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Lapa ME, Swabe GM, Magnani JW. Association of Depression and Adherence to Oral Anticoagulation in Patients With Atrial Fibrillation. J Am Heart Assoc 2023; 12:e031281. [PMID: 37982265 PMCID: PMC10727299 DOI: 10.1161/jaha.123.031281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/25/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Adherence to oral anticoagulation is essential for stroke prevention in atrial fibrillation (AF). Depression has been associated with decreased adherence to medications in multiple disease states and in AF is further associated with increased risk of stroke. We hypothesized that individuals with depression and AF have decreased adherence to anticoagulation than those without depression. METHODS AND RESULTS We used administrative claims data to identify individuals with AF initiating anticoagulation with direct-acting oral anticoagulants (DOACs) or warfarin between 2013 and 2019. We quantified adherence using proportion of days covered, categorized as limited (proportion of days covered, <80%), adequate (proportion of days covered, ≥80% to <90%), or optimal (proportion of days covered, ≥90%). We related depression to 12-month adherence to anticoagulation in logistic regression models, adjusting for demographics, medical and psychiatric comorbidities, household income, educational attainment, and insurance type. As a secondary analysis, we determined the association of depression to adherence for each DOAC agent. We identified 101 041 individuals (aged 74.5±8.9 years; 50.6% women; 29.5% race or ethnicity other than White, including Asian or Black race and Hispanic ethnicity) who initiated either DOACs or warfarin. The odds of adequate adherence to DOACs was 11% (95% CI, 0.85-0.93), and the odds of optimal adherence was 12% (95% CI, 0.83-0.91) less in individuals with depression than those without. Depression was not associated with adherence to warfarin. CONCLUSIONS We identified an association between depression and decreased adherence to DOACs but not warfarin in individuals with AF. Recognizing depression in AF may guide interventions to improve anticoagulation adherence and reduce stroke risk.
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Affiliation(s)
| | | | - Jared W. Magnani
- Department of MedicineUniversity of PittsburghPittsburghPA
- Center for Research on Health Care, Department of MedicineUniversity of PittsburghPittsburghUSA
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2
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Burkhardt H. [Anticoagulation in older patients]. Dtsch Med Wochenschr 2023; 148:1102-1107. [PMID: 37611574 DOI: 10.1055/a-2020-0196] [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: 08/25/2023]
Abstract
Prescribing oral anticoagulation in older patients for e.g. stroke prophylaxis has proven to be beneficial, but some special risks have to be considered. Renal function may be substantial impaired and dose reduction in at least some of the substances is recommended. Therefore, a closer monitoring of renal function is essential. Further as bleeding risk also increases with age usual scoring lists do less help this therapeutic dilemma than in younger patients. Adequate blood pressure control is essential in preventing intracerebral hemorrhage. Fall risk has to be assessed to initiate early compensation for this risk. Only high and unimprovable fall incidence may outweigh the benefits of oral anticoagulation therapy (>1 hospital admission per month due to a fall incident). Comprehensive geriatric assessment is crucial for early detection of specific adherence problems in older patients and is also helpful for discussion of individual deprescribing options in an end of live situation.
