Clinical characteristics and outcomes of Japanese atrial fibrillation patients with poor medication adherence: A sub-analysis of the GENERAL study

Factors Influencing Drug Prescribing for Patients with Hospitalization History in Circulatory Disease: Patient Severity, Composite Adherence, and Physician-Patient Relationship - A Retrospective Cohort Study

BACKGROUND

With countries promoting generic drug prescribing, their growth may plateau, warranting further investigation into the factors influencing this trend, including physician and patient perspectives. Additional strategies may be needed to maximize the switch to generic drugs while ensuring healthcare system sustainability, focusing on factors beyond mere low cost. Emphasizing affordability and clarifying other prescription considerations are essential.

OBJECTIVE

This study aimed to provide initial insights into how patient severity, composite adherence, and physician-patient relationships impact generic switching.

METHODS

This study utilized a long-term retrospective cohort design by analyzing data from a national healthcare database. The population included patients of all ages, primarily older adults, who required primary-to-tertiary preventive actions with a history of hospitalization for cardiovascular diseases (CVDs) (International Classification of Diseases, Tenth Revision) during April 2014 to March 2018 (4 years). We focused on switching to generic drugs, with temporal variations in clinical parameters as independent variables. Lifestyle factors (smoking and drinking) were also considered. Adherence was measured as a composite score comprising 11 elements. The physician-patient relationship was established based on the interval between physician change and prescription. Logistic regression analysis and propensity score matching (PSM) were employed, along with complementary analysis of physician-patient relationships, proportion of days covered (PDC), and adherence for a subset of the population.

RESULTS

The study included 48,456 patients with an average follow-up of 36.1±8.8 months. The mean age was 68.3 ± 9.9 years, body mass index was 23.4 ± 3.4 kg/m2, systolic blood pressure was 131.2 ± 15.0 mmHg, low-density lipoprotein cholesterol (LDL-C) was 116.6 ± 29.3 mg/dL, hemoglobin A1c (HbA1c) was 5.9% ± 0.8%, and serum creatinine was 0.9 ± 0.8 mg/dL. Logistic regression analysis revealed significant associations between generic switching and systolic blood pressure (odds ratio [OR], 0.996, 95% confidence interval [CI]: 0.993-0.999), serum creatinine levels (OR, 0.837, 95% CI: 0.729-0.962), glutamic oxaloacetic transaminase levels (OR, 0.994, 95% CI: 0.990-0.997), PDC score (OR, 0.959, 95% CI: 0.948-0.970), and adherence score (OR, 0.910, 95% CI: 0.875-0.947). Additionally, generic drug rates increased with improvements in the HbA1c level band and smoking level (P<.01, P<.001). The group with a superior physician-patient relationship after PSM had a significantly higher rate of generic drug prescribing (51.6±15.2%) than the inferior relationship group (47.7±17.7%) (P<.001).

CONCLUSIONS

Although physicians' understanding influences the choice of generic drugs, patient condition (severity) and adherence also impact this decision. For example, improved creatinine levels are associated with generic drug choice, while stronger physician-patient relationships correlate with higher rates of generic drug utilization. These findings may contribute to the appropriate prescription of pharmaceuticals if the policy diffusion of generic drugs begins to slow down. Thus, preventing serious illness while building trust may result in clinical benefits and positive socio-economic outcomes.

CLINICALTRIAL

Predictors of adherence to direct oral anticoagulants after cardiovascular or bleeding events in Medicare Advantage Plan enrollees with atrial fibrillation

BACKGROUND

Direct oral anticoagulants (DOACs) are recommended for patients with atrial fibrillation (AF) given their improved safety profile. Suboptimal adherence to DOACs remains a significant concern among individuals with AF. However, the extent of adherence to DOACs following a cardiovascular or bleeding event has not been fully evaluated.

OBJECTIVE

To evaluate the pattern of adherence trajectories of DOACs after a cardiovascular or bleeding event and to investigate the sociodemographic and clinical predictors associated with each adherence trajectory by using claims-based data.

METHODS

This retrospective study was conducted among patients with AF prescribed with DOACs (dabigatran/apixaban/rivaroxaban) between July 2016 and December 2017 and who were continuously enrolled in the Texas-based Medicare Advantage Plan. Patients who experienced a cardiovascular or bleeding event while using the DOACs were further included in the analysis. The sample was limited to patients who experienced a clinical event such as a cardiovascular or bleeding event while using the DOACs. The clinical events considered in this study were cardiovascular (stroke, congestive heart failure, myocardial infarction, systemic embolism) and bleeding events. To assess adherence patterns, each patient with a DOAC prescription was followed up for a year after experiencing a clinical event. The monthly adherence to DOACs after these events was evaluated using the proportion of days covered (PDC). A group-based trajectory model incorporated the monthly PDC to classify groups of patients based on their distinct patterns of adherence. Predictors associated with each trajectory were assessed using a multinomial logistic regression model, with the adherent trajectory serving as the reference group in the outcome variable.

RESULTS

Among the 694 patients with AF who experienced clinical events after the initiation of DOACs, 3 distinct adherence trajectories were identified: intermediate nonadherent (30.50%), adherent (37.7%), and low adherent (31.8%); the mean PDC was 0.47 for the intermediate nonadherent trajectory, 0.93 for the adherent trajectory, and 0.01 for low adherent trajectory. The low-income subsidy was significantly associated with lower adherence trajectories (odds ratio [OR] = 4.81; 95% CI = 3.07-7.51) and with intermediate nonadherent trajectories (OR = 1.57; 95% CI = 1.06-2.34). Also, nonsteroidal anti-inflammatory drug use was significantly associated with lower adherence trajectories (OR = 5.10; 95% CI = 1.95-13.36) and intermediate nonadherent trajectories (OR = 3.17; 95% CI = 1.26-7.93). Other predictors significantly associated with both nonadherent trajectories are type of DOACs (OR = 0.53; 95% CI = 0.35-0.79), presence of coronary artery disease (OR = 1.89; 95% CI = 1.01-3.55), and having 2 or more clinical events (OR = 1.65; 95% CI = 1.09-2.50).

CONCLUSIONS

Predictors identified provide valuable insights into the suboptimal adherence of DOACs among Medicare Advantage Plan enrollees with AF, which can guide the development of targeted interventions to enhance adherence in this high-risk patient population.

Effect of frailty on medication deviation during the hospital-family transition period in older patients with cardiovascular disease: An observational study

Studies have shown that frailty increases cardiovascular disease (CVD) incidence in older patients and is associated with poor patient prognosis. However, the relationship between medication deviation (MD) and frailty remains unclear. This study aimed to explore the influence of frailty on MD during the hospital-family transition period among older patients with CVD. Between February 2022 and February 2023, 231 older people CVD patients were selected from a class III hospital in Nantong City using a multi-stage sampling method. A general information questionnaire was used to collect the socio-demographic characteristics of the participants prior to discharge, the frailty assessment scale was used to assess the participants frailty, and a medication deviation instrument was used to assess the participants MD on the 10th day after discharge. Propensity score matching was used to examine the effect of frailty on MD in older patients with CVD during the hospital-family transition period. The incidences of frailty and MD were 32.9% (76/231) and 75.8% (175/231), respectively. After propensity score matching, the risk of MD in frail patients with CVD was 4.978 times higher than that in non-frail patients with CVD (95% CI: [1.616, 15.340]; P = .005). Incidences of frailty and MD during the hospital-family transition period are high in older patients with CVD, and frailty has an impact on MD. Medical staff in the ward should comprehensively examine older patients with CVD for frailty and actively promote quality medication management during the hospital-family transition period to reduce MD occurrence and delay disease progression.

Comprehension of Nonvalvular Atrial Fibrillation and Anticoagulant Adherence in Elderly Patients in a Subcohort Study of the All Nippon Atrial Fibrillation in the Elderly Registry

In this subcohort study of the ANAFIE (All Nippon Atrial Fibrillation In the Elderly) Registry enrolling >30,000 Japanese elderly (aged ≥75 years) patients with nonvalvular atrial fibrillation (NVAF), we assessed the association between patient comprehension of NVAF and adherence to anticoagulant therapy with clinical outcomes. Data from 1,968 patients evaluated for NVAF comprehension by a questionnaire consisting of 4 key questions, and 2,362 patients who completed the Morisky Medication Adherence Scale-8 questionnaire were analyzed. Overall, NVAF comprehension was low (81.9% had <3 points), and compared with high comprehension (score ≥3), low comprehension (0 points: 42.1%) was associated with poor prognosis, nonsignificantly higher risk of stroke or systemic embolic event (adjusted hazard ratio [aHR] 2.60 [95% confidence interval 0.97 to 6.94, p = 0.057]), all-cause death (aHR 1.71 [0.96 to 3.04, p = 0.069]), and significantly higher risk of net clinical outcome (composite of stroke/systemic embolic events, major bleeding, and all-cause death) (aHR 1.63 [1.04 to 2.54, p = 0.032]). Adherence to anticoagulant therapy assessed by Morisky Medication Adherence Scale-8 was high (64.9% had high adherence; 29.2%, had medium adherence), but compared with high adherence (score 8), low adherence (score <6: 5.9%) was associated with poor prognosis, significantly higher risk of ischemic stroke (aHR 2.95 [1.08 to 8.04, p = 0.035]), all-cause death (aHR 1.93 [1.16 to 3.21, p = 0.011]), and net clinical outcome (aHR 1.75 [1.12 to 2.75, p = 0.015]). Overall, NVAF comprehension and adherence showed a weak correlation to anticoagulant therapy at baseline (correlation coefficient 0.049). In conclusion, low NVAF comprehension and low anticoagulant adherence were associated with poor clinical outcomes in elderly patients with NVAF.