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Amir MA, Amir MA, Kumar A, Arsal SA. Comment on: Long-term outcome and predictor of mortality in patient with pulmonary embolism undergoing catheter-directed thrombolysis: A 10-year retrospective study. Curr Probl Cardiol 2024; 49:102525. [PMID: 38492620 DOI: 10.1016/j.cpcardiol.2024.102525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 03/13/2024] [Indexed: 03/18/2024]
Affiliation(s)
| | | | - Aashish Kumar
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari, Karachi
| | - Syed Ali Arsal
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari, Karachi.
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Bawa D, Darden D, Ahmed A, Garg J, Karst E, Kabra R, Pothineni K, Gopinathannair R, Mansour M, Winterfield J, Lakkireddy D. Lower-adherence direct oral anticoagulant use is associated with increased risk of thromboembolic events than warfarin. J Interv Card Electrophysiol 2024; 67:709-718. [PMID: 37556090 DOI: 10.1007/s10840-023-01585-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/01/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Real-world data have suggested inconsistent adherence to oral anticoagulation for thromboembolic event (TE) prevention in patients with Non valvular atrial fibrillation (NVAF), yet it remains unclear if event risk is elevated during gaps of non-adherence. OBJECTIVE To compare difference in outcomes between direct oral anticoagulant (DOAC) and warfarin based on adherence to the therapy in patients with NVAF. METHODS Using the MarketScan claims data, patients receiving prescription of warfarin or a DOAC for NVAF from January 2015 to June 2016 were included. Outcomes included hospitalization for TE (ischemic stroke or systemic embolism), hemorrhagic stroke, stroke of any kind, and major bleeding. Event rates were reported for warfarin and DOACs at a higher-adherence proportion of days covered (PDC > 80%) and lower-adherence (PDC 40-80%). RESULTS The cohort included 83,168 patients prescribed warfarin (51% [n = 42,639]) or DOAC (49% [n = 40,529]). Lower adherence occurred in 36% (n = 15,330) of patients prescribed warfarin and 26% (n = 10,956) prescribed DOAC. As compared to higher-adherence warfarin after multivariable adjustment, the risk of TE was highest in lower-adherence DOAC (HR 1.26; 95% CI, 1.14-1.33), and lowest in higher-adherence DOAC (HR, 0.93; 95% CI, 0.88-0.99). There was a significantly higher risk of hemorrhagic stroke and stroke of any kind in the lower-adherence groups. Major bleeding was more common with lower-adherence DOAC (HR, 1.43, 95% CI, 1.35-1.52) and lower-adherence warfarin (HR, 1.32, 95% CI, 1.26-1.39). CONCLUSIONS In this large real-world study, low adherence DOAC was associated with higher risk of TE events as compared to high and low adherence warfarin.
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Affiliation(s)
- Danish Bawa
- The Kansas City Heart Rhythm Institute (KCHRI) @ HCA Midwest, the University of Missouri - Columbia, 12200, W 106Th Street, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA
| | - Douglas Darden
- The Kansas City Heart Rhythm Institute (KCHRI) @ HCA Midwest, the University of Missouri - Columbia, 12200, W 106Th Street, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA
| | - Adnan Ahmed
- The Kansas City Heart Rhythm Institute (KCHRI) @ HCA Midwest, the University of Missouri - Columbia, 12200, W 106Th Street, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA
| | - Jalaj Garg
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, CA, USA
| | | | - Rajesh Kabra
- The Kansas City Heart Rhythm Institute (KCHRI) @ HCA Midwest, the University of Missouri - Columbia, 12200, W 106Th Street, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA
| | - Krishna Pothineni
- The Kansas City Heart Rhythm Institute (KCHRI) @ HCA Midwest, the University of Missouri - Columbia, 12200, W 106Th Street, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA
| | - Rakesh Gopinathannair
- The Kansas City Heart Rhythm Institute (KCHRI) @ HCA Midwest, the University of Missouri - Columbia, 12200, W 106Th Street, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA
| | | | - Jeffrey Winterfield
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Dhanunjaya Lakkireddy
- The Kansas City Heart Rhythm Institute (KCHRI) @ HCA Midwest, the University of Missouri - Columbia, 12200, W 106Th Street, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA.
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Wang Z, Lu Y, Wang P, Fei C, Li S, Xue H, Li Z, Wang Q, Zhang K, Ma T. Suboptimal Use of DOACs Post-Discharge for Geriatric Hip Fractures with Isolated Calf Deep Vein Thrombosis: Do Clinician Prescribing Preferences and Patient Compliance Alters Clinical Outcomes? Clin Interv Aging 2023; 18:1423-1436. [PMID: 37663122 PMCID: PMC10473050 DOI: 10.2147/cia.s421422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/06/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction This study aimed to examine the impacts of DOACs compliance and prescribing preferences on clinical outcomes in elderly hip fracture patients with isolated calf deep vein thrombosis (ICDVT). Methods We conducted a retrospective cohort study that evaluated 702 patients who underwent surgical treatment combined with ICDVT in an academic university hospital between January 2016 and October 2021. DOACs compliance was investigated through telephone and outpatient follow-up, and ICDVT clinical outcomes were collected 30 and 90 days post-discharge, respectively. Variables of interest were collected through the electronic medical record system, and data were analyzed after adjusting for predictors of non-completely dissolved (CD) of ICDVT. Results The DOACs compliance survey revealed that 375 (53.42%) patients were fully adherent, 270 (38.46%) were fairly adherent, and 57 (8.12%) were poorly adherent. Approximately 62% of patients had ICDVT dissipation within 30 days after discharge, reaching 94% within 90 days. DOACs QD/BID regimen is often based on economic status, activity capacity, discharge destination and post-operative weight-bearing activities (p<0.05).The mechanism of injury, ASA classification, surgical technique and timing of ICDVT formation were significantly correlated with DOACs 14/28 days regimen (p<0.05).Multivariate analysis revealed that rural patients [OR 1.518 (95% CI, 1.117-2.236)], pre-operative ICDVT[OR 2.816 (95% CI, 1.862-4.259)] and thrombus length [OR 1.157 (95% CI, 1.263-1.821)] were ICDVT risk factors for non-CD. Furthermore, DOACs fair compliance [OR 0.087 (95% CI, 0.042-0.178)], DOACs full compliance [OR 0.283 (95% CI, 0.139-0.579)], and hospitalization duration [OR 0.793 (95% CI, 0.694-0.907)] were ICDVT protective factors for CD. Conclusion Better compliance with DOACs benefits early ICDVT dissipation, but final clinical outcomes have to be validated with longer follow-up periods. When managing elderly patients with hip fractures, indications for anticoagulation should be considered and individualized protocols should be used.
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Affiliation(s)
- Zhimeng Wang
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Yao Lu
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Pengfei Wang
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Chen Fei
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Shuhao Li
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Hanzhong Xue
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Zhong Li
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Qian Wang
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Kun Zhang
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Teng Ma
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
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Tarn DM, Shih K, Tseng CH, Thomas A, Schwartz JB. Reasons for Nonadherence to the Direct Oral Anticoagulant Apixaban: A Cross-Sectional Survey of Atrial Fibrillation Patients. JACC. ADVANCES 2023; 2:100175. [PMID: 38939023 PMCID: PMC11198726 DOI: 10.1016/j.jacadv.2022.100175] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/22/2022] [Indexed: 06/29/2024]
Abstract
Background Nonadherence to direct oral anticoagulants to prevent stroke occurs in up to 40% of atrial fibrillation patients. Underlying reasons are poorly understood. Objectives This study quantified patient-reported reasons for nonadherence and identified strategies to improve adherence. Methods This is a cross-sectional survey of atrial fibrillation patients in 2 academic health systems who reported apixaban nonadherence. We examined patient-reported reasons for nonadherence and level of nonadherence (assessed by a validated 3-item adherence measure) using a multivariable logistic regression model. Results Of 419 study patients, 41.5% were women. The mean age was 71.1 ± 10 years and mean CHA2DS2VASc score was 3.2 ± 1.6. About two-thirds had adherence scores ≥80 (mild nonadherence) and one-third scores <80 (poor adherence). In all groups, forgetfulness contributed to nonadherence. Attitudes/beliefs associated with adherence score <80 included: not believing apixaban was needed (odds ratio [OR]: 12.24 [95% CI: 2.25-66.47]); medication cost (OR: 3.97 [95% CI: 1.67-9.42]); and fear of severe bleeding (OR: 3.28 [95% CI: 1.20-8.96]). Strategies that patients with adherence scores <80 selected as helping "a great deal/a lot" to increase adherence included bloodwork to evaluate efficacy (56%), physician counseling about adherence (55%), and having a reversal agent (39%). Almost one-half of all patients did not disclose nonadherence to their providers. Conclusions Patients may not disclose their nonadherence to prescribers, and attitudes related to apixaban nonadherence differ among patients with mild nonadherence versus poor adherence. While all patients may benefit from strategies to address forgetfulness, concerns related to the purpose of apixaban, cost, and bleeding risk may require special attention in those with poor adherence.
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Affiliation(s)
- Derjung M. Tarn
- Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, California, USA
| | - Kevin Shih
- Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, California, USA
| | - Chi-hong Tseng
- Division of General Internal Medicine/Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, California, USA
| | - Alveena Thomas
- Division of Geriatrics, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Janice B. Schwartz
- Division of Geriatrics, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Division of Clinical Pharmacology, Departments of Medicine and Bioengineering and Therapeutic Sciences, University of California-San Francisco, San Francisco, California, USA
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Oral anticoagulants: a systematic overview of reviews on efficacy and safety, genotyping, self-monitoring, and stakeholder experiences. Syst Rev 2022; 11:232. [PMID: 36303235 PMCID: PMC9615370 DOI: 10.1186/s13643-022-02098-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/08/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND This systematic overview was commissioned by England's Department of Health and Social Care (DHSC) to assess the evidence on direct (previously 'novel') oral anticoagulants (OACs), compared with usual care, in adults, to prevent stroke related to atrial fibrillation (AF), and to prevent and treat venous thromboembolism (VTE). Specifically, to assess efficacy and safety, genotyping, self-monitoring, and patient and clinician experiences of OACs. METHODS We searched MEDLINE, Embase, ASSIA, and CINAHL, in October, 2017, updated in November 2021. We included systematic reviews, published from 2014, in English, assessing OACs, in adults. We rated review quality using AMSTAR2 or the JBI checklist. Two reviewers extracted and synthesised the main findings from the included reviews. RESULTS We included 49 systematic reviews; one evaluated efficacy, safety, and cost-effectiveness, 17 assessed genotyping, 23 self-monitoring or adherence, and 15 experiences (seven assessed two topics). Generally, the direct OACs, particularly apixaban (5 mg twice daily), were more effective and safer than warfarin in preventing AF-related stroke. For VTE, there was little evidence of differences in efficacy between direct OACs and low-molecular-weight heparin (prevention), warfarin (treatment), and warfarin or aspirin (secondary prevention). The evidence suggested that some direct OACs may reduce the risk of bleeding, compared with warfarin. One review of genotype-guided warfarin dosing assessed AF patients; no significant differences in stroke prevention were reported. Education about OACs, in patients with AF, could improve adherence. Pharmacist management of coagulation may be better than primary care management. Patients were more adherent to direct OACs than warfarin. Drug efficacy was highly valued by patients and most clinicians, followed by safety. No other factors consistently affected patients' choice of anticoagulant and adherence to treatment. Patients were more satisfied with direct OACs than warfarin. CONCLUSIONS For stroke prevention in AF, direct OACs seem to be more effective and safer than usual care, and apixaban (5 mg twice daily) had the best profile. For VTE, there was no strong evidence that direct OACs were better than usual care. Education and pharmacist management could improve coagulation control. Both clinicians and patients rated efficacy and safety as the most important factors in managing AF and VTE. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017084263-one deviation; efficacy and safety were from one review.
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Yang SY, Kang DW, Nam JH, Choi EK, Lee EK, Shin JY, Kwon SH. Adherence is an optimal factor for maximizing the effective and safe use of oral anticoagulants in patients with atrial fibrillation. Sci Rep 2022; 12:3413. [PMID: 35233055 PMCID: PMC8888574 DOI: 10.1038/s41598-022-07316-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 02/15/2022] [Indexed: 11/24/2022] Open
Abstract
Few studies assessed the association between major adverse cardiovascular events and adherence to warfarin and direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF). Therefore, we aimed to evaluate the effects of adherence to oral anticoagulants (OACs) in patients with AF using claims data (July 2014–April 2019). Using the initial 3-month medication possession rate (MPR), patients were categorized into adherent (MPR ≥ 0.8) or non-adherent (MPR < 0.8) groups. Propensity score matching of non-adherent group to adherent group was conducted for warfarin (1:1) and DOAC (1:3), respectively. Incidence of ischemic stroke, myocardial infarction (MI), intracranial hemorrhage, and all-cause death was assessed in the matched cohort (67,147 patients). The hazard ratio (HR) for adherence to OAC was estimated using the Cox proportional hazard model with adjusting covariate including age and sex. The risk for ischemic stroke, MI, and all-cause death was lower in the DOAC adherent group than in the DOAC non-adherent group (HR: 0.78; 95% confidence intervals: 0.73–0.84; 0.75, 0.60–0.94; 0.54, 0.51–0.57, respectively). Adherence to OAC was not associated with the risk of intracranial hemorrhage (1.01, 0.85–1.20). Commitment programs to improve adherence in patients with AF could maximize drug effectiveness and safety.
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Affiliation(s)
- So-Young Yang
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea
| | - Dong-Won Kang
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea
| | - Jin Hyun Nam
- Department of Big Data Science, Korea University Sejong Campus, Sejong, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eui-Kyung Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea. .,Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, Republic of Korea.
| | - Sun-Hong Kwon
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea.
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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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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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Moudallel S, van Laere S, Cornu P, Dupont A, Steurbaut S. Assessment of adherence, treatment satisfaction and knowledge of direct oral anticoagulants in atrial fibrillation patients. Br J Clin Pharmacol 2021; 88:2419-2429. [PMID: 34907577 DOI: 10.1111/bcp.15180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/29/2021] [Accepted: 12/02/2021] [Indexed: 11/28/2022] Open
Abstract
AIM The direct oral anticoagulants (DOACs) are increasingly used for stroke prevention in atrial fibrillation (AF). However, little is known about the association between medication adherence, patient satisfaction and treatment knowledge. The objective was to determine patients' DOAC adherence and their treatment satisfaction over time. Furthermore, we respectively investigated possible associations of treatment satisfaction and treatment knowledge in relation to adherence. METHODS Longitudinal study conducted in AF patients hospitalized in 2019 in a tertiary university hospital. DOAC adherence, treatment satisfaction and knowledge were assessed with validated questionnaires. Mixed effects logistic regression was modelled to investigate the effect of both treatment satisfaction and knowledge on DOAC adherence over time. RESULTS In total, 164 patients participated of which 128 and 101 patients could be recontacted after a period of respectively 3 (first contact) and 6 months (second contact) to assess adherence and treatment satisfaction. Suboptimal adherence was observed in 40.6% of the patients after 3 months and in 42.6% after 6 months (p=0.78). There was no significant difference (p=0.29) in the total score for treatment satisfaction between the first (79.2%) and the second contact (80.6%). DOAC adherence was not affected by time (p=0.71) nor by total knowledge score (p=0.61) or treatment satisfaction score (p=0.34). Nonetheless, a strong correlation between treatment satisfaction and knowledge was found (p=0.004). CONCLUSION DOAC adherence was suboptimal. Treatment satisfaction and knowledge were not associated with DOAC adherence over a 6 month period. Knowledge gaps were identified that could be remediated through patient education and follow-up.
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Affiliation(s)
- Souad Moudallel
- Research Group Clinical Pharmacology and Clinical Pharmacy; Vrije Universiteit Brussel, Brussel, Belgium
| | - Sven van Laere
- Research Group of Biostatistics and Medical Informatics, Department of Public Health (GEWE), Vrije Universiteit Brussel, Brussel, Belgium
| | - Pieter Cornu
- Research Group Clinical Pharmacology and Clinical Pharmacy; Vrije Universiteit Brussel, Brussel, Belgium
| | - Alain Dupont
- Research Group Clinical Pharmacology and Clinical Pharmacy; Vrije Universiteit Brussel, Brussel, Belgium
| | - Stephane Steurbaut
- Research Group Clinical Pharmacology and Clinical Pharmacy; Vrije Universiteit Brussel, Brussel, Belgium
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Mansukhani SG, MacLean EA, Manzey LL, Possidente CJ, Cappelleri JC, Deal LS. Development of a New Patient-Reported Medication Adherence Instrument: Concerns Influencing Medication Adherence. Patient Prefer Adherence 2021; 15:1991-2007. [PMID: 34526767 PMCID: PMC8437415 DOI: 10.2147/ppa.s318030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/16/2021] [Indexed: 01/23/2023] Open
Abstract
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.
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Affiliation(s)
| | - Elizabeth A MacLean
- Medical Outcomes Specialists (EAM, LLM, CJP); Patient Centered Outcome Assessment (LSD); Biostatistics (JCC), Pfizer Inc., New York, NY, USA
| | - Laura L Manzey
- Medical Outcomes Specialists (EAM, LLM, CJP); Patient Centered Outcome Assessment (LSD); Biostatistics (JCC), Pfizer Inc., New York, NY, USA
| | - Carl J Possidente
- Medical Outcomes Specialists (EAM, LLM, CJP); Patient Centered Outcome Assessment (LSD); Biostatistics (JCC), Pfizer Inc., New York, NY, USA
| | - Joseph C Cappelleri
- Medical Outcomes Specialists (EAM, LLM, CJP); Patient Centered Outcome Assessment (LSD); Biostatistics (JCC), Pfizer Inc., New York, NY, USA
| | - Linda S Deal
- Medical Outcomes Specialists (EAM, LLM, CJP); Patient Centered Outcome Assessment (LSD); Biostatistics (JCC), Pfizer Inc., New York, NY, USA
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Examining Adherence to Medication in Patients With Atrial Fibrillation: The Role of Medication Beliefs, Attitudes, and Depression. J Cardiovasc Nurs 2021; 35:337-346. [PMID: 32084080 DOI: 10.1097/jcn.0000000000000650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND/OBJECTIVES This study examined whether beliefs about medicines, drug attitudes, and depression independently predicted anticoagulant and antiarrhythmic adherence (focusing on the implementation phase of nonadherence) in patients with atrial fibrillation (AF). METHODS This cross-sectional study was part of a larger longitudinal study. Patients with AF (N = 118) completed the Patient Health Questionnaire-8. The Beliefs about Medicines Questionnaire, Drug Attitude Inventory, and Morisky-Green-Levine Medication Adherence Scale (self-report adherence measure), related to anticoagulants and antiarrhythmics, were also completed. Correlation and multiple logistic regression analyses were conducted. RESULTS There were no significant differences in nonadherence to anticoagulants or antiarrhythmics. Greater concerns (r = 0.23, P = .01) were significantly, positively associated with anticoagulant nonadherence only. Depression and drug attitudes were not significantly associated with anticoagulant/antiarrhythmic adherence. Predictors reliably distinguished adherers and nonadherers to anticoagulant medication in the regression model, explaining 14% of the variance, but only concern beliefs (odds ratio, 1.20) made a significant independent contribution to prediction (χ = 11.40, P = .02, with df = 4). When entered independently into a regression model, concerns (odds ratio, 1.24) significantly explained 10.3% of the variance (χ = 7.97, P = .01, with df = 1). Regressions were not significant for antiarrhythmic medication (P = .30). CONCLUSIONS Specifying medication type is important when examining nonadherence in chronic conditions. Concerns about anticoagulants, rather than depression, were significantly associated with nonadherence to anticoagulants but not antiarrhythmics. Anticoagulant concerns should be targeted at AF clinics, with an aim to reduce nonadherence and potentially modifiable adverse outcomes such as stroke.
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Toorop MMA, Chen Q, Tichelaar VYIG, Cannegieter SC, Lijfering WM. Predictors, time course, and outcomes of persistence patterns in oral anticoagulation for non-valvular atrial fibrillation: a Dutch Nationwide Cohort Study. Eur Heart J 2021; 42:4126-4137. [PMID: 34269375 PMCID: PMC8530535 DOI: 10.1093/eurheartj/ehab421] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/06/2021] [Accepted: 06/18/2021] [Indexed: 12/02/2022] Open
Abstract
Aims Persistence with direct oral anticoagulants (DOACs) has become a concern in non-valvular atrial fibrillation (NVAF) patients, but whether this affects prognosis is rarely studied. We investigated the persistence with oral anticoagulants (OACs) and its association with prognosis among a nationwide cohort of NVAF patients. Methods and results DOAC-naive NVAF patients who started to use DOACs for ischaemic stroke prevention between 2013 and 2018 were included using Dutch national statistics. Persistence with OACs was determined based on the presence of a 100-day gap between the last prescription and the end of study period. In 93 048 patients, 75.7% had a baseline CHA2DS2-VASc score of ≥2. The cumulative incidence of persistence with OACs was 88.1% [95% confidence interval (CI) 87.9–88.3%], 82.6% (95% CI 82.3–82.9%), 77.7% (95% CI 77.3–78.1%), and 72.0% (95% CI 71.5–72.5%) at 1, 2, 3, and 4 years after receiving DOACs, respectively. Baseline characteristics associated with better persistence with OACs included female sex, age range 65–74 years, permanent atrial fibrillation, previous exposure to vitamin K antagonists, stroke history (including transient ischaemic attack), and a CHA2DS2-VASc score ≥2. Non-persistence with OACs was associated with an increased risk of the composite outcome of ischaemic stroke and ischaemic stroke-related death [adjusted hazard ratio (aHR) 1.79, 95% CI 1.49–2.15] and ischaemic stroke (aHR 1.58, 95% CI 1.29–1.93) compared with being persistent with OACs. Conclusion At least a quarter of NVAF patients were non-persistent with OACs within 4 years, which was associated with poor efficacy of ischaemic stroke prevention. The identified baseline characteristics may help identify patients at risk of non-persistence.
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Affiliation(s)
- Myrthe M A Toorop
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, Box 9600, Leiden 2300 RC, The Netherlands
| | - Qingui Chen
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, Box 9600, Leiden 2300 RC, The Netherlands
| | - Vladimir Y I G Tichelaar
- Department of Haematology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9713 GZ, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, Box 9600, Leiden 2300 RC, The Netherlands.,Department of Internal Medicine, Section of Thrombosis and Haemostasis, Leiden University Medical Center, Albinusdreef 2, Box 9600, Leiden 2300 RC, The Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, Box 9600, Leiden 2300 RC, The Netherlands
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12
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Guo C, Hu B, Guo C, Meng X, Kuang Y, Huang L, Wang D, Xu K, Zhao Y, Yang G, Cai W, Shu Y. A Survey of Pharmacogenomics Testing Among Physicians, Pharmacists, and Researchers From China. Front Pharmacol 2021; 12:682020. [PMID: 34322018 PMCID: PMC8311355 DOI: 10.3389/fphar.2021.682020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/30/2021] [Indexed: 11/13/2022] Open
Abstract
To elucidate current domestic factors influencing pharmacogenomics (PGx) implementation and its future in China, we conducted a questionnaire survey on PGx applications and testing. A questionnaire-based survey was created on the popular online professional survey platform "Wenjuanxing" (www.wjx.cn) and performed via the social media platform WeChat. Among 422 participants, there were physicians (27.7%), pharmacists (31.3%), and researchers (41.0%). We found that less than 50% of physicians were aware of the importance of PGx in drug therapy, while over 50% of pharmacists and researchers recognized the importance. Only 38.5% of physicians, 40.9% of pharmacists, and 55.5% of researchers concurred that PGx analysis could lower the economic burdens for patients. However, most of the responders affirmed that PGx should be effectively implemented in clinical practices. A lack of sector standards, a lack of clinical research, and a lack of guidelines were found to be the major factors for hindering PGx clinical application. Among drugs associated with PGx assays, the most common were warfarin and clopidogrel. Although PGx research has advanced rapidly in recent years in mainland China, the clinical implementation of PGx has a long way to go.
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Affiliation(s)
- Chengxian Guo
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Biwen Hu
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chengjun Guo
- School of Applied Mathematics, Guangdong University of Technology, Guangzhou, China
| | - Xiangguang Meng
- Laboratory of Cardiovascular Disease and Drug Research, Zhengzhou No. 7 People’s Hospital, Zhengzhou, China
| | - Yun Kuang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Longjian Huang
- Youjiang Medical University for Nationalities, Baise, China
| | - Danling Wang
- Department of Neuroscience, Hengyang School of Medicine, University of South China, Hengyang, China
- Changsha Central Hospital, University of South China, Hengyang, China
| | - Kangwei Xu
- Hunan Normal University School of Medicine, Changsha, China
| | - Yanlin Zhao
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Guoping Yang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Weimin Cai
- Department of Clinical Pharmacy, School of Pharmacy, Fudan University, Shanghai, China
| | - Yan Shu
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland at Baltimore, Baltimore, MD, United States
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13
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Kamath CC, Giblon R, Kunneman M, Lee AI, Branda ME, Hargraves IG, Sivly AL, Bellolio F, Jackson EA, Burnett B, Gorr H, Torres Roldan VD, Spencer-Bonilla G, Shah ND, Noseworthy PA, Montori VM, Brito JP. Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2116009. [PMID: 34255051 PMCID: PMC8278261 DOI: 10.1001/jamanetworkopen.2021.16009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
IMPORTANCE How patients with atrial fibrillation (AF) and their clinicians consider cost in forming care plans remains unknown. OBJECTIVE To identify factors that inform conversations regarding costs of anticoagulants for treatment of AF between patients and clinicians and outcomes associated with these conversations. DESIGN, SETTING, AND PARTICIPANTS This cohort study of recorded encounters and participant surveys at 5 US medical centers (including academic, community, and safety-net centers) from the SDM4AFib randomized trial compared standard AF care with and without use of a shared decision-making (SDM) tool. Included patients were considering anticoagulation treatment and were recruited by their clinicians between January 30, 2017, and June 27, 2019. Data were analyzed between August and November 2019. MAIN OUTCOMES AND MEASURES The incidence of and factors associated with cost conversations, and the association of cost conversations with patients' consideration of treatment cost burden and their choice of anticoagulation. RESULTS A total of 830 encounters (out of 922 enrolled participants) were recorded. Patients' mean (SD) age was 71.0 (10.4) years; 511 patients (61.6%) were men, 704 (86.0%) were White, 303 (40.9%) earned between $40 000 and $99 999 in annual income, and 657 (79.2%) were receiving anticoagulants. Clinicians' mean (SD) age was 44.8 (13.2) years; 75 clinicians (53.2%) were men, and 111 (76%) practiced as physicians, with approximately half (69 [48.9%]) specializing in either internal medicine or cardiology. Cost conversations occurred in 639 encounters (77.0%) and were more likely in the SDM arm (378 [90%] vs 261 [64%]; OR, 9.69; 95% CI, 5.77-16.29). In multivariable analysis, cost conversations were more likely to occur with female clinicians (66 [47%]; OR, 2.85; 95% CI, 1.21-6.71); consultants vs in-training clinicians (113 [75%]; OR, 4.0; 95% CI, 1.4-11.1); clinicians practicing family medicine (24 [16%]; OR, 12.12; 95% CI, 2.75-53.38]), internal medicine (35 [23%]; OR, 3.82; 95% CI, 1.25-11.70), or other clinicians (21 [14%]; OR, 4.90; 95% CI, 1.32-18.16) when compared with cardiologists; and for patients with an annual household income between $40 000 and $99 999 (249 [82.2%]; OR, 1.86; 95% CI, 1.05-3.29) compared with income below $40 000 or above $99 999. More patients who had cost conversations reported cost as a factor in their decision (244 [89.1%] vs 327 [69.0%]; OR 3.66; 95% CI, 2.43-5.50), but cost conversations were not associated with the choice of anticoagulation agent. CONCLUSIONS AND RELEVANCE Cost conversations were common, particularly for middle-income patients and with female and consultant-level primary care clinicians, as well as in encounters using an SDM tool; they were associated with patients' consideration of treatment cost burden but not final treatment choice. With increasing costs of care passed on to patients, these findings can inform efforts to promote cost conversations in practice. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02905032.
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Affiliation(s)
- Celia C. Kamath
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Rachel Giblon
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Marlene Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander I. Lee
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Megan E. Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Colorado School of Public Health, Anschutz Medical Campus, University of Colorado, Denver, Aurora
| | - Ian G. Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Angela L. Sivly
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Elizabeth A. Jackson
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Lois Park, Minnesota
| | - Haeshik Gorr
- Division of General Internal Medicine, Hennepin Health, Minneapolis, Minnesota
| | - Victor D. Torres Roldan
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Peter A. Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Juan P. Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
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14
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Olsson K, Hörnsten Å, Hellström Ängerud K. Treated with preventive anticoagulation therapy in atrial fibrillation: The patients' perspective. Nurs Open 2021; 9:2657-2664. [PMID: 34132062 PMCID: PMC9584489 DOI: 10.1002/nop2.964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/24/2021] [Accepted: 05/28/2021] [Indexed: 11/11/2022] Open
Abstract
AIM The aim of this study was to explore patients' experiences of preventive anticoagulation therapy in atrial fibrillation. DESIGN This was a descriptive qualitative study based on interviews. METHODS Individual interviews with 15 patients, 6 women and 9 men, treated with preventive oral anticoagulant due to atrial fibrillation, were conducted. The interviews were analysed with qualitative content analysis. RESULTS Based on the analysis, the theme Managing a necessary evil emerged. The theme comprised the three categories: Coping with anxiety and changes in daily life, Having confidence in care and Being a partner or only a receiver of treatment. Patients described it like being faced with a situation where a treatment perceived as vital was weighed against undesirable consequences and risks. Patients trusted caregivers and had confidence in care, but there was a risk of being a receiver of care instead of becoming a partner.
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Affiliation(s)
- Karin Olsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Åsa Hörnsten
- Department of Nursing, Umeå University, Umeå, Sweden
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15
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Bekele BB, Harsha N, Kőrösi L, Vincze F, Czifra Á, Ádány R, Sándor J. Is Prescription Nonredemption a Source of Poor Health Among the Roma? Cross-Sectional Analysis of Drug Consumption Data From the National Health Insurance Fund of Hungary. Front Pharmacol 2021; 12:616092. [PMID: 33767624 PMCID: PMC7985259 DOI: 10.3389/fphar.2021.616092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/28/2021] [Indexed: 12/01/2022] Open
Abstract
Background: The health status of the Roma is inferior to that of the general population. The causes of poor health among this population are still ambiguous, but they include low utilization of healthcare services. Our study aimed to investigate prescription redemptions in segregated Roma colonies (SRC) where the most disadvantaged quartile of Roma people are living. Methods: A cross-sectional study was carried out with data obtained from the National Institute of Health Insurance Fund Management in the settlements belonging to the study area of the “Public Health-Focused Model Program for Organizing Primary Care Services.” The study included 4,943 residents of SRC and 62,074 residents of the complementary area (CA) of the settlements where SRC were located. Crude and age- and sex-standardized redemption ratios for SRC and CA were calculated for each Anatomic Therapeutic Chemical (ATC) group and for the total practice by ATC group. Standardized relative redemptions (RR) with 95% confidence intervals were calculated for SRC, with CA as a reference. Results: The crude redemption ratios were 73.13% in the SRC and 71.15% in the CA. RRs were higher in the SRC than in the CA for cardiovascular, musculoskeletal system, and alimentary tract and metabolism drugs (11.5, 3.7, and 3.5%, respectively). In contrast, RRs were lower in the SRC than in the CA for anti-infective agents (22.9%) due to the poor redemption of medicines prescribed for children or young adults. Despite the overall modest differences in redemption ratios, some ATC groups showed remarkable differences. Those include cardiovascular, alimentary and musculoskeletal drugs. Conclusion: Redemption of prescriptions was significantly higher among Roma people living in SRC than among those living in CA. The better redemption of cardiovascular and alimentary tract drugs was mainly responsible for this effect. These findings contradict the stereotype that the Roma do not use health services properly and that prescription non-redemption is responsible for their poor health.
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Affiliation(s)
- Bayu Begashaw Bekele
- Doctoral School of Health Sciences, University of Debrecen, Debrecen, Hungary.,Department of Public Health, College of Health Sciences, Mizan Tepi University, Mizan Aman, Ethiopia.,Department of Public Health and Epidemiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Nouh Harsha
- Doctoral School of Health Sciences, University of Debrecen, Debrecen, Hungary.,Department of Public Health and Epidemiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Kőrösi
- Department of Financing, National Health Insurance Fund, Budapest, Hungary
| | - Ferenc Vincze
- Doctoral School of Health Sciences, University of Debrecen, Debrecen, Hungary
| | - Árpád Czifra
- Department of Public Health and Epidemiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Róza Ádány
- Department of Public Health and Epidemiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,MTA-DE Public Health Research Group, University of Debrecen, Debrecen, Hungary
| | - János Sándor
- Department of Public Health and Epidemiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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16
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Moudallel S, van den Bemt BJF, Zwikker H, de Veer A, Rydant S, Dijk LV, Steurbaut S. Association of conflicting information from healthcare providers and poor shared decision making with suboptimal adherence in direct oral anticoagulant treatment: A cross-sectional study in patients with atrial fibrillation. PATIENT EDUCATION AND COUNSELING 2021; 104:155-162. [PMID: 32622691 DOI: 10.1016/j.pec.2020.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To assess direct oral anticoagulant (DOAC) adherence and to determine possible determinants for suboptimal adherence in Dutch patients with atrial fibrillation (AF). METHODS Cross-sectional study of DOAC users who completed a self-reported questionnaire. Adherence was measured with Morisky8-item Medication Adherence Scale (MMAS-8). Logistic regression analysis was conducted to investigate determinants affecting adherence. RESULTS 398 DOAC users completed the questionnaire (mean age 70.6 ± 9.2years). Approximately one in four patients had suboptimal adherence (MMAS-8 < 8). Multivariable analysis showed that patients who felt to have received conflicting information about the treatment, patients with higher educational level and patients who were not sufficiently involved in the treatment choice had a higher odds of suboptimal adherence. CONCLUSION DOAC adherence was suboptimal. Conflicting information received from different healthcare providers (HCPs), lack of shared decision making and the patients' educational level were determinants negatively affecting DOAC adherence. PRACTICE IMPLICATIONS Efforts towards identifying suboptimally adherent DOAC patients are needed since they are at higher risk to develop thromboembolic events. Adherence counselling should be systematically and repeatedly encouraged and shared decision making should become more mainstream. Moreover, reinforced education of both patients and HCPs combined with interprofessional collaboration are potential solutions to prevent knowledge gaps and communication of conflicting information.
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Affiliation(s)
- Souad Moudallel
- Vrije Universiteit Brussel, Faculty of Medicine and Pharmacy, Centre for Pharmaceutical Research (CePhar), Brussels, Belgium; Department of Clinical Pharmacology and Pharmacotherapy, Universitair Ziekenhuis (UZ) Brussel, Brussels, Belgium.
| | - Bart J F van den Bemt
- Department of Rheumatology and Pharmacy, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Hanneke Zwikker
- Dutch Institute for Rational Use of Medicine (IVM), Utrecht, the Netherlands
| | - Anne de Veer
- Department of Cardiology, St-Antonius Hospital, Nieuwegein, the Netherlands
| | - Silas Rydant
- Vrije Universiteit Brussel, Faculty of Medicine and Pharmacy, Centre for Pharmaceutical Research (CePhar), Brussels, Belgium; KAVA, Royal Pharmaceutical Society of Antwerp, Antwerp, Belgium
| | - Liset van Dijk
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Stephane Steurbaut
- Vrije Universiteit Brussel, Faculty of Medicine and Pharmacy, Centre for Pharmaceutical Research (CePhar), Brussels, Belgium; Department of Clinical Pharmacology and Pharmacotherapy, Universitair Ziekenhuis (UZ) Brussel, Brussels, Belgium
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17
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Antithrombotic Preventive Medication Prescription Redemption and Socioeconomic Status in Hungary in 2016: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17186855. [PMID: 32961765 PMCID: PMC7559548 DOI: 10.3390/ijerph17186855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 01/02/2023]
Abstract
This work was designed to investigate antithrombotic drug utilization and its link with the socioeconomic characteristics of specific population groups in Hungary by a comparative analysis of data for prescriptions by general practitioners and the redeemed prescriptions for antithrombotic drugs. Risk analysis capabilities were applied to estimate the relationships between socioeconomic status, which was characterized by quintiles of a multidimensional composite indicator (deprivation index), and mortality due to thromboembolic diseases as well as antithrombotic medications for the year 2016 at the district level in Hungary. According to our findings, although deprivation is a significant determinant of mortality due to thromboembolic diseases, clusters can be identified that represent exemptions to this rule: an eastern part of Hungary, consisting of two highly deprived counties, had significantly lower mortality than the country average; by contrast, the least-deprived northwestern part of the country, consisting of five counties, had significantly higher mortality than the country average. The fact that low socioeconomic status in general and poor adherence to antithrombotic drugs irrespective of socioeconomic status were associated with increased mortality indicates the importance of more efficient control of preventive medication and access to healthcare in all districts of the country to reduce mortality due to thromboembolic diseases.
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18
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Abstract
Warfarin is the most commonly prescribed anticoagulant for children in the outpatient setting in Australia. Pediatric patients likely have different challenges to warfarin adherence compared with their adult counterparts; however, little is known about warfarin adherence among this population. This study aimed to understand warfarin adherence among community-based pediatric patients by using an online survey design. The survey instrument incorporated parent or patient self-reported warfarin doses missed in the preceding month, a validated warfarin adherence assessment tool, the 13-item Self-Efficacy for Appropriate Medication use Scale (SEAMS-13), and an open-ended question asking about the challenges of warfarin adherence. The indication of warfarin administration and patient's time in therapeutic range were obtained from medical records. The study recruited outpatients managed by a tertiary pediatric hospital who had previously consented to participate in warfarin research. In total, 53 families were contacted with 43 responses (81% response rate) and 41 completed surveys. The median age of the children from participating families was 10.6 years (range, 4.1 to 18.9 y). The majority of these children (n=42) used warfarin prophylactically and only 1 child used it to treat deep venous thrombosis. The time in therapeutic range achievement of this cohort was 64.4% (95% confidence interval, 58.7-70.2). The mean SEAMS-13 score was 33.5 (95% confidence interval, 31.75-35.37) and the total missed doses was 2.5%. Participants also identified barriers and enablers of warfarin adherence. This study was the first of its kind and thus it provides baseline data for future research. The warfarin adherence of this cohort was likely optimized because of frequent clinical contact and access to self-testing. Future studies are required to examine the different approaches aiming to improve the anticoagulant adherence after the emergence of direct oral anticoagulants with a wider therapeutic index and minimal monitoring that could contribute to less clinical contact.
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19
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Metaxas C, Albert V, Habegger S, Messerli M, Hersberger KE, Arnet I. Patient Knowledge about Oral Anticoagulation Therapy Assessed during an Intermediate Medication Review in Swiss Community Pharmacies. PHARMACY 2020; 8:pharmacy8020054. [PMID: 32231095 PMCID: PMC7355591 DOI: 10.3390/pharmacy8020054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/22/2020] [Accepted: 03/25/2020] [Indexed: 12/27/2022] Open
Abstract
Background: Therapy with oral anticoagulation (OAC) can be challenging, especially in high risk groups such as chronic patients. Gaps in patient knowledge about OAC are linked to reduced effectiveness and safety of treatment. The objectives of this study were i) to assess OAC knowledge gathered during an intermediate medication review (MR) in patients taking vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC); ii) to assess OAC knowledge two weeks after the MR, and iii) to evaluate patient satisfaction with the MR service in community pharmacies. Methods: Chronic OAC patients were invited for a regular MR service in Swiss community pharmacies, the so-called “Polymedication-Check” (PMC). OAC knowledge was assessed with seven newly generated items asked face-to-face during a PMC and by telephone two weeks later. Knowledge gaps, pharmacists’ spontaneous interventions, and patient satisfaction were documented by observing pharmacy students. Treatment groups were compared. Results: Of all patients (n = 81), the number of patients with one or more knowledge gaps decreased from 66% to 31.3% after PMC (p < 0.001). NOAC patients (n = 31) had more knowledge gaps than VKA patients (n = 50; p < 0.05). Most patients (98.6%) were satisfied with the counselling provided by the pharmacists. Conclusion: The majority of chronic OAC patients shows knowledge gaps. Although spontaneous, the provision of tailored education during a PMC increased patient OAC knowledge.
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20
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Adherence to Cardiac Medications in Patients With Atrial Fibrillation: A Pilot Study. Heart Lung Circ 2020; 29:e131-e139. [PMID: 32089489 DOI: 10.1016/j.hlc.2019.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 11/13/2019] [Accepted: 11/24/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Non-adherence to medications is common in patients with atrial fibrillation (AF), increasing the risk of stroke, co-morbidities, and AF symptoms. Understanding factors influencing medication adherence is important in providing holistic care to patients with AF. This study aimed to explore medication adherence in patients with AF, and explore associations with health literacy, cognition, or AF knowledge. METHODS A single-centre pilot study, using survey questionnaires and open questions. Patients with a primary cardiac diagnosis, with AF as primary or secondary diagnosis, were eligible for recruitment. During hospitalisation, adherence to cardiac medications was assessed using the Basel Assessment of Adherence to Immunosuppressive Medication Scale (BAASIS). Health literacy, cognition, and AF knowledge were assessed through validated questionnaires. Facilitators and barriers for medication adherence were obtained through open-ended question and coded using a content analysis approach. RESULTS Fifty-four (54) patients were recruited (61% male, mean age 71±11). Twenty-two (22) participants (41%) were classified as non-adherent using the BAASIS; with a corresponding self-reported adherence of 87.7% in non-adherent participants compared to 97.8% in adherent participants. No associations were identified between medication adherence and cognition, health literacy, or AF knowledge. Facilitators for adherence included external assistance, routines, and medication knowledge, and these were reported by both adherent and non-adherent participants. Non-adherent participants reported more barriers including medication concerns, forgetfulness, and lifestyle factors. CONCLUSIONS Large numbers of AF patients are likely to be non-adherent to medications. Medication adherence is influenced by multiple factors, individual to each patient. Diverse strategies are required to ensure adherence to cardiac medications.
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21
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Waring ME, Hills MT, Lessard DM, Saczynski JS, Libby BA, Holovatska MM, Kapoor A, Kiefe CI, McManus DD. Characteristics Associated With Facebook Use and Interest in Digital Disease Support Among Older Adults With Atrial Fibrillation: Cross-Sectional Analysis of Baseline Data From the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) Cohort. JMIR Cardio 2019; 3:e15320. [PMID: 31758791 PMCID: PMC6883367 DOI: 10.2196/15320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/28/2019] [Accepted: 08/31/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Online support groups for atrial fibrillation (AF) and apps to detect and manage AF exist, but the scientific literature does not describe which patients are interested in digital disease support. OBJECTIVE The objective of this study was to describe characteristics associated with Facebook use and interest in digital disease support among older patients with AF who used the internet. METHODS We used baseline data from the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF), a prospective cohort of older adults (≥65 years) with AF at high stroke risk. Participants self-reported demographics, clinical characteristics, and Facebook and technology use. Online patients (internet use in the past 4 weeks) were asked whether they would be interested in participating in an online support AF community. Mobile users (owns smartphone and/or tablet) were asked about interest in communicating with their health care team about their AF-related health using a secure app. Logistic regression models identified crude and multivariable predictors of Facebook use and interest in digital disease support. RESULTS Online patients (N=816) were aged 74.2 (SD 6.6) years, 47.8% (390/816) were female, and 91.1% (743/816) were non-Hispanic white. Roughly half (52.5%; 428/816) used Facebook. Facebook use was more common among women (adjusted odds ratio [aOR] 2.21, 95% CI 1.66-2.95) and patients with mild to severe depressive symptoms (aOR 1.50, 95% CI 1.08-2.10) and less common among patients aged ≥85 years (aOR 0.27, 95% CI 0.15-0.48). Forty percent (40.4%; 330/816) reported interest in an online AF patient community. Interest in an online AF patient community was more common among online patients with some college/trade school or Bachelors/graduate school (aOR 1.70, 95% CI 1.10-2.61 and aOR 1.82, 95% CI 1.13-2.92, respectively), obesity (aOR 1.65, 95% CI 1.08-2.52), online health information seeking at most weekly or multiple times per week (aOR 1.84, 95% CI 1.32-2.56 and aOR 2.78, 95% CI 1.86-4.16, respectively), and daily Facebook use (aOR 1.76, 95% CI 1.26-2.46). Among mobile users, 51.8% (324/626) reported interest in communicating with their health care team via a mobile app. Interest in app-mediated communication was less likely among women (aOR 0.48, 95% CI 0.34-0.68) and more common among online patients who had completed trade school/some college versus high school/General Educational Development (aOR 1.95, 95% CI 1.17-3.22), sought online health information at most weekly or multiple times per week (aOR 1.86, 95% CI 1.27-2.74 and aOR 2.24, 95% CI 1.39-3.62, respectively), and had health-related apps (aOR 3.92, 95% CI 2.62-5.86). CONCLUSIONS Among older adults with AF who use the internet, technology use and demographics are associated with interest in digital disease support. Clinics and health care providers may wish to encourage patients to join an existing online support community for AF and explore opportunities for app-mediated patient-provider communication.
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Affiliation(s)
- Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Mellanie T Hills
- StopAfib.org, American Foundation for Women's Health, Decatur, TX, United States
| | - Darleen M Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, United States
| | - Brooke A Libby
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Marta M Holovatska
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Alok Kapoor
- Division of Hospital Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.,Division of Cardiology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
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[Oral anticoagulation in atrial fibrillation: differential therapy with non vitamin K antagonist oral anticoagulants (NOAC) and vitamin K antagonists (VKA)]. MMW Fortschr Med 2019; 161:15-23. [PMID: 31587168 DOI: 10.1007/s15006-019-0920-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Non-vitamin K-dependent oral anticoagulants (NOAC) have changed the management of patients with oral anticoagulation. This raises the question of which patients should preferably be anticoagulated with NOAC and which preferably with vitamin K antagonists (VKA). This discussion has so far been insufficiently conducted and often decided on a flat-rate basis in favor of the NOAC. METHOD To clarify the question owhich form of anticoagulation - NOAC or VKA - is the best choice for patients with atrial fibrillation, an interdisciplinary team of experts met. RESULTS AND CONCLUSIONS The experts discussed essential practical aspects of NOAC and VKA therapy. Based on typical clinical scenarios, they developed assistance, comments and tips on the differentiated use of oral anticoagulants in patients with atrial fibrillation. A criteria served amongst others practicability in daily medical practice, contraindications, side effects and interactions, but also the patient's desire. The advantages and disadvantages of therapy with VKA and NOAC were summarized in a table.
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Yiu A, Ng KK, Lee VW, Bajorek BV. Evaluating the Understandability and Actionability of Web-Based Education Materials for Patients Taking Non–vitamin K Oral Anticoagulants. Ther Innov Regul Sci 2019. [DOI: 10.1177/2168479019849878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Angela Yiu
- Graduate School of Health Pharmacy, University of Technology, Sydney, New South Wales, Australia
| | - Kingsley K. Ng
- Department of Renal Medicine, Westmead Hospital, New South Wales, Australia
| | - Vincent W. Lee
- Department of Renal Medicine, Westmead Hospital, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Beata V. Bajorek
- Graduate School of Health Pharmacy, University of Technology, Sydney, New South Wales, Australia
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25
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Brieger D, Amerena J, Attia J, Bajorek B, Chan KH, Connell C, Freedman B, Ferguson C, Hall T, Haqqani H, Hendriks J, Hespe C, Hung J, Kalman JM, Sanders P, Worthington J, Yan TD, Zwar N. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018. Heart Lung Circ 2019; 27:1209-1266. [PMID: 30077228 DOI: 10.1016/j.hlc.2018.06.1043] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - David Brieger
- Department of Cardiology, Concord Hospital, Sydney, Australia; University of Sydney, Sydney, Australia.
| | - John Amerena
- Geelong Cardiology Research Unit, University Hospital Geelong, Geelong, Australia
| | - John Attia
- University of Newcastle, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Beata Bajorek
- Graduate School of Health, University of Technology Sydney & Department of Pharmacy, Royal North Shore Hospital, Australia
| | - Kim H Chan
- Royal Prince Alfred Hospital, Sydney, Australia; Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Cia Connell
- The National Heart Foundation of Australia, Melbourne, Australia
| | - Ben Freedman
- Sydney Medical School, The University of Sydney, Sydney, Australia; Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Caleb Ferguson
- Western Sydney University, Western Sydney Local Health District, Blacktown Clinical and Research School, Blacktown Hospital, Sydney, Australia
| | | | - Haris Haqqani
- University of Queensland, Department of Cardiology, Prince Charles Hospital, Brisbane, Australia
| | - Jeroen Hendriks
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia; Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Charlotte Hespe
- General Practice and Primary Care Research, School of Medicine, The University of Notre Dame Australia, Sydney, Australia
| | - Joseph Hung
- Medical School, Sir Charles Gairdner Hospital Unit, University of Western Australia, Perth, Australia
| | - Jonathan M Kalman
- University of Melbourne, Director of Heart Rhythm Services, Royal Melbourne Hospital, Melbourne, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - John Worthington
- RPA Comprehensive Stroke Service, Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Nicholas Zwar
- Graduate Medicine, University of Wollongong, Wollongong, Australia
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26
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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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Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L. Antithrombotic Therapy for Atrial Fibrillation. Chest 2018; 154:1121-1201. [DOI: 10.1016/j.chest.2018.07.040] [Citation(s) in RCA: 481] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023] Open
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Pandya EY, Anderson E, Chow C, Wang Y, Bajorek B. Contemporary utilization of antithrombotic therapy for stroke prevention in patients with atrial fibrillation: an audit in an Australian hospital setting. Ther Adv Drug Saf 2018; 9:97-111. [PMID: 29387335 PMCID: PMC5772521 DOI: 10.1177/2042098617744926] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 11/07/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND To document antithrombotic utilization in patients with nonvalvular atrial fibrillation (NVAF), particularly, recently approved NOACs (nonvitamin K antagonist oral anticoagulants) and warfarin; and identify factors predicting the use of NOACs versus warfarin. METHODS A retrospective audit was conducted in an Australian hospital. Data pertaining to inpatients diagnosed with atrial fibrillation (AF) admitted between January and December 2014 were extracted. This included patient demographics, risk factors (stroke, bleeding), social history, medical conditions, medication history, medication safety issues, medication adherence, and antithrombotic prescribed at admission and discharge. RESULTS Among 199 patients reviewed, 84.0% were discharged on antithrombotics. Anticoagulants (± antiplatelets) were most frequently (52.0%) prescribed (two-thirds were prescribed warfarin, the remainder NOACs), followed by antiplatelets (33.0%). Among 41 patients receiving NOACs, 59.0% were prescribed rivaroxaban, 24.0% dabigatran, and 17.0% apixaban. Among patients aged 75 years and over, antiplatelets were most frequently used (37.0%), followed by warfarin (33.0%), then NOACs (14.0%). Compared with their younger counterparts, patients aged 75 years and over were significantly less likely to receive NOACs (14.0% versus 28.0%, p = 0.01). Among the 'most eligible' patients (Congestive Cardiac Failure, Hypertension (, Age ⩾ 75 years, Age= 65-74 years, Diabetes Mellitus, Stroke/ Transient Ischaemic Attack/ Thromboembolism, Vascular disease, Sex female[CHA2DS2-VASc] score ⩾2 and no bleeding risk factors), 46.0% were not anticoagulated on discharge. Patients with anaemia (68.0% versus 86.0%, p = 0.04) or a history of bleeding (65.0% versus 87.0%, p = 0.01) were less likely to receive antithrombotics compared with those without these risk factors. Warfarin therapy was less frequently prescribed among patients with cognitive impairment compared with patients with no cognitive issues (12.0% versus 23.0%, p = 0.01). Multivariate logistic regression modelling identified that patients with renal impairment were 3.6 times more likely to receive warfarin compared with NOACs (odds ratio = 3.6, 95% confidence interval = 0.08-0.90, p = 0.03, 60.0% correctly predicted; Cox and Snell R2 = 0.51, Nagelkerke R2 = 0.69). CONCLUSION Despite the availability of NOACs, warfarin remains a preferred treatment option, particularly among patients with renal impairment. The high proportion of eligible patients still being prescribed antiplatelet therapy or 'no therapy' needs to be addressed.
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Affiliation(s)
- Ekta Yogeshkumar Pandya
- University of Technology Sydney Faculty of Health, Broadway, Ultimo, Sydney, NSW 2007, Australia
| | | | - Clara Chow
- Westmead Hospital, Westmead, NSW, Australia
| | - Yishen Wang
- University of Technology Sydney Faculty of Health, Broadway, Sydney, NSW, Australia
| | - Beata Bajorek
- University of Technology Sydney Faculty of Health, Broadway, Sydney, NSW, Australia
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29
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Bajorek B, Saxton B, Anderson E, Chow CK. Patients' preferences for new versus old anticoagulants: a mixed-method vignette-based study. Eur J Cardiovasc Nurs 2017; 17:429-438. [PMID: 29090608 DOI: 10.1177/1474515117739618] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND For both patients and clinicians, differences between older and new anticoagulants have major implications for treatment selection, day-to-day management of therapy and adherence. AIMS To explore patients' preferences for warfarin versus direct oral anticoagulant (DOAC) therapy. METHODS Mixed-method study involving anticoagulated older patients admitted to hospital. Part A comprised a vignette-based questionnaire; patients were asked whether they preferred Medicine A (warfarin) or Medicine B (DOAC). Part B interviews explored patients' satisfaction with their current anticoagulant. Responses were thematically analysed. RESULTS Forty patients participated: 23 warfarin-treated, 17 DOAC-treated. Collectively, Parts A and B identified that most patients were satisfied with their current therapy (warfarin or DOAC), expressing reluctance to change to alternatives. Among patients who were able to numerically rate their satisfaction with therapy, most were 'satisfied' with their current anticoagulant, although warfarin-treated patients were slightly less 'satisfied' (median score 3.5) than those on DOACs (median score 5.0). Despite this, warfarin-treated patients still preferred their current therapy (over DOACs) due to familiarity and the security of regular international normalised ratio (INR) monitoring; those who preferred DOACs cited previous warfarin-related bleeding and unstable INRs as key reasons. DOAC-treated patients who preferred warfarin perceived regular monitoring as a major advantage; only those having had negative experiences with warfarin clearly preferred DOACs. CONCLUSION Most patients accepted their currently prescribed anticoagulant, be it warfarin or DOACs. Features of specific anticoagulants, such as regular monitoring with warfarin, were perceived variably - some patients cited them as advantages and others as disadvantages. The clearest preference identified was for the agent already being taken.
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Affiliation(s)
- Beata Bajorek
- 1 Graduate School of Health, University of Technology Sydney, Broadway, NSW, Australia
- 4 Department of Pharmacy, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Brooke Saxton
- 1 Graduate School of Health, University of Technology Sydney, Broadway, NSW, Australia
| | | | - Clara K Chow
- 2 Pharmacy Department, Westmead Hospital, Westmead, NSW, Australia
- 3 The George Institute for Global Health, University of Sydney, Camperdown, NSW, Australia
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30
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Simons LA, Ortiz M, Freedman B, Waterhouse BJ, Colquhoun D. Medium- to long-term persistence with non-vitamin-K oral anticoagulants in patients with atrial fibrillation: Australian experience. Curr Med Res Opin 2017; 33:1337-1341. [PMID: 28425296 DOI: 10.1080/03007995.2017.1321535] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Long-term anticoagulant therapy with non-valvular atrial fibrillation (AF) is essential to prevent thromboembolic complications, especially ischemic stroke. This study examines medium-term persistence in AF patients using a non-vitamin-K antagonist oral anticoagulant drug (NOAC). RESEARCH DESIGN AND METHODS We assessed national Pharmaceutical Benefit Scheme records December 2013 through September 2016 for initial prescription of a NOAC in a 10% random sample of concessional patients. Key outcome measures were: (a) proportions filling first repeat prescription, (b) proportions persisting with NOAC over 12 and 30 months and (c) proportions switching to another NOAC or warfarin. RESULTS A total of 8656 patients with AF initiated a NOAC (3352 apixaban, 1340 dabigatran, 3964 rivaroxaban). Mean age was 77 years, 53% male; 91% collected the first repeat prescription for any NOAC, 70% and 57% collected any NOAC or subsequent warfarin prescription over 12 months and 30 months respectively; 8.9% had switched to warfarin. The proportions switching from apixaban, dabigatran and rivaroxaban to a different NOAC were 14%, 31% and 17% respectively. In a regression model adjusting for age, gender and comorbidity, apixaban-initiated patients over 30 months were 28% more likely to persist with any anticoagulant therapy compared with dabigatran-initiated patients (hazard ratio [95% CI] 1.28 [1.16-1.42]) and 15% more likely to persist compared with rivaroxaban-initiated (1.15 [1.06-1.24]). Rivaroxaban-initiated patients were 12% more likely to persist compared with dabigatran-initiated patients (1.12 [1.02-1.24]). CONCLUSIONS Long-term persistence with anticoagulation in patients with AF remains a concern, even with NOACs. Patients initiated to apixaban appear to experience better medium-term persistence compared with rivaroxaban or dabigatran.
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Affiliation(s)
- Leon A Simons
- a UNSW Lipid Research Department , St Vincent's Hospital , Darlinghurst , NSW , Australia
| | - Michael Ortiz
- b UNSW St Vincent's Clinical School, Darlinghurst, NSW and Zitro Consulting Services , Sydney , Australia
| | - Ben Freedman
- c Heart Research Institute, Charles Perkins Centre, University of Sydney , Sydney , NSW , Australia
| | | | - David Colquhoun
- e University of Queensland, Wesley Medical Centre , Auchenflower , QLD , Australia
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Reading SR, Go AS, Fang MC, Singer DE, Liu ILA, Black MH, Udaltsova N, Reynolds K. Health Literacy and Awareness of Atrial Fibrillation. J Am Heart Assoc 2017; 6:JAHA.116.005128. [PMID: 28400367 PMCID: PMC5533014 DOI: 10.1161/jaha.116.005128] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Atrial fibrillation (AF) is the most common clinically significant arrhythmia in adults and a major risk factor for ischemic stroke. Nonetheless, previous research suggests that many individuals diagnosed with AF lack awareness about their diagnosis and inadequate health literacy may be an important contributing factor to this finding. Methods and Results We examined the association between health literacy and awareness of an AF diagnosis in a large, ethnically diverse cohort of Kaiser Permanente Northern and Southern California adults diagnosed with AF between January 1, 2006 and June 30, 2009. Using self‐reported questionnaire data completed between May 1, 2010 and September 30, 2010, awareness of an AF diagnosis was evaluated using the question “Have you ever been told by a doctor or other health professional that you have a heart rhythm problem called atrial fibrillation or atrial flutter?” and health literacy was assessed using a validated 3‐item instrument examining problems because of reading, understanding, and filling out medical forms. Of the 12 517 patients diagnosed with AF, 14.5% were not aware of their AF diagnosis and 20.4% had inadequate health literacy. Patients with inadequate health literacy were less likely to be aware of their AF diagnosis compared with patients with adequate health literacy (prevalence ratio=0.96; 95% CI [0.94, 0.98]), adjusting for sociodemographics, health behaviors, and clinical characteristics. Conclusions Lower health literacy is independently associated with less awareness of AF diagnosis. Strategies designed to increase patient awareness of AF and its complications are warranted among individuals with limited health literacy.
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Affiliation(s)
- Stephanie R Reading
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Margaret C Fang
- Division of Hospital Medicine, University of California San Francisco, San Francisco, CA
| | - Daniel E Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - In-Lu Amy Liu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Mary Helen Black
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
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Far SS, Miraj S. Single-incision laparoscopy surgery: a systematic review. Electron Physician 2016; 8:3088-3095. [PMID: 27957308 PMCID: PMC5133033 DOI: 10.19082/3088] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 09/01/2016] [Indexed: 12/30/2022] Open
Abstract
Background Laparoscopic surgery is a modern surgical technique in which operations are performed far from their location through small incisions elsewhere in the body. Objective This systematic review is aimed to overview single-incision laparoscopy surgery. Methods This systematic review was carried out by searching studies in PubMed, Medline, Web of Science, and IranMedex databases. The initial search strategy identified about 87 references. In this study, 54 studies were accepted for further screening and met all our inclusion criteria [in English, full text, therapeutic effects of single-incision laparoscopy surgery and dated mainly from the year 1990 to 2016]. The search terms were “single-incision,” “surgery,” and “laparoscopy.” Results Single-incision laparoscopy surgery is widely used for surgical operations in cholecystectomy, sleeve gastrectomy, cholecystoduodenostomy, hepatobiliary disease, colon cancer, obesity, appendectomy, liver surgery, rectosigmoid cancer, vaginal hysterectomy, vaginoplasty, colorectal lung metastases, pyloroplasty, endoscopic surgery, hernia repair, nephrectomy, rectal cancer, colectomy and uterus-preserving repair, bile duct exploration, ileo-ileal resection, lymphadenectomy, incarcerated inguinal hernia, anastomosis, congenital anomaly, colectomy for cancer. Conclusion Based on the findings, single-incision laparoscopy surgery is a scarless surgery with minimal access. Although it possesses lots of benefits, including less incisional pain and scars, cosmesis, and the ability to convert to standard multiport laparoscopic surgery, it has some disadvantages, for example, less freedom of movement, fewer number of ports that can be used, and the proximity of the instruments to each other during the operation.
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Affiliation(s)
- Sasan Saeed Far
- MD of General Surgery, Instructor, Molecular and Cellular Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Sepide Miraj
- M.D., Gynecologist, Fellowship of Infertility, Assistant Professor, Faculty of Medicine, Shahrekord University of Medical Sciences, Shahrekord, Iran
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