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Affiliation(s)
- Heinrich Burkhardt
- IV. Medizinische Klinik - Geriatrie, Universitätsmedizin Mannheim, Mannheim
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3
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King K, Cai S, Barrera L, Reddy P, Heneghan MB, Badawy SM. Barriers to medication adherence in sickle cell disease: A comprehensive theory-based evaluation using the COM-B model. Pediatr Blood Cancer 2023; 70:e30440. [PMID: 37243925 PMCID: PMC10679470 DOI: 10.1002/pbc.30440] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/19/2023] [Accepted: 05/04/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Sickle cell disease (SCD) affects more than 100,000 Americans, with complications such as pain episodes and acute chest syndrome. Despite the efficacy of hydroxyurea in reducing these complications, adherence remains low. Study objectives were to examine barriers to hydroxyurea adherence, and to evaluate the relationship between barriers and their impact on adherence. METHODS In this cross-sectional study, patients with SCD and their caregivers were enrolled if they were taking hydroxyurea. Study measures included demographics, self-report of adherence using visual analog scale (VAS), and the Disease Management and Barriers Interview (DMI)-SCD. The DMI-SCD was mapped to the Capability, Opportunity, Motivation, and Behavior (COM-B) model. RESULTS Forty-eight caregivers (females 83%, median age 38 [34-43]) and 19 patients (male 53%, median age 15 [13.5-18]) participated. Using VAS, many patients (63%) reported low hydroxyurea adherence, while most caregivers (75%) reported high adherence. Caregivers endorsed barriers across multiple COM-B components, with physical opportunity (e.g., cost) and reflective motivation (e.g., SCD perceptions) being the most identified categories (48% and 42%), respectively. Patients' most identified barriers included psychological capability (e.g., forgetfulness) and reflective motivation (84% and 68%), respectively. Patients' and caregivers' VAS scores negatively correlated with the number of barriers (rs = -.53, p = .01; rs = -.28, p = .05) and COM-B categories (rs = -.51, p = .02; rs = -.35, p = .01), respectively, suggesting lower adherence with more endorsed barriers. CONCLUSIONS Fewer barriers to hydroxyurea adherence were associated with higher adherence. Understanding barriers to adherence is essential to develop tailored interventions aimed at improving adherence.
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Affiliation(s)
- Kathryn King
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Stephanie Cai
- Department of Obstetrics & Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Leonardo Barrera
- Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Ann & Robert H. Lurie Children’s Hospital of Chicago , Chicago, IL
| | - Paavani Reddy
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mallorie B. Heneghan
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Sherif M. Badawy
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
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4
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Delavar A, Baxter SL. Cilioretinal artery occlusion in antiphospholipid syndrome and the decision to anticoagulate. BMJ Case Rep 2022; 15:e249509. [PMID: 36384882 PMCID: PMC9670929 DOI: 10.1136/bcr-2022-249509] [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: 11/17/2022] Open
Abstract
A patient in her late 50s with antiphospholipid syndrome presented to general ophthalmology clinic for annual hydroxychloroquine retinopathy screening. She had taken 400 mg hydroxychloroquine daily for over a decade. She denied any visual changes and visual acuity was 20/20. Her examination and fundus photos were normal, but macular optical coherence tomography of the right eye demonstrated inner retinal atrophy and visual field tests revealed a corresponding paracentral scotoma, consistent with a prior cilioretinal artery occlusion. Prior testing from visits with other ophthalmologists revealed that this occlusion had occurred previously, but she had only been informed of not having hydroxychloroquine retinopathy. The possibility of vision loss prompted her to reconsider her prior decision to discontinue anticoagulation. This case demonstrates how anchoring bias may lead clinicians astray, and how the risk of blindness is a strong motivator for patients regarding anticoagulation.
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Affiliation(s)
- Arash Delavar
- Department of Ophthalmology, University of California, La Jolla, California, USA
- Department of Medicine, Division of Biomedical Informatics, University of California, La Jolla, California, USA
| | - Sally L Baxter
- Department of Ophthalmology, University of California, La Jolla, California, USA
- Department of Medicine, Division of Biomedical Informatics, University of California, La Jolla, California, USA
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5
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Duffy S. Understanding patient assessment and treatment in deep vein thrombosis. Nurs Stand 2022; 37:71-75. [PMID: 36278279 DOI: 10.7748/ns.2022.e12050] [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] [Accepted: 10/03/2022] [Indexed: 06/16/2023]
Abstract
Deep vein thrombosis (DVT) commonly develops in the deep veins of the legs, but it can potentially form in any part of the body. There are several risk factors associated with DVT including prolonged immobility, malignancy, recent surgery and family history. One of the main risks of DVT is that the thrombus that has formed in a vein may travel through the body and become lodged in the pulmonary system, causing a pulmonary embolism, which is life-threatening. In the UK, specialist services and diagnostic pathways have been developed to speed up the diagnosis and treatment of DVT, many of which are now nurse-led. This article uses a case study to outline the assessment of patients with suspected DVT and the treatment of patients with a confirmed diagnosis of DVT.
