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Elling T, Hak E, Bos JH, Tichelaar VYIG, Veeger NJGM, Meijer K. Effect of Previous INR Control during VKA Therapy on Subsequent DOAC Adherence and Persistence, in Patients Switched from VKA to DOAC. Thromb Haemost 2024; 124:778-790. [PMID: 37673103 PMCID: PMC11259495 DOI: 10.1055/a-2168-9378] [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: 04/25/2023] [Accepted: 09/03/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Current guideline suggests a switch from vitamin K antagonist (VKA) to direct oral anticoagulant (DOAC) in patients with low time in therapeutic range (TTR < 70%). Poor international normalized ratio (INR) control may be the result of poor compliance, and might therefore be associated with subsequent DOAC intake. Therefore, this study evaluates the effect of previous TTR and other measures of INR control on DOAC nonadherence and nonpersistence, in patients who switched from VKA to DOAC. METHODS A total of 437 patients who switched from VKA to DOAC between 2012 and 2019 were included using data from Certe Thrombosis Service, IADB.nl pharmacy community database University Groningen, and Statistics Netherlands. DOAC prescriptions were used to determine nonadherence and nonpersistence. INR control (i.e., TTR, time under therapeutic range [TUR], and INR variability) was assessed during the last 180 days of VKA use. Multivariable regression models were applied to determine the association between INR control and DOAC nonpersistence/nonadherence. RESULTS On VKA, 67.7% of the patients had a TTR below 70%. DOAC nonpersistence was 39.8% (95% confidence interval [CI]: 33.4-45.5%) during a median follow-up of 34.4 months (interquartile range: 19.1-49.2). Approximately 80% of persistent patients were DOAC-adherent. Low TTR was not associated with DOAC nonpersistence (hazard ratio: 1.14, 95% CI: 0.69-1.87) and DOAC nonadherence (odds ratio: 1.38, 95% CI: 0.67-2.84), nor were TUR and INR variability. CONCLUSION Previous INR control during VKA therapy is not associated with subsequent DOAC nonadherence and nonpersistence. This study suggests that INR control on VKA cannot, and therefore should not, be used for predicting DOAC adherence or persistence.
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Affiliation(s)
- Tessa Elling
- Department of Hematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Eelko Hak
- Groningen Research Institute of Pharmacy, Unit of Pharmacotherapy, Epidemiology and Economy, University of Groningen, Groningen, The Netherlands
| | - Jens H. Bos
- Groningen Research Institute of Pharmacy, Unit of Pharmacotherapy, Epidemiology and Economy, University of Groningen, Groningen, The Netherlands
| | - Vladimir Y. I. G. Tichelaar
- Department of Hematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- Certe Thrombosis Service, Groningen, The Netherlands
| | - Nic J. G. M. Veeger
- Department of Epidemiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Karina Meijer
- Department of Hematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Coons JC, Anupindi VR, Doshi R, DeKoven M, Dai F, Russ C, Stellhorn R, Cheng D, Shi L, Deeba S, Hines DM. Post-Discharge Treatment Patterns among Patients Treated with Apixaban or Warfarin during Hospitalization for Venous Thromboembolism (VTE). J Clin Med 2024; 13:3512. [PMID: 38930040 PMCID: PMC11204765 DOI: 10.3390/jcm13123512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/04/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Oral anticoagulants (OACs), such as apixaban and warfarin, are indicated for reducing the risk of recurrent venous thromboembolism (VTE) and are often initiated in the hospital. The aim of this study was to evaluate OAC continuity from inpatient to outpatient settings and the risk of recurrent VTE among patients with an initial event. Methods: This retrospective cohort study utilized hospital charge data and medical and prescription claims from 1 July 2016 to 31 December 2022 to identify adults treated with apixaban or warfarin while hospitalized for VTE. Patients were followed to assess switching or discontinuation post-discharge and the risk of recurrent VTE. The index date was the date of the first apixaban or warfarin claim within 30 days post-discharge. Results: Of the 19,303 eligible patients hospitalized with VTE, 85% (n = 16,401) were treated with apixaban and 15% (n = 2902) received warfarin. After discharge, approximately 70% had ≥1 fill for their respective apixaban or warfarin therapy. The cumulative incidence of discontinuation over the 6 months following index was 50.5% and 52.2% for the apixaban and warfarin cohorts, respectively; the cumulative incidence of switching was 6.0% and 20.9%, respectively. The incidence rates of recurrent VTE were 1.2 and 2.5 per 100 person-years for the apixaban and warfarin cohorts, respectively. Conclusions: The majority of patients continued their apixaban or warfarin therapy following hospital discharge; however, a considerable proportion either switched or discontinued OAC upon transitioning from inpatient care. Among those who continued therapy, discontinuation, switch, and recurrent VTE occurred less often with apixaban vs. warfarin.
