1
|
Deitelzweig S, Keshishian A, Kang A, Jenkins A, Atreja N, Schuler P, Jiang J, Yuce H, Sun X, Lip GYH. Delaying clinical events among patients with non-valvular atrial fibrillation treated with oral anticoagulants: Insights from the ARISTOPHANES study. Eur J Intern Med 2023; 108:37-42. [PMID: 36456387 DOI: 10.1016/j.ejim.2022.10.021] [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: 05/26/2022] [Revised: 09/30/2022] [Accepted: 10/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Oral anticoagulants (OACs) mitigate stroke and systemic embolism (SE) risk in non-valvular atrial fibrillation (AF) patients but can increase the risk of major bleeding (MB). This study analyzed the gains in event-free time for these outcomes among OAC treatment options represented in the ARISTOPHANES study. METHODS This sub-analysis consisted of NVAF patients who initiated warfarin, apixaban, dabigatran, or rivaroxaban from 01JAN2013-30SEP2015, with data pooled from Medicare and 4 US commercial claims databases. Propensity score matching was conducted between non-vitamin K antagonist OAC (NOAC) and warfarin cohorts in each database and results were pooled. Laplace regression was used to evaluate the delay in time to stroke/SE and MB events between NOACs and warfarin and between NOACs after the first 12-months of follow-up. RESULTS The population included 466,991 patients (167,413 warfarin; 108,852 apixaban; 37,724 dabigatran; and 153,002 rivaroxaban). Event-free time gain (95% confidence interval) for apixaban versus warfarin was 101 days (78- 124) for stroke/SE and 116 (103- 130) days for MB. The gain in event-free time for dabigatran versus warfarin was 45 days (3- 87) for stroke/SE and 92 (68- 116) days for MB. The gain in event-free time for rivaroxaban versus warfarin was 63 days (42- 84) for stroke/SE but event-free time decreased by 18 (-31-6) days for MB. CONCLUSIONS Over 12 months after initiation, apixaban and dabigatran conferred progressive increases in event free time for stroke/SE and MB vs warfarin, whereas rivaroxaban conferred an increase in stroke/SE-free time but a loss in MB-free time vs warfarin.
Collapse
Affiliation(s)
- Steven Deitelzweig
- Ochsner Clinic Foundation, Department of Hospital Medicine, New Orleans, LA, USA and The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA.
| | | | - Amiee Kang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - Nipun Atreja
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - Jenny Jiang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, USA
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
2
|
Sedelius H, Tistad M, Bergsten U, Dehlin M, Iggman D, Wallin L, Svärd A. Professionals’ perspectives on existing practice and conditions for nurse-led gout care based on treatment recommendations: a qualitative study in primary healthcare. BMC PRIMARY CARE 2022; 23:71. [PMID: 35392809 PMCID: PMC8988383 DOI: 10.1186/s12875-022-01677-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/30/2022] [Indexed: 11/24/2022]
Abstract
Background Gout affects nearly 2 % of the population and is associated with repeated painful flares of arthritis. Preventive urate-lowering therapy is widely available, but only one third of patients receive adequate treatment. Lack of knowledge among healthcare professionals and patients within primary healthcare are implicated as partial explanations for this undertreatment. Nurse-led care has proved to be an effective model when treating patients with gout, but there is a need for more knowledge about factors that can be expected to influence the future implementation of such care. The aim of this study was to describe factors influencing existing gout care in primary healthcare and the conditions for a future implementation of nurse-led gout care based on national treatment recommendations. Methods In this qualitative study, focus group discussions with 56 nurses and physicians and individual interviews with eight managers were conducted at nine primary healthcare units in central Sweden. A deductive qualitative content analysis based on the main constructs of the framework Integrated Promoting Action on Research Implementation in Health Services was followed by an inductive analysis within the frames of the main constructs: innovation, recipients and context. Results Gout-related contacts with primary healthcare was described as being patient initiated, diagnostics was in some respects complex and nurse-led care was experienced as a favourable primary healthcare model in general (innovation). Gout was seen as a low-priority condition with acute flares and there was inadequate knowledge of gout, including preventive treatment (recipients). Primary healthcare was perceived as having a holistic but fragmented responsibility for gout care, recommendations against keeping waiting lists complicated follow-up appointments and a need for motivation and support when introducing new practices was emphasised (context). Conclusion In this study, investigating the perspective of professionals, several factors were found to influence existing gout care. It will be crucial to target these factors in the development of a future implementation strategy. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01677-z.
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Berglund E, Wallentin L, Oldgren J, Renlund H, Alexander JH, Granger CB, Hohnloser SH, Hylek EM, Lopes RD, McMurray JJ, Lytsy P. Effects of apixaban compared with warfarin as gain in event-free time - a novel assessment of the results of the ARISTOTLE trial. Eur J Prev Cardiol 2019; 27:1311-1319. [PMID: 31698965 DOI: 10.1177/2047487319886959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A novel approach to determine the effect of a treatment is to calculate the delay of event, which estimates the gain of event-free time. The aim of this study was to estimate gains in event-free time for stroke or systemic embolism, death, bleeding events, and the composite of these events, in patients with atrial fibrillation randomized to either warfarin or apixaban in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation trial (ARISTOTLE). DESIGN The ARISTOTLE study was a randomized double-blind trial comparing apixaban with warfarin. METHODS Laplace regression was used to estimate the delay in time to the outcomes between the apixaban and the warfarin group in 6, 12, 18 and 22 months of follow-up. RESULTS The gain in event-free time for apixaban versus warfarin was 181 (95% confidence interval 76 to 287) days for stroke or systemic embolism and 55 (-4 to 114) days for death after 22 months of follow-up. The corresponding gains in event-free times for major and intracranial bleeding were 206 (130 to 281) and 392 (249 to 535) days, respectively. The overall gain for the composite of all these events was a gain of 116 (60 to 171) days. CONCLUSIONS In patients with atrial fibrillation, 22 months of treatment with apixaban, as compared with warfarin, provided gains of approximately 6 months in event-free time for stroke or systemic embolism, 7 months for major bleeding and 13 months for intracranial bleeding.
Collapse
Affiliation(s)
- Erik Berglund
- Department of Public Health and Caring Sciences, Uppsala University, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Sweden.,Uppsala Clinical Research Centre (UCR), Uppsala University, Sweden
| | - Jonas Oldgren
- Department of Medical Sciences, Cardiology, Uppsala University, Sweden.,Uppsala Clinical Research Centre (UCR), Uppsala University, Sweden
| | - Henrik Renlund
- Uppsala Clinical Research Centre (UCR), Uppsala University, Sweden
| | | | | | - Stefan H Hohnloser
- Department of Medicine, Division of Cardiology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Elaine M Hylek
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke Medicine, Durham, USA
| | - John Jv McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Per Lytsy
- Department of Public Health and Caring Sciences, Uppsala University, Sweden.,Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
5
|
Berglund E, Westerling R, Sundström J, Lytsy P. Length of time periods in treatment effect descriptions and willingness to initiate preventive therapy: a randomised survey experiment. BMC Med Inform Decis Mak 2018; 18:106. [PMID: 30458757 PMCID: PMC6247706 DOI: 10.1186/s12911-018-0662-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 09/27/2018] [Indexed: 12/01/2022] Open
Abstract
Background Common measures used to describe preventive treatment effects today are proportional, i.e. they compare the proportions of events in relative or absolute terms, however they are not easily interpreted from the patient’s perspective and different magnitudes do not seem to clearly discriminate between levels of effect presented to people. Methods In this randomised cross-sectional survey experiment, performed in a Swedish population-based sample (n = 1041, response rate 58.6%), the respondents, aged between 40 and 75 years were given information on a hypothetical preventive cardiovascular treatment. Respondents were randomised into groups in which the treatment was described as having the effect of delaying a heart attack for different periods of time (Delay of Event, DoE): 1 month, 6 months or 18 months. Respondents were thereafter asked about their willingness to initiate such therapy, as well as questions about how they valued the proposed therapy. Results Longer DoE:s were associated with comparatively greater willingness to initiate treatment. The proportions accepting treatment were 81, 71 and 46% when postponement was 18 months, 6 months and 1 month respectively. In adjusted binary logistic regression models the odds ratio for being willing to take therapy was 4.45 (95% CI 2.72–7.30) for a DoE of 6 months, and 6.08 (95% CI 3.61–10.23) for a DoE of 18 months compared with a DoE of 1 month. Greater belief in the necessity of medical treatment increased the odds of being willing to initiate therapy. Conclusions Lay people’s willingness to initiate preventive therapy was sensitive to the magnitude of the effect presented as DoE. The results indicate that DoE is a comprehensible effect measure, of potential value in shared clinical decision-making.
Collapse
Affiliation(s)
- Erik Berglund
- Department of Public Health and Caring Sciences, Uppsala University, Box 564, SE-751 22, UPPSALA, Sweden.
| | - Ragnar Westerling
- Department of Public Health and Caring Sciences, Uppsala University, Box 564, SE-751 22, UPPSALA, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Lytsy
- Department of Public Health and Caring Sciences, Uppsala University, Box 564, SE-751 22, UPPSALA, Sweden
| |
Collapse
|
6
|
Bellavia A, Wallentin L, Orsini N, James SK, Cannon CP, Himmelmann A, Sundström J, Renlund H, Lytsy P. Time-based measures of treatment effect: reassessment of ticagrelor and clopidogrel from the PLATO trial. Open Heart 2017; 4:e000557. [PMID: 28761675 PMCID: PMC5515127 DOI: 10.1136/openhrt-2016-000557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/18/2017] [Accepted: 02/14/2017] [Indexed: 11/26/2022] Open
Abstract
Objective Treatment effects to binary endpoints using time-to-event data in randomised controlled trials are typically summarised by reporting HRs derived with Cox proportional hazard models. Alternative and complementary methods include summarising the between-treatment differences on the metric time scale, quantifying the effect as delay of the event (DoE). The aim of this study was to reassess data from the PLATO study expressing the effects as the time by which the main outcomes are delayed or hastened due to treatment. Methods PLATO was a randomised controlled double-blind multicentre study (n=18,624), conducted between 2006 and 2008, which demonstrated superiority of the antiplatelet treatment ticagrelor over clopidogrel in reducing risk of several cardiovascular events. In the present study, four of the main PLATO outcomes were reassessed by calculating the time by which an event may be delayed due to the treatment. Results The effects of ticagrelor, as compared with clopidogrel, consisted of a substantial delay of the evaluated outcomes, ranging from 83 to 98 days over 400-day follow-up. The Delay of Events Curves showed that the effects progressively increased over time, and the significant findings were concordant with those presented in the original PLATO study. Conclusions This study confirmed evidence of a beneficial effect of ticagrelor over clopidogrel, and provided the magnitude of such effects in terms of delayed event time. Investigating time-to-event data with a percentile approach allows presenting treatment effects from randomised controlled studies as absolute measures of the time by which an event may be delayed due to the treatment. Trial registration number PLATO (www.clinicaltrials.gov; NCT00391872); Results.
Collapse
Affiliation(s)
- Andrea Bellavia
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Nicola Orsini
- Department of Public Health Science, Karolinska Institutet, Stockholm, Sweden
| | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Christopher P Cannon
- Division of Cardiovascular, Brigham and Women's Hospital, Boston, Massachusetts, USA.,HarvardClinical Research Institute, Boston, Massachusetts, USA
| | | | - Johan Sundström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Henrik Renlund
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Per Lytsy
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| |
Collapse
|