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Affiliation(s)
- Sinead Duffy
- King's College Hospital NHS Foundation Trust, London, England
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6
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Khatiwada B, Rajbhandari B, Mistry SK, Parsekar S, Yadav UN. Prevalence of and factors associated with health literacy among people with Noncommunicable diseases (NCDs) in South Asian countries: A systematic review. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2022. [DOI: 10.1016/j.cegh.2022.101174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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7
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Fomicheva AV, Troshina DV, Simonov AN, Kopylov PI, Andreev DA, Volel BA. [Impact of anxiety disorders on adherence to anticoagulant therapy in patients with atrial fibrillation]. TERAPEVT ARKH 2022; 94:1085-1093. [PMID: 36286760 DOI: 10.26442/00403660.2022.09.201891] [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: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 06/16/2023]
Abstract
AIM To evaluate the impact of anxiety disorders on adherence to anticoagulant therapy (ACT) in patients with atrial fibrillation (AF). MATERIALS AND METHODS 179 outpatients (131 women, 48 men, mean age 69.96.2 years) with AF were examined. The research methods included a physical examination according to the standards of medical care in an outpatient facility, clinical and psychopathological examination using psychometric scales. RESULTS Based on the assessment of adherence to ACT using the MoriskyGreen test, 2 groups of patients were identified: Group 1 patients with high adherence to ACT, Group 2 patients with partial/low adherence to ACT. In group 1, anxiety disorders were verified in 51.7% of cases, in group 2 54.3%. There were no statistically significant differences in the prevalence and severity of anxiety in the study groups. In accordance with the binary logistic regression model, the probability of high adherence to therapy is determined by higher (compared with the group of patients with partial/low adherence to therapy) scores in terms of mental health (p0.001), vital activity (p=0.02) and the total score of the SF-36 scale (p=0.08), as well as the extraversion parameter (p=0.02) of the NEO-FFI scale. CONCLUSION In the present study, no significant association was found between anxiety symptoms and a decrease in adherence to ACT in patients with AF. However, the results obtained suggest a contribution to the adherence to therapy of personality characteristics.
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Affiliation(s)
- A V Fomicheva
- Sechenov First Moscow State Medical University (Sechenov University)
| | - D V Troshina
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | - P I Kopylov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - D A Andreev
- Sechenov First Moscow State Medical University (Sechenov University)
| | - B A Volel
- Sechenov First Moscow State Medical University (Sechenov University)
- Mental Health Research Center
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8
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Schulz A, Herrmann E, Ott O, Lindhoff-Last E. Thromboembolic Antiphospholipid Syndrome (APS): Efficacy and Safety of Different Anticoagulants-Results of the APSantiCO Registry. J Clin Med 2022; 11:jcm11164845. [PMID: 36013082 PMCID: PMC9409774 DOI: 10.3390/jcm11164845] [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: 06/29/2022] [Revised: 07/29/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The particular challenge in dealing with patients with thromboembolic antiphospholipid syndrome (APS) is to establish an adequate therapy regime, as patients suffer from an increased risk of relapse despite antithrombotic treatment (ATT). Vitamin K antagonists (VKA) are the standard medication of choice. The current data on the use of direct oral anticoagulants (DOAC) in APS patients remain limited. Methods: The results of the retrospective APSantiCO registry are presented. In 80 patients with APS, the efficacy and safety of different ATT regimens were analyzed. Results: At the time of inclusion, 43.8% of patients were treated with VKA and 36.3% with DOAC. Medication regimes changed several times and 279 treatment phases were further analyzed with a total treatment length of 7529 months. The incidence of recurrent arterial thrombosis was significantly larger in the DOAC group compared with the VKA group (p < 0.001), while the incidence of recurrent venous thrombosis was comparable between both groups, as was the incidence of bleedings. Heavy menstrual bleeding was the most frequently observed bleeding complication. Conclusions: The data suggest that DOAC may be an alternative to VKA for APS patients with venous thromboembolism, while VKA should be used in APS-related arterial thrombosis.
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Affiliation(s)
- Annabel Schulz
- Coagulation Centre, Cardiology Angiology Centre Bethanien Hospital (CCB), 60389 Frankfurt, Germany
- Coagulation Research Centre Bethanien Hospital, 60389 Frankfurt, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University, 60590 Frankfurt, Germany
| | - Olivia Ott
- Coagulation Centre, Cardiology Angiology Centre Bethanien Hospital (CCB), 60389 Frankfurt, Germany
- Coagulation Research Centre Bethanien Hospital, 60389 Frankfurt, Germany
| | - Edelgard Lindhoff-Last
- Coagulation Centre, Cardiology Angiology Centre Bethanien Hospital (CCB), 60389 Frankfurt, Germany
- Coagulation Research Centre Bethanien Hospital, 60389 Frankfurt, Germany
- Correspondence:
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9
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Deceptive Adherence to Anticoagulation in Secondary Stroke Prevention. Stroke Res Treat 2022; 2022:5318259. [PMID: 35859782 PMCID: PMC9293572 DOI: 10.1155/2022/5318259] [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: 02/16/2022] [Revised: 05/17/2022] [Accepted: 06/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background Oral anticoagulants (OAC) effectively reduce the risk for ischemic stroke in patients with atrial fibrillation (AF). We aimed to assess OAC treatment adherence in secondary stroke prevention and to find predictors of adherence using individualized patient data. Methods This retrospective cohort study included patients with a discharge diagnosis of ischemic stroke and AF from Tartu University Hospital from 2017 to 2018. Data from patient charts and the Electronic Hospital Information, Estonian Electronic Prescription, and Estonian Electronic Health Record systems were registered. Results Of the 353 patients, 237 (67%) were prescribed OAC treatment at discharge and during the first year after stroke, 202 (85%) of them used OAC treatment. The mean adherence was 81%, while only 68% had good adherence. Reduced non-vitamin K antagonist OAC (NOAC) dose was used in 68 patients (39%), which was justified in 23 (34%). First-ever stroke occurrence was the only significant factor for good treatment adherence in logistic regression analysis. There were 47 patients (23%) with complications among the patients on OAC treatment. Majority of the patients (70%) with hemorrhagic complications and 52% of patients with thromboembolic complications had good treatment adherence Conclusions Our study showed that OAC treatment adherence following stroke was modest and first-ever stroke was the only predictor of good or full treatment adherence.
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10
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Alkhameys S, Barrett R. Impact of the COVID-19 pandemic on England's national prescriptions of oral vitamin K antagonist (VKA) and direct-acting oral anticoagulants (DOACs): an interrupted time series analysis (January 2019-February 2021). Curr Med Res Opin 2022; 38:1081-1092. [PMID: 35582854 DOI: 10.1080/03007995.2022.2078100] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Direct-acting oral anticoagulants (DOACs) were developed as an alternative to warfarin to treat and prevent thromboembolism, including stroke prevention in non-valvular atrial fibrillation patients. The COVID-19 pandemic could increase the risk of stroke and/or the risk of bleeding in patients due to nonadherence or sub/supra-optimal dosing. OBJECTIVE To investigate DOAC prescription trends in England's community settings during the complete first wave of COVID-19 pandemic. METHODS Descriptive and interrupted time series (ITS) analyses were conducted to examine the prescription patterns of DOACs (dabigatran, rivaroxaban, apixaban and edoxaban) and warfarin for primary care patients in the English Prescribing Dataset from January 2019 to February 2021, with March 2020 as the cut-off point. RESULTS A 19% increase in mean DOAC's accompanied with 20% warfarin prescriptions decline was observed. ITS modelling showed an increase in DOAC prescription volume in March 2020 (+7 million items, p = 0.008). The pre-existing upward trend in DOAC prescriptions slowed during the period (-427,000 items, p = 0.007). Apixaban was the most frequently used DOAC and had the largest step-change in March 2020 (+5 million items, p = 0.010). The mean monthly combined cost of DOACs and warfarin was higher during the period. DOAC prescription trends were consistent across England's regions. Conclusion: The overall oral anticoagulants use in this period was lower than expected, indicating a medical needs gap, possibly due to adherence issues. The potential clinical and logistical consequences warrant further study to identify contributing factors and mitigate avoidable risks.
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Affiliation(s)
| | - Ravina Barrett
- Senior Lecturer in Pharmacy Practice, School of Applied Sciences, Cockcroft Building, University of Brighton, Brighton, UK
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11
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McGrady ME, Todd K, Ignjatovic V, Jones S, Rizzi M, Luchtman-Jones L, Thornburg CD. Results of an international survey on adherence with anticoagulation in children, adolescents, and young adults: Communication from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis. J Thromb Haemost 2022; 20:1720-1728. [PMID: 35427434 DOI: 10.1111/jth.15730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 08/31/2023]
Abstract
BACKGROUND The ISTH Scientific and Standardization Committee (SSC) Subcommittee on Pediatric/Neonatal Thrombosis and Hemostasis convened a working group on medication adherence to begin to understand the current state of clinical practice to inform priority areas for efforts to improve adherence for children, and adolescents and young adults (AYA) prescribed anticoagulants. OBJECTIVES We sought to survey an international group of clinicians involved in anticoagulation management in children and/or AYA about perceptions of medication on health outcomes, clinical practice related to medication adherence, and barriers to assessing and improving medication adherence. METHODS Clinicians involved in anticoagulation management in children and/or AYA were surveyed via REDCap® . Descriptive statistics were used to summarize demographic and clinical characteristics and responses to multiple choice and Likert-type questions. Free-text answers were coded based on the Behaviour Change Technique Taxonomy and the Expert Recommendations for Implement Change project. RESULTS AND CONCLUSIONS There were 200 participants, 90% of whom were pediatric hematology/oncology physicians. Based on the results, which demonstrate that clinicians are concerned about impact of poor medication adherence and have limited resources to identify and improve adherence, the working group has identified next steps to further understand impact of medication adherence on anticoagulation-related health outcomes, address the need for validated measures to assess medication adherence for all anticoagulants prescribed to this population, and develop an intervention and implementation research agenda to improve outcomes.
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Affiliation(s)
- Meghan E McGrady
- Division of Behavioral Medicine and Clinical Psychology, Center for Adherence and Self-Management, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kevin Todd
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pediatric Hematology/Oncology, Children's Hospital of the King's Daughters, Norfolk, Virginia, USA
| | - Vera Ignjatovic
- Haematology, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Sophie Jones
- Haematology, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Nursing, The University of Melbourne, Parkville, Victoria, Australia
| | - Mattia Rizzi
- Hematology/Oncology Unit, Division of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | - Lori Luchtman-Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Courtney D Thornburg
- Division of Pediatric Hematology/Oncology, Rady Children's Hospital San Diego, San Diego, California, USA
- Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California, USA
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12
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Pandor A, Fuller G, Essat M, Sabir L, Holt C, Buckley Woods H, Chatha H. Individual risk factors predictive of major trauma in pre-hospital injured older patients: a systematic review. Br Paramed J 2022; 6:26-40. [PMID: 35340581 PMCID: PMC8892449 DOI: 10.29045/14784726.2022.03.6.4.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background Older adults with major trauma are frequently under-triaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to identify which individual risk factors and predictors are likely to increase the risk of major trauma in elderly patients presenting to emergency medical services (EMS) following injury, to inform future elderly triage tool development. Methods Several electronic databases (including Medline, EMBASE, CINAHL and the Cochrane Library) were searched from inception to February 2021. Prospective or retrospective diagnostic studies were eligible if they examined a prognostic factor (often termed predictor or risk factor) for, or diagnostic test to identify, major trauma. Selection of studies, data extraction and risk of bias assessments using the Quality in Prognostic Studies (QUIPS) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarise the findings. Results Nine studies, all performed in US trauma networks, met review inclusion criteria. Vital signs (Glasgow Coma Scale (GCS) score, systolic blood pressure, respiratory rate and shock index with specific elderly cut-off points), EMS provider judgement, comorbidities and certain crash scene variables (other occupants injured, occupant not independently mobile and head-on collision) were identified as significant pre-hospital variables associated with major trauma in the elderly in multi-variable analyses. Heart rate and anticoagulant were not significant predictors. Included studies were at moderate or high risk of bias, with applicability concerns secondary to selected study populations. Conclusions Existing pre-hospital major trauma triage tools could be optimised for elderly patients by including elderly-specific physiology thresholds. Future work should focus on more relevant reference standards and further evaluation of novel elderly relevant triage tool variables and thresholds.
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Affiliation(s)
- Abdullah Pandor
- The University of Sheffield ORCID iD: https://orcid.org/0000-0003-2552-5260
| | - Gordon Fuller
- The University of Sheffield ORCID iD: https://orcid.org/0000-0001-8532-3500
| | - Munira Essat
- The University of Sheffield ORCID iD: https://orcid.org/0000-0003-2397-402X
| | - Lisa Sabir
- The University of Sheffield ORCID iD: https://orcid.org/0000-0001-6488-3314
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Toorop MMA, Chen Q, Kruip MJHA, van der Meer FJM, Nierman MC, Faber L, Goede L, Cannegieter SC, Lijfering WM. Switching from vitamin K antagonists to direct oral anticoagulants in non-valvular atrial fibrillation patients: Does low time in therapeutic range affect persistence? J Thromb Haemost 2022; 20:339-352. [PMID: 34779140 PMCID: PMC9299168 DOI: 10.1111/jth.15592] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/20/2021] [Accepted: 11/10/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Non-valvular atrial fibrillation (NVAF) patients are advised to switch from a vitamin K antagonist (VKA) to direct oral anticoagulant (DOAC) when time in therapeutic range (TTR) is low. OBJECTIVE To examine if pre-switch TTR determines persistence patterns in NVAF patients who are switched from a VKA to DOAC. PATIENTS/METHODS Adult NVAF patients from three Dutch anticoagulation clinics who were newly switched from a VKA to DOAC between July 1, 2013 and September 30, 2018 were stratified by pre-switch TTR levels. DOAC prescription records were examined to determine persistence patterns according to a 100-day prescription gap. Cumulative incidences of non-persistence to DOAC were estimated using the cumulative incidence competing risk method. The association of pre-switch TTR levels with DOAC non-persistence was evaluated by Cox regression models. RESULTS A total of 3696 NVAF patients were included, of whom 690 (18.7%) had a pre-switch TTR ≤ 45%. After switching from VKA to DOAC, 14.0% (95% confidence interval [CI] 11.3-17.0%) of the patients with a pre-switch TTR ≤ 45% became non-persistent to DOAC within 1 year, while 9.8% (95% CI 8.7-11.0%) did in those with a pre-switch TTR > 45%. In a multivariable model, a pre-switch TTR ≤ 45% was associated with a higher risk of non-persistence to DOAC (adjusted hazard ratio 1.55, 95% CI 1.22-1.97). Results were similar when using other cut-off points (60% or 70%) to define a low TTR. CONCLUSION NVAF patients switching from VKA to DOAC due to a low pre-switch TTR saw a worse persistence pattern to DOAC after the switch compared to patients with a high pre-switch TTR.
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Affiliation(s)
- Myrthe M. A. Toorop
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Qingui Chen
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Marieke J. H. A. Kruip
- Department of HaematologyErasmus MCErasmus University Medical CenterRotterdamthe Netherlands
- Thrombosis Service Star‐shlRotterdamthe Netherlands
| | | | | | - Laura Faber
- Department of MedicineRed Cross HospitalBeverwijkthe Netherlands
| | - Lies Goede
- Thrombosis Service of Utrecht (Saltro)Utrechtthe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
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14
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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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Bartoli-Abdou JK, Patel JP, Vadher B, Brown A, Roberts LN, Patel RK, Arya R, Auyeung V. Long-term adherence to direct acting oral anticoagulants and the influence of health beliefs after switching from vitamin-K antagonists: Findings from the Switching Study. Thromb Res 2021; 208:162-169. [PMID: 34801919 DOI: 10.1016/j.thromres.2021.11.003] [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: 08/25/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 11/17/2022]
Abstract
AIMS Switching non-adherent patients prescribed anticoagulant treatment to a regime with less monitoring could lead to significant non-adherence. Health beliefs are known to influence medication adherence; however, the extent of this influence is unknown in patients switched from vitamin-K antagonists (VKAs) to direct oral anticoagulants (DOACs). This study aimed to determine adherence to long-term therapy in patients switched from VKAs to DOAC due to low time in therapeutic range (TTR) and if adherence is associated with health beliefs. METHODS The Switching Study is a longitudinal observational cohort study following patients for at least 1-year. 254 patients anticoagulated with VKAs for stroke prevention in atrial fibrillation (AF) or secondary prevention of venous thromboembolism (VTE) and TTR < 50% were recruited from anticoagulation clinics at King's College Hospital, London, UK. All participants were switched to DOAC and had health beliefs measured at baseline with VKA, 1-month and 12-months after switching. RESULTS Of the 220 patients who completed 12-month follow-up 39% had sub-optimal adherence measured by self-report. 23% were non-adherent according to prescriptions issued. Increasing concerns about anticoagulation over time relative to beliefs about necessity was associated with lower self-reported adherence (OR = 0.902 95%C.I: 0.836, 0.974; p = 0.008). At baseline, believing that medications in general were overused in healthcare was negatively associated with adherence to DOAC (β = -1.5, 95%C.I: -2.7, -0.3; p = 0.013). CONCLUSIONS Although many patients who switched were adherent to therapy long-term, between 23 and 39% of patients exhibited sub-optimal adherence: these patients can be identified through their modifiable health beliefs at the time of switching.
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Affiliation(s)
- John K Bartoli-Abdou
- Institute of Pharmaceutical Science, King's College London, London, United Kingdom; King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom.
| | - Jignesh P Patel
- Institute of Pharmaceutical Science, King's College London, London, United Kingdom; King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Bipin Vadher
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Alison Brown
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Raj K Patel
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Roopen Arya
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Vivian Auyeung
- Institute of Pharmaceutical Science, King's College London, London, United Kingdom
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Apixaban compared with warfarin to prevent thrombosis in thrombotic antiphospholipid syndrome: a randomized trial. Blood Adv 2021; 6:1661-1670. [PMID: 34662890 PMCID: PMC8941474 DOI: 10.1182/bloodadvances.2021005808] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/21/2021] [Indexed: 11/20/2022] Open
Abstract
The primary outcome, stroke, occurred in 6 of 23 patients randomized to apixaban compared with 0 of 25 patients randomized to warfarin. This study with limitations suggests that apixaban is not an equitable substitute for warfarin to prevent thrombosis among TAPS patients.
Thrombotic antiphospholipid syndrome (TAPS) is characterized by venous, arterial, or microvascular thrombosis. Patients with TAPS merit indefinite anticoagulation, and warfarin has historically been the standard treatment. Apixaban is an oral factor Xa inhibitor anticoagulant that requires no dose adjustment or monitoring. The efficacy and safety of apixaban compared with warfarin for TAPS patients remain unknown. This multicenter prospective randomized open-label blinded endpoint study assigned anticoagulated TAPS patients to apixaban or warfarin (target international normalized ratio 2-3) for 12 months. The primary efficacy outcome was clinically overt thrombosis and vascular death. Apixaban was first given at 2.5 mg twice daily. Two protocol changes were instituted based on recommendations from the data safety monitoring board. After the twenty-fifth patient was randomized, the apixaban dose was increased to 5 mg twice daily, and after the thirtieth patient was randomized, subjects with prior arterial thrombosis were excluded. Primary outcomes were adjudicated by independent experts blinded to treatment allocation. Patients randomized between 23 February 2015 and 7 March 2019 to apixaban (n = 23) or warfarin (n = 25) were similar. Among the components of the primary efficacy outcome, only stroke occurred in 6 of 23 patients randomized to apixaban compared with 0 of 25 patients randomized to warfarin. The study ended prematurely after the forty-eighth patient was enrolled. Conclusions from our study are limited due to protocol modifications and low patient accrual. Despite these limitations, our results suggest that apixaban may not be routinely substituted for warfarin to prevent recurrent thrombosis (especially strokes) among patients with TAPS. This trial was registered at www.clinicaltrials.gov as #NCT02295475.
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Charlton A, Vidal X, Sabaté M, Bailarín E, Martínez LML, Ibáñez L. Factors associated with primary nonadherence to newly initiated direct oral anticoagulants in patients with nonvalvular atrial fibrillation. J Manag Care Spec Pharm 2021; 27:1210-1220. [PMID: 34464214 PMCID: PMC10391044 DOI: 10.18553/jmcp.2021.27.9.1210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Direct oral anticoagulants (DOACs) are widely used for the prevention of stroke in nonvalvular atrial fibrillation (NVAF); however, real-world primary nonadherence (failing to collect the first prescription) has been measured in very few studies. OBJECTIