain suboptimal, which may translate into poor health outcomes and increased healthcare costs. Factors influencing adherence and persistence have been suggested to be patient-related, physician-related, and healthcare system-related. In this review, we discuss factors influencing patient adherence and persistence to NOACs and possible problem solving strategies, especially involving an integrated care management, aiming for the improvement in patient outcomes and treatment satisfaction.
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Affiliation(s)
- José Maria Farinha
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Ian D Jones
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- School of Nursing and Allied Health, Liverpool John Moores University, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Senoo K, Miki T, Ohkura T, Iwakoshi H, Nishimura T, Shiraishi H, Teramukai S, Matoba S. A Smartphone App to Improve Oral Anticoagulation Adherence in Patients With Atrial Fibrillation: Prospective Observational Study. JMIR Mhealth Uhealth 2022; 10:e30807. [PMID: 34894626 PMCID: PMC8783280 DOI: 10.2196/30807] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 11/25/2021] [Accepted: 12/07/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Poor adherence to oral anticoagulation in elderly patients with atrial fibrillation (AF) has been shown to negatively impact health care costs, morbidity, and mortality. Although various methods such as automated reminders, counseling, telephone support, and patient education have been effective in improving medication adherence, the burden on health care providers has been considerable. Recently, an attempt has been made to improve medication adherence without burdening health care providers by using smartphone apps; however, the use of the app for elderly patients with AF is still limited. OBJECTIVE The purpose of this study was to determine whether the newly developed smartphone app for patients with AF (the Smart AF), which integrates education, automatic reminder, and patient engagement strategies with a simple user interface, can improve medication adherence in elderly patients with AF. METHODS Patient enrollment was carried out by obtaining informed consent from patients with AF attending Kyoto Prefectural University of Medicine hospital between May 2019 and September 2020. Follow-up was planned at 1, 3, and 6 months after enrollment, and questionnaire reminders were automatically sent to patient apps at designated follow-up time points. A questionnaire-based survey of medication adherence was performed electronically using the self-reported 8-item Morisky Medication Adherence Scale (MMAS-8) as the survey tool. RESULTS A total of 136 patients with AF were enrolled in this study. During the follow-up period, 112 (82%) patients underwent follow-up at 1 month, 107 (79%) at 3 months, and 96 (71%) at 6 months. The mean age of the enrolled patients was 64.3 years (SD 9.6), and male participants accounted for 79.4% (108/136) of the study population. The mean CHADS2 (congestive heart failure, hypertension, age, diabetes, previous stroke, or transient ischemic attack) score was 1.2, with hypertension being the most common comorbidity. At the time of enrollment, 126 (93%) and 10 (7%) patients were taking direct oral anticoagulants and warfarin, respectively. For medication adherence as measured according to the MMAS-8, MMAS scores at 1 month, 3 months, and 6 months were significantly improved compared with baseline MMAS scores (all P values less than .01). The overall improvement in medication adherence achieved by the 6-month intervention was as follows: 77.8% (14/18) of the patients in the high adherence group (score=8) at baseline remained in the same state, 45.3% (24/53) of the patients in the medium adherence group (score=6 to <8) at baseline moved to the high adherence group, and 72% (18/25) of the patients in the low adherence group (score <6) moved to either the medium or high adherence group. CONCLUSIONS The Smart AF app improved medication adherence among elderly patients with AF. In the realm of medication management, an approach using a mobile health technology that emphasizes education, automatic reminder, and patient engagement may be helpful.
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Affiliation(s)
- Keitaro Senoo
- Department of Cardiac Arrhythmia Research and Innovation, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomonori Miki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takashi Ohkura
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hibiki Iwakoshi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuro Nishimura
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hirokazu Shiraishi
- Department of Cardiac Arrhythmia Research and Innovation, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Teramukai
- Departments of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiac Arrhythmia Research and Innovation, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Abstract
Cardiovascular disease is the leading cause of death globally. While pharmacological advancements have improved the morbidity and mortality associated with cardiovascular disease, non-adherence to prescribed treatment remains a significant barrier to improved patient outcomes. A variety of strategies to improve medication adherence have been tested in clinical trials, and include the following categories: improving patient education, implementing medication reminders, testing cognitive behavioral interventions, reducing medication costs, utilizing healthcare team members, and streamlining medication dosing regimens. In this review, we describe specific trials within each of these categories and highlight the impact of each on medication adherence. We also examine ongoing trials and future lines of inquiry for improving medication adherence in patients with cardiovascular diseases.
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Affiliation(s)
- Steven T Simon
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Vinay Kini
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Andrew E Levy
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of Cardiology, Denver Health Medical Center, Denver, CO, USA
| | - P Michael Ho
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Cardiology Section, VA Eastern Colorado Health Care System, Aurora, CO, USA
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11
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Rasmussen PV, Hylek E. Persistence with treatment in atrial fibrillation: still a pressing issue in the era of direct oral anticoagulants. Eur Heart J 2021; 42:4138-4140. [PMID: 34347053 DOI: 10.1093/eurheartj/ehab524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Peter Vibe Rasmussen
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
| | - Elaine Hylek
- Department of Medicine, Boston University Medical Centre, Boston, MA, USA
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12
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Turakhia M, Sundaram V, Smith SN, Ding V, Michael Ho P, Kowey PR, Piccini JP, Foody J, Birmingham MC, Ianus J, Rajmane A, Mahaffey KW. Efficacy of a centralized, blended electronic, and human intervention to improve direct oral anticoagulant adherence: Smartphones to improve rivaroxaban ADHEREnce in atrial fibrillation (SmartADHERE) a randomized clinical trial. Am Heart J 2021; 237:68-78. [PMID: 33676886 DOI: 10.1016/j.ahj.2021.02.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 02/26/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Improving adherence to direct oral anticoagulants (DOAC) is challenging, and simple text messaging reminders have not been effective. METHODS SmartADHERE was a randomized trial that tested a personalized digital and human direct oral anticoagulant adherence intervention compared to usual care. Eligibility required age ≥ 18, newly-prescribed (≤90 days) rivaroxaban for atrial fibrillation (AF), 1 of 4 at-risk criteria for nonadherence, and a smartphone. The intervention consisted of combination of a medication management smartphone app, daily app-based reminders, adaptive text messaging, and phone-based counseling for severe nonadherence. The primary outcome was the proportion of days covered by rivaroxaban (PDC) at 6 months. There were 25 U.S. sites, all cardiology and electrophysiology outpatient practices, activated for a target sample size of 378, but the study was terminated by the sponsor prior to reaching target enrollment. RESULTS There were 139 participants (age 65±9.6 years, 30% female, median CHA2DS2-VASc score 3 with IQR 2 to 4, mean total medication burden 7.7±4.4). DOAC adherence was high in both arms with no difference in the primary outcome (PDC 0.86±0.25 intervention vs 0.88±0.25 control, p=0.62) or in secondary outcomes including PDC ≥ 0.80 and medication persistence. Per protocol analyses had similar results. Because of the high overall PDC, the likelihood to answer the primary hypothesis was only 51% even if target enrollment were achieved. There were no study-related adverse events. CONCLUSIONS The use of a centralized digital and human adherence intervention was feasible across multiple sites. Overall adherence was much higher than expected despite prescreening for at-risk individuals. SmartADHERE illustrates the challenges of trials of behavioral and technology interventions, where enrollment itself may lead to selection bias or treatment effects. Pragmatic study designs, such as cluster randomization or stepped-wedge implementation, should be considered to improve enrollment and generalizability.
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13
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Pouls BPH, Vriezekolk JE, Bekker CL, Linn AJ, van Onzenoort HAW, Vervloet M, van Dulmen S, van den Bemt BJF. Effect of Interactive eHealth Interventions on Improving Medication Adherence in Adults With Long-Term Medication: Systematic Review. J Med Internet Res 2021; 23:e18901. [PMID: 33416501 PMCID: PMC7822716 DOI: 10.2196/18901] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/06/2020] [Accepted: 10/30/2020] [Indexed: 12/15/2022] Open
Abstract
Background Medication nonadherence leads to suboptimal treatment outcomes, making it a major priority in health care. eHealth provides an opportunity to offer medication adherence interventions with minimal effort from health care providers whose time and resources are limited. Objective The aim of this systematic review is twofold: (1) to evaluate effectiveness of recently developed and tested interactive eHealth (including mHealth) interventions on medication adherence in adult patients using long-term medication and (2) to describe strategies among effective interventions. Methods MEDLINE, EMBASE, Cochrane Library, PsycINFO, and Web of Science were systematically searched from January 2014 to July 2019 as well as reference lists and citations of included articles. Eligible studies fulfilled the following inclusion criteria: (1) randomized controlled trial with a usual care control group; (2) a total sample size of at least 50 adult patients using long-term medication; (3) applying an interactive eHealth intervention aimed at the patient or patient’s caregiver; and (4) medication adherence as primary outcome. Methodologic quality was assessed using the Cochrane risk of bias tool. Selection and quality assessment of studies were performed by 2 researchers (BP and BvdB or JV) independently. A best evidence synthesis was performed according to the Cochrane Back Review Group. Results Of the 9047 records screened, 22 randomized clinical trials were included reporting on 29 interventions. Most (21/29, 72%) interventions specified using a (mobile) phone for calling, SMS text messaging, or mobile apps. A majority of all interactive interventions (17/29) had a statistically significant effect on medication adherence (P<.05). Of these interventions, 9 had at least a small effect size (Cohen d ≥ 0.2) and 3 showed strong odds for becoming adherent in the intervention group (odds ratio > 2.0). Our best evidence synthesis provided strong evidence for a positive effect of interventions using SMS text messages or interactive voice response, mobile app, and calls as mode of providing adherence tele-feedback. Intervention strategies “to teach medication management skills,” “to improve health care quality by coordinating medication adherence care between professionals,” and “to facilitate communication or decision making between patients and health care providers” also showed strong evidence for a positive effect. Conclusions Overall, this review supports the hypothesis that interactive eHealth interventions can be effective in improving medication adherence. Intervention strategies that improve patients’ treatment involvement and their medication management skills are most promising and should be considered for implementation in practice.
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Affiliation(s)
- Bart P H Pouls
- Department of Rheumatology Research, Sint Maartenskliniek, Nijmegen, Netherlands.,Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Johanna E Vriezekolk
- Department of Rheumatology Research, Sint Maartenskliniek, Nijmegen, Netherlands
| | - Charlotte L Bekker
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Annemiek J Linn
- Amsterdam School of Communication Research, University of Amsterdam,, Amsterdam, Netherlands
| | - Hein A W van Onzenoort
- Department of Clinical Pharmacy, Amphia Hospital, Breda, Netherlands.,Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Marcia Vervloet
- Nivel (Netherlands Institute for Health Services Research), Utrecht, Netherlands
| | - Sandra van Dulmen
- Nivel (Netherlands Institute for Health Services Research), Utrecht, Netherlands.,Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands.,Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Bart J F van den Bemt
- Department of Rheumatology Research, Sint Maartenskliniek, Nijmegen, Netherlands.,Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
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Insights Into Direct Oral Anticoagulant Therapy Implementation of Stroke Survivors with Atrial Fibrillation in an Ambulatory Setting. J Stroke Cerebrovasc Dis 2020; 30:105530. [PMID: 33333334 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/25/2020] [Accepted: 12/01/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To describe how stroke survivors with atrial fibrillation implement direct oral anticoagulant treatment and propose appropriate metrics to describe adherence. MATERIALS AND METHODS Stroke patients with atrial fibrillation electronically recorded their self-administered direct oral anticoagulants (apixaban, dabigatran, edoxaban, rivaroxaban) during a 6-month observation phase after hospitalisation for ischemic stroke. Taking and timing adherence, correct dosing days, drug holidays, time of the day and day of the week subsets, dose-to-dose intervals and longest intervals between two consecutive doses were calculated from electronic monitoring data to describe and discuss the implementation phase of adherence. RESULTS Data from 41 patients were analysed. Median age was 77 (IQR = 69-84), 63.4% were male and the majority suffered a mild stroke (median NIHSS: 1). Mean taking and timing adherence exceeded 90%. Correct dosing occurred in 86.6% of the days. Seven patients (17.1%) had intake pauses of three or more consecutive days. Patients with twice-daily regimen (70.7%) had higher taking adherence in the morning than in the evening (94.4% versus 89.9%; p = 0.001). No therapy- or anamneses-related characteristic was associated with taking adherence. CONCLUSIONS Although adherence to direct oral anticoagulants of stroke patients with atrial fibrillation exceeded 90%, deviant intake patterns such as drug holidays and missed evening doses were common and raise concerns. Appropriate adherence metrics calculated from electronic monitoring data may guide healthcare professionals elucidating patient-tailored adherence-enhancing interventions. ClinicalTrials.gov registration number: NCT03344146.
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15
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Zeymer U, Lober C, Wolf A, Richard F, Schäfer H, Taggeselle J, Kabitz HJ, Prondzinsky R, Süselbeck T. Use, Persistence, Efficacy, and Safety of Apixaban in Patients with Non-Valvular Atrial Fibrillation in Unselected Patients in Germany. Results of the Prospective Apixaban in Atrial Fibrillation (APAF) Registry. Cardiol Ther 2020; 9:467-478. [PMID: 32638266 PMCID: PMC7584711 DOI: 10.1007/s40119-020-00188-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Apixaban has been shown to be superior to warfarin in patients with non-valvular atrial fibrillation in the randomized ARISTOTLE trial and its use is recommended in current guidelines. There are only scarce data about its use, efficacy, and safety in unselected patients in Germany. METHODS AND RESULTS The APAF registry is a prospective non-interventional study enrolling 5015 patients with non-valvular atrial fibrillation. Of these, 1349 (26.9%) patients were initially treated with apixaban and followed up at 3 and 12 months. The dose of apixaban used was 1 × 2.5 mg in 1.6%, 2 × 2.5 mg in 30.4%, and 2 × 5 mg daily in 68.0% of patients, respectively. Inappropriate underdosing of apixaban was observed in 22.3%, mostly in elderly patients with higher HAS-BLED Score and a history of bleeding. Persistence to apixaban after 1 year was 88.6%, while the dose was changed in 3.7% of patients. Switching to other NOACs or VKAs occurred in 5.1%. After 12 months, all-cause mortality was 5.0%, non-fatal stroke occurred in 0.4%, non-fatal myocardial infarction in 0.6%, ISTH major bleeding in 0.8%, moderate or minor bleeding in 4.3% of patients, respectively. CONCLUSIONS In this prospective experience in unselected patients with atrial fibrillation, persistence to apixaban was high, and efficacy and safety were comparable to the results in clinical trials, supporting its use in clinical practice.
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Affiliation(s)
- Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen, Germany.
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany.
| | - Christiane Lober
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | | | | | | | | | | | | | - Tim Süselbeck
- Kardiologische Praxisklinik Ludwigshafen, Ludwigshafen, Germany
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16
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Wawruch M, Wimmer G, Murin J, Paduchova M, Tesar T, Hlinkova L, Slavkovsky P, Aarnio E. Factors Associated with Reinitiation of Statin Treatment in Older Patients with Peripheral Arterial Disease. Drugs Aging 2020; 37:595-604. [PMID: 32514873 DOI: 10.1007/s40266-020-00772-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Long-term persistence represents a basic precondition of successful statin treatment in patients with peripheral arterial disease (PAD). OBJECTIVES The aims of our study were evaluation of reinitiation in older PAD patients who were non-persistent with statin treatment, and identification of patient-related characteristics associated with the patient's probability of reinitiation. METHODS Our study cohort included 2977 older patients (≥ 65 years) who were non-persistent with statin treatment in whom PAD was newly diagnosed in 2012. Reinitiation was defined as the first statin prescription recorded after discontinuation. To analyze factors associated with the patient´s probability of reinitiation, Cox regression with time-dependent covariates was applied. RESULTS After post-discontinuation follow-up of a mean of 27 months, reinitiation of statin treatment was recorded for 1244 (41.8%) patients. Increasing age, Parkinson's disease, being a new statin user (patient in whom statin treatment was initiated in association with PAD diagnosis), general practitioner as the index prescriber who prescribed a statin for the first time after diagnosis of PAD, coadministration of loop diuretics, and longer persistence before discontinuation decreased the patient's likelihood of reinitiation, whereas myocardial infarction during non-persistence, high-intensity statin treatment, and increasing number of medications increased the patient's probability of reinitiation. CONCLUSIONS In patients with characteristics associated with a lower probability of reinitiation, more concentrated outreach and further evaluation of these groups to identify interventions that might be helpful to encourage reinitiation are needed.
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Affiliation(s)
- Martin Wawruch
- Institute of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Comenius University, Sasinkova 4, 811 08, Bratislava, Slovakia.
| | - Gejza Wimmer
- Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Jan Murin
- 1st Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | | | - Tomas Tesar
- Department of Organization and Management of Pharmacy, Faculty of Pharmacy, Comenius University, Odbojarov 10, 832 32, Bratislava, Slovakia.
| | - Lubica Hlinkova
- General Health Insurance Company, Bratislava, Slovakia.,Institute for Healthcare Disciplines, St. Elizabeth College of Health and Social Work, Bratislava, Slovakia
| | - Peter Slavkovsky
- Institute of Pathophysiology, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Emma Aarnio
- Institute of Biomedicine, University of Turku, Turku, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
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Barrios V, Escobar C, Gómez-Doblas JJ, Fernández-Dueñas J, Garrido RR, Rodríguez JP, Sánchez JU, Arellano-Rodrigo E, Donado E. Patients' perceptions with dabigatran in patients with atrial fibrillation previously treated with vitamin K antagonists. J Comp Eff Res 2020; 9:615-625. [PMID: 32469278 DOI: 10.2217/cer-2020-0001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Vivencio Barrios
- Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Carlos Escobar
- Cardiology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Juan José Gómez-Doblas
- Cardiology Department, Hospital Clínico Universitario Virgen de la Victoria, CIBERCV, Málaga, Spain
| | | | | | | | | | | | - Esther Donado
- Medical Affairs Department, Boehringer-Ingelheim, Sant Cugat del Vallès, Barcelona, Spain
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Kochetkov AI, Ostroumova OD. Optimization of Pharmacotherapy with Direct Oral Anticoagulants: the Need to Choose the Right Dosage Regimen. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2019. [DOI: 10.20996/1819-6446-2019-15-4-593-603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In recent years, there has been a persistent trend towards the more frequent prescription of direct oral anticoagulants (DOACs) compared with vitamin K antagonists due to the extensive body of evidence showing their high safety and efficacy, which in some cases exceed those of warfarin, and also by reason of there is no necessity for regular monitoring of international normalized ratio. However, the question of the reasonable and rational prescription of DOACs becomes relevant, including issues of their dosing, especially as a result of increasing in the number of patients with a complex cardiovascular risk profile and multimorbidity. In these terms, apixaban stands high among the DOAC class, and its high efficacy and safety both in full dose and reasonably reduced dosage has been proved, including older patients, patients with chronic kidney disease, coronary artery disease, with history of acute coronary syndrome and individuals undergoing percutaneous coronary intervention. This DOAC has strict indications to reduce the dose, they are specified in the drug label, and in such cases a reduced dose should be prescribed, in these clinical conditions the effectiveness and safety of apixaban is also proven. The favorable apixaban pharmacokinetic properties, consisting in low renal clearance, lack of clinically relevant interaction with food and the linear smooth effect on the blood coagulation components without episodes of hypo- and hypercoagulation, are the most important components of high efficacy and safety of this DOAC. The optimal efficacy and safety coupling of apixaban is reflected in the exclusively high patients’ adherence to the treatment confirmed by evidence-based medicine data, and therefore there is no necessity for additional procedures to maintain adherence. All the aforementioned facts allow us to recommend apixaban for widespread use in patients requiring anticoagulant therapy for optimal prevention of systemic thromboembolism and minimizing the associated risk of bleeding.
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Affiliation(s)
- A. I. Kochetkov
- Pirogov Russian National Research Medical University, Russian Clinical and Research Center of Gerontology
| | - O. D. Ostroumova
- Pirogov Russian National Research Medical University, Russian Clinical and Research Center of Gerontology;
I.M. Sechenov First Moscow State Medical University (Sechenov University
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19
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Lowres N, Giskes K, Hespe C, Freedman B. Reducing Stroke Risk in Atrial Fibrillation: Adherence to Guidelines Has Improved, but Patient Persistence with Anticoagulant Therapy Remains Suboptimal. Korean Circ J 2019; 49:883-907. [PMID: 31535493 PMCID: PMC6753021 DOI: 10.4070/kcj.2019.0234] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/24/2022] Open
Abstract
Atrial fibrillation (AF) is a significant risk factor for avoidable stroke. Among high-risk patients with AF, stroke risk can be mitigated using oral anticoagulants (OACs), however reduction is largely contingent on physician prescription and patient persistence with OAC therapy. Over the past decade significant advances have occurred, with revisions to clinical practice guidelines relating to management of stroke risk in AF in several countries, and the introduction of non-vitamin K antagonist OACs (NOACs). This paper summarises the evolving body of research examining guideline-based clinician prescription over the past decade, and patient-level factors associated with OAC persistence. The review shows clinicians' management over the past decade has increasingly reflected guideline recommendations, with an increasing proportion of high-risk patients receiving OACs, driven by an upswing in NOACs. However, a treatment gap remains, as 25–35% of high-risk patients still do not receive OAC treatment, with great variation between countries. Reduction in stroke risk directly relates to level of OAC prescription and therapy persistence. Persistence and adherence to OAC thromboprophylaxis remains an ongoing issue, with 2-year persistence as low as 50%, again with wide variation between countries and practice settings. Multiple patient-level factors contribute to poor persistence, in addition to concerns about bleeding. Considered review of individual patient's factors and circumstances will assist clinicians to implement appropriate strategies to address poor persistence. This review highlights the interplay of both clinician's awareness of guideline recommendations and understanding of individual patient-level factors which impact adherence and persistence, which are required to reduce the incidence of preventable stroke attributable to AF.
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Affiliation(s)
- Nicole Lowres
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Katrina Giskes
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,School of Medicine, The University of Notre Dame, Sydney, Australia
| | - Charlotte Hespe
- School of Medicine, The University of Notre Dame, Sydney, Australia
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Cardiology, Concord Hospital, The University of Sydney Concord Clinical School, Concord, Australia
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