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Affiliation(s)
- James C. Coons
- Department of Pharmacy, UPMC Presbyterian Hospital, Pittsburgh, PA 15213, USA
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA 15261, USA
| | | | - Riddhi Doshi
- IQVIA Inc., Durham, NC 27703, USA (M.D.); (L.S.)
| | | | | | | | | | - Dong Cheng
- Bristol Myers Squibb, Lawrenceville, NJ 08543, USA
| | - Liucheng Shi
- IQVIA Inc., Durham, NC 27703, USA (M.D.); (L.S.)
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Park H, Jones BL, Huang PL, Kang HR, Dietrich EA, DeRemer CE, Lo-Ciganic WH. Trajectories of Oral Anticoagulation Adherence and Associated Clinical Outcomes During Long-Term Anticoagulation Among Medicare Beneficiaries With Venous Thromboembolism. Ann Pharmacother 2023; 57:1349-1360. [PMID: 36999519 DOI: 10.1177/10600280231155489] [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] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Little is known about anticoagulation medication nonadherence patterns impacting effectiveness and safety outcomes in clinical practice. OBJECTIVE We identified adherence trajectories of extended therapy with direct-acting oral anticoagulants (DOACs) and warfarin after 6 months initial anticoagulant therapy among Medicare beneficiaries with venous thromboembolism (VTE). We further assessed the associated recurrent VTE and major bleeding risks. METHODS Using group-based trajectory models, this retrospective cohort study identified distinct beneficiary subgroups with similar adherence patterns of extended-phase anticoagulant treatment (DOACs or warfarin) for patients with VTE who completed 6 months of initial anticoagulant treatment. We examined associations between adherence trajectories and risks of recurrent VTE and major bleeding using inverse probability treatment weighted Cox proportional hazards models. RESULTS Compared with no extended treatment, consistently high DOAC adherence was associated with decreased recurrent VTE risk (hazard ratio [HR] = 0.33, 95% confidence interval [CI] = 0.21-0.51) without increased major bleeding risk, and consistently high warfarin adherence was associated with decreased recurrent VTE risk (HR = 0.62, 95% CI = 0.40-0.95) and increased major bleeding risk (HR = 1.64, 95% CI = 1.12-2.41). Gradually declining adherence to DOACs (HR = 1.80, 95% CI = 1.07-3.03) or warfarin (HR = 2.34, 95% CI = 1.57-3.47) was associated with increased bleeding risk with no change in recurrent VTE risk. CONCLUSION AND RELEVANCE This real-world evidence suggests persistently adhering to extended DOAC therapy is associated with lower recurrent VTE risk without increasing major bleeding among Medicare beneficiaries with VTE. Persistently adhering to extended warfarin therapy was associated with lower recurrent VTE risk but higher major bleeding risk.
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Affiliation(s)
- Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Bobby L Jones
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Pei-Lin Huang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Hye-Rim Kang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Eric A Dietrich
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Christina E DeRemer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL, USA
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Kang HR, Jones BL, Lo-Ciganic WH, DeRemer CE, Dietrich EA, Huang PL, Wilson DL, Park H. Trajectories of adherence to extended treatment with direct oral anticoagulants and risks of recurrent venous thromboembolism and major bleeding. J Manag Care Spec Pharm 2023; 29:1219-1230. [PMID: 37889866 PMCID: PMC10776268 DOI: 10.18553/jmcp.2023.29.11.1219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
BACKGROUND: Little is known about medication adherence patterns and their association with effectiveness and safety among patients with venous thromboembolism (VTE) receiving direct oral anticoagulant (DOAC) therapy beyond 3-6 months of initial treatment. OBJECTIVE: To examine the associations between adherence trajectories of extended treatment with DOAC and the risks of recurrent VTE and major bleeding among patients with VTE. METHODS: We conducted a retrospective cohort study of patients with incident VTE who completed 6 months of initial anticoagulant treatment and received either DOAC extended therapy or no extended therapy using MarketScan Commercial and Medicare Supplemental databases (2013-2019). We used group-based trajectory models to identify distinct adherence patterns during extended treatment. Using inverse probability treatment weighted Cox proportional hazards models, we examined the association between the adherence trajectories and the risks of recurrent VTE and major bleeding. RESULTS: Among 10,960 patients with extended treatment with DOACs (rivaroxaban, apixaban, dabigatran, edoxaban) and 5,133 patients with no extended treatment, we identified 4 distinct trajectories (consistently high, gradually declining, rapidly declining, and no extended treatment). Compared with the no extended treatment group, the groups with consistently high adherence (hazard ratio = 0.09, 95% CI = 0.05-0.17) and with gradually declining adherence (0.13, 0.03-0.53) showed decreased recurrent VTE risk without increased major bleeding risk (consistently high adherence 1.19, 0.71-1.99; gradually declining adherence 1.96, 0.81-4.70). There was no difference in the risk of recurrent VTE (0.34, 0.10-1.16) for the group with rapidly declining adherence, but this group was associated with increased major bleeding risk (2.65, 1.01-6.92). CONCLUSIONS: Our findings underscore the clinical importance of continuing and remaining adherent to extended DOAC treatment without increased major bleeding risk for patients with VTE. DISCLOSURES: This research was supported by the BMS/Pfizer Alliance American Thrombosis Investigator Initiated Research Program. The funding source had no role in the design, collection, analysis, or interpretation of the data or the decision to submit the article for publication. Dr Lo-Ciganic reported receiving research funding from Merck Sharp & Dohme Corp. Dr Dietrich reported receiving honorarium for training and education from BMS/Pfizer. Dr DeRemer is a stockholder of Portola Pharmaceuticals and reported receiving personal fees for advisory board meeting from BMS. No other disclosures were reported.
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Affiliation(s)
- Hye-Rim Kang
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville
| | - Bobby L Jones
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
| | - Christina E DeRemer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville
| | - Eric A Dietrich
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville
| | - Pei-Lin Huang
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville
| | - Debbie L Wilson
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
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Dix C, Bortz H, da Gama M, Treloar M, Reynolds M, Ramanan R, Day T, Tran H. Adherence and persistence to direct factor Xa inhibitors in the community following newly diagnosed venous thromboembolism: a retrospective pharmacy-linkage study. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023; 31:528-533. [PMID: 37494677 DOI: 10.1093/ijpp/riad053] [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: 11/12/2022] [Accepted: 07/13/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVES To assess adherence and persistence to the direct factor Xa inhibitor oral anticoagulants in the community following newly diagnosed venous thromboembolism (VTE). METHODS We retrospectively reviewed community pharmacy dispensing data on all patients with newly diagnosed VTE who were prescribed direct factor Xa inhibitors, apixaban or rivaroxaban, between January 2018 and December 2019 at our institution. Proportion of days covered (PDC) was used to assess adherence at 90 days, and 6- and 12 months. Persistence was measured by participants having both dispensed supply of a factor Xa inhibitor at the end of the treatment period and no significant gaps (maximum of 60 days) in supply. KEY FINDINGS There were 225 patients identified. Overall PDC at 90 days, 6- and 12 months were 84.6%, 86.2% and 86.1%, respectively. Apixaban had a higher mean overall PDC than rivaroxaban (86.2% and 80.6%, respectively). Females demonstrated higher PDC compared with males (87.3% versus 81.2%). Overall, 133 patients (64%) were persistent with therapy. CONCLUSIONS In patients with newly diagnosed VTE treated with a factor Xa inhibitor, adherence rates are high at >80%, with females and those prescribed apixaban exhibiting higher adherence. These findings may assist clinicians in identifying those patients with VTE at risk of poor adherence.
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Affiliation(s)
- Caroline Dix
- Department of Clinical Haematology, Alfred Health, Melbourne, Victoria, Australia
| | - Hadley Bortz
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | | | | | | | - Radha Ramanan
- Department of Clinical Haematology, Alfred Health, Melbourne, Victoria, Australia
| | - Thomas Day
- Department of Haematology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Huyen Tran
- Department of Clinical Haematology, Alfred Health, Melbourne, Victoria, Australia
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Alberts M, Zhdanava M, Pilon D, Caron-Lapointe G, Lefebvre P, Bookhart B, Kharat A. Venous thromboembolism recurrence among one-and-done direct oral anticoagulant users: a retrospective longitudinal study. Int J Clin Pharm 2023:10.1007/s11096-023-01589-7. [PMID: 37204616 PMCID: PMC10366276 DOI: 10.1007/s11096-023-01589-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/30/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are the American Society of Hematology guideline-recommended treatment for venous thromboembolism (VTE) in the United States (US). AIM To compare risk of VTE recurrence between patients who, following the first fill, discontinued ("one-and-done") versus those who continued ("continuers") DOACs. METHOD Open source US insurance claims data (04/1/2017 to 10/31/2020) were used to select adult patients with VTE initiated on DOACs (index date). Patients with only one DOAC claim during the 45-day landmark period (starting on the index date) were classified as one-and-done and the remaining as continuers. Inverse probability of treatment weighting was used to reweight baseline characteristics between cohorts. VTE recurrence based on the first post-index deep vein thrombosis or pulmonary embolism event was compared using weighted Kaplan-Meier and Cox proportional hazard models from landmark period end to clinical activity or data end. RESULTS 27% of patients initiating DOACs were classified as one-and-done. After weighting, 117,186 and 116,587 patients were included in the one-and-done and continuer cohorts, respectively (mean age 60 years; 53% female; mean follow-up 15 months). After 12 months of follow-up, the probability of VTE recurrence was 3.99% and 3.36% in the one-and-done and continuer cohorts; the risk of recurrence was 19% higher in the one-and-done cohort (hazard ratio [95% confidence interval] = 1.19 [1.13, 1.25]). CONCLUSION Substantial proportion of patients discontinued DOAC therapy after the first fill, which was associated with significantly higher risk of VTE recurrence. Early access to DOACs should be encouraged to reduce the risk of VTE recurrence.
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Affiliation(s)
| | | | | | | | | | | | - Akshay Kharat
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
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Mefford MT, Zhou H, Fan D, Fang MC, Prasad PA, Go AS, Portugal C, Chang JM, Reynolds K. Health Literacy and Treatment Satisfaction Among Patients with Venous Thromboembolism. J Gen Intern Med 2023; 38:1585-1592. [PMID: 36326991 PMCID: PMC10212857 DOI: 10.1007/s11606-022-07852-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) treatment requires complex management, and patients with limited health literacy (HL) may perceive higher burden and lower benefits associated with their treatment. OBJECTIVE To examine the association of HL with treatment satisfaction among patients with VTE. DESIGN Retrospective cohort study PARTICIPANTS: Kaiser Permanente Southern and Northern California members who were taking oral anticoagulants (OAC) for incident VTE between 2015 and 2018 were surveyed. Main Measures HL was assessed using a 3-item HL assessment and dichotomized as having adequate or limited HL. High treatment burden and low treatment benefit were defined as Anti-Clot Treatment Scale (ACTS) scores below the 25th percentile of the distributions for ACTS Burdens and Benefits survey components, respectively. Using Poisson regression, multivariable adjusted risk ratios (RR) and 95% confidence intervals (CI) were calculated for the association of HL with high treatment burden and low treatment benefits. RESULTS Among 2154 respondents, 397 (18.4%) had limited HL. Patients with limited vs adequate HL were older (47.9% vs 27.5% aged ≥ 75 years, p<0.001), more likely to use a non-English language when discussing their health (10.8% vs 1.7%, p<0.001), to have less than high school education (10.1% vs 1.7%, p<0.001), and to self-rate their health as fair or poor (47.6% vs 25.5%, p<0.001). After multivariable adjustment, patients with limited HL were more likely to have higher perceived treatment burden (RR 1.24, 95% CI 1.07, 1.45) and lower perceived treatment benefits (RR 1.21, 95% CI 1.08, 1.37). CONCLUSIONS Limited HL was associated with lower OAC treatment satisfaction, though absolute differences in satisfaction scores were small. Further examination of the intersection of HL with VTE treatment satisfaction and compliance among older and non-English speaking patients is warranted.
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Affiliation(s)
- Matthew T Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
| | - Hui Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Margaret C Fang
- Divison of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Priya A Prasad
- Divison of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Alan S Go
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
- Departments of Medicine, Health Research and Policy, Stanford University, Palo Alto, CA, USA
| | - Cecilia Portugal
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - John M Chang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Wilson AS, Pham T, Mbusa D, Patel P, Chennupati S, Crawford S, Kapoor A. Pharmacist-led, checklist intervention did not improve adherence in ambulatory patients starting/resuming DOACs. J Am Pharm Assoc (2003) 2023; 63:878-884.e3. [PMID: 36966089 DOI: 10.1016/j.japh.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/18/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND High adherence to direct-acting oral anticoagulant (DOAC) is critical to treat and prevent thromboembolic disease. The Anticoagulation Forum recently endorsed a checklist (DOAC checklist) that recommends care processes that may improve adherence. OBJECTIVES This study aimed to determine whether checklist-driven care from a clinical pharmacist improves adherence in ambulatory patients starting a DOAC or resuming it after a setback. METHODS This study included ambulatory patients starting a DOAC or resuming it after setback (thromboembolic event or bleeding) in an ambulatory setting. Settings included office, emergency department, and short-stay hospital visit. Following the DOAC checklist, a clinical pharmacist verified DOAC appropriateness, instructed dose de-escalation, educated through 3 tele-visits, fielded hotline calls, and handed off to a continuity provider after 3 months. Intervention and control patients received coupons and help with completing manufacturer-based medication assistance applications. Using pharmacy dispense records, our group measured medication possession ratio (MPR) at 90 days (primary outcome) and proportion of days covered (PDC) at 90 days and MPR and PDC at 180 and 365 days (secondary outcomes). Given skewing, our team analyzed adherence as < 80%, 80%-89%, and 90% or more and conducted ordered logistic regression. RESULTS Of 561 patients randomized, 427 had sufficient records to analyze. Adherence was high with only 41 patients (9.6%) having MPR less than 80% at 90 days. There was no difference in adherence between intervention and control patients for primary outcome (odds ratio 0.94 [95% CI 0.60-1.49]) or secondary outcomes. CONCLUSION Our checklist-driven intervention did not appreciably improve adherence beyond that seen in control patients treated with usual care (plus coupons and medication assistance we provided to all patients) in ambulatory patients starting or resuming DOACs, although it should be noted that high levels of adherence in both study groups were noted. Given high adherence, reassessing the DOAC checklist outside of a traditional trial may be more fruitful.
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9
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Risk of posthospital venous thromboembolism in patients with COVID-19 varies by SARS-CoV-2 period and vaccination status. Blood Adv 2022; 7:141-144. [PMID: 36260734 PMCID: PMC9585885 DOI: 10.1182/bloodadvances.2022008984] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 01/07/2023] Open
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10
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Gulpen AJW, Braeken DCW, Schalla S, Ten Cate H, Crijns HJ, Ten Cate-Hoek AJ. Long-term adherence to direct oral anticoagulants in patients with atrial fibrillation; a comparative cross-sectional study. Acta Haematol 2022; 145:476-483. [PMID: 35306490 DOI: 10.1159/000524094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 03/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Long-term treatment with direct oral anticoagulants (DOAC) is required for the majority of patients with non-valvular atrial fibrillation (AF) to prevent ischemic stroke and systemic embolism. Adherence to therapy may impact clinical outcomes. Therefore, the purpose of this study was to assess the potential impact of structured follow-up on long-term adherence to DOAC therapy compared to standard care. METHODS This is a cross sectional study on the implementation phase of medication adherence to DOACs, comparing patients with AF following completion of structured follow-up of minimally 1 year with those who received standard care. All patients used DOACs for more than two years and completed a questionnaire on adherence. Adherence was measured with the MMAS-8 score and assessed via an online webportal. RESULTS A total of 212 patients were included. The mean MMAS-8 score was 7.55(SD 0.93) after structured follow-up and 7.25(SD 1.01) for standard care; p=0.045. Following structured follow-up 64.1% of patients had a high adherence (MMAS score of 8) compared to 50% receiving standard care; p=0.05. Patients following structured follow-up on a once daily DOAC regime had higher MMAS-8 scores compared to those on a twice daily regime; 7.74(SD 0.74) vs. 7.00(SD 1.22); p<0.001. The rates of minor bleedings were 10.6% versus 21.4% respectively, p=0.038. CONCLUSION In patients on long-term DOAC treatment, adherence to therapy was significantly increased after receiving an initial period of structured follow-up compared to standard care. Additionally, adherence to DOAC therapy was higher with once-daily treatment regimen. Significant more minor bleedings were reported in the standard care group. . These results indicate that implementation of structured follow-up of patients with AF using DOACs merits further evaluation.
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Affiliation(s)
- Anouk J W Gulpen
- Thrombosis Expert Center Maastricht and Laboratory for Clinical Thrombosis and Hemostasis, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dionne C W Braeken
- Thrombosis Expert Center Maastricht and Laboratory for Clinical Thrombosis and Hemostasis, Maastricht, The Netherlands
| | - Simon Schalla
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Cardiology and Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hugo Ten Cate
- Thrombosis Expert Center Maastricht and Laboratory for Clinical Thrombosis and Hemostasis, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Harry J Crijns
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Cardiology and Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Arina J Ten Cate-Hoek
- Thrombosis Expert Center Maastricht and Laboratory for Clinical Thrombosis and Hemostasis, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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11
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Speed V, Auyeung V, Patel JP, Cooper D, Miller S, Roberts LN, Patel RK, Arya R. Adherence to rivaroxaban for the treatment of venous thromboembolism-Results from the FIRST registry. Res Pract Thromb Haemost 2021; 5:e12614. [PMID: 34849447 PMCID: PMC8606029 DOI: 10.1002/rth2.12614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 09/24/2021] [Accepted: 09/29/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Medication nonadherence can result in poor clinical outcomes and significant costs to health care providers. When treating venous thromboembolism (VTE), subtherapeutic anticoagulation may contribute to complications such as recurrent VTE or postthrombotic syndrome. OBJECTIVES To describe the extent, reasons for, and predictors of nonadherence to rivaroxaban for the treatment of VTE in clinical practice in the United Kingdom reported by participants of the FIRST registry. PATIENTS/METHODS The FIRST registry was an observational, multicenter registry reporting on the use of rivaroxaban in routine clinical practice. FIRST registry participants completed an adherence screening questionnaire during their treatment and follow-up. RESULTS In total, 1028 participants completed 1660 questionnaires over 2 years. One hundred thirteen of 1028 (11%) reported nonadherence at 28 days (interquartile range, 21-45). Reasons given for nonadherence at 1 month were forgetfulness (8.6% vs 74.7%; P < .001), carelessness (2.7% vs 27.3%; P < .001) or a change in routine (7.4% vs 25.5%; P < .001) reported by adherent and nonadherent participants, respectively. Older age (10-year increments) was the strongest predictor of good adherence (adjusted odds ratio, 1.21; 95% confidence interval, 1.06-1.39; 1 = adherent). CONCLUSIONS Overall adherence to rivaroxaban was high, and most nonadherence was unintentional. Identification of those at risk of nonadherence may reduce the risk of VTE recurrence and long-term complications.
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Affiliation(s)
- Victoria Speed
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
- Institute of Pharmaceutical SciencesKing’s College LondonLondonUK
| | - Vivian Auyeung
- Institute of Pharmaceutical SciencesKing’s College LondonLondonUK
| | - Jignesh P. Patel
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
- Institute of Pharmaceutical SciencesKing’s College LondonLondonUK
| | | | | | - Lara N. Roberts
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
| | - Raj K. Patel
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
| | - Roopen Arya
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
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Roubinian NH, Dusendang JR, Mark DG, Vinson DR, Liu VX, Schmittdiel JA, Pai AP. Incidence of 30-Day Venous Thromboembolism in Adults Tested for SARS-CoV-2 Infection in an Integrated Health Care System in Northern California. JAMA Intern Med 2021; 181:997-1000. [PMID: 33818615 PMCID: PMC8022258 DOI: 10.1001/jamainternmed.2021.0488] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/01/2021] [Indexed: 01/07/2023]
Affiliation(s)
- Nareg H. Roubinian
- Division of Research, Kaiser Permanente Northern California, Oakland
- The Permanente Medical Group, Kaiser Permanente Northern California
- Vitalant Research Institute, San Francisco, California
| | | | - Dustin G. Mark
- Division of Research, Kaiser Permanente Northern California, Oakland
- The Permanente Medical Group, Kaiser Permanente Northern California
| | - David R. Vinson
- Division of Research, Kaiser Permanente Northern California, Oakland
- The Permanente Medical Group, Kaiser Permanente Northern California
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland
- The Permanente Medical Group, Kaiser Permanente Northern California
| | | | - Ashok P. Pai
- The Permanente Medical Group, Kaiser Permanente Northern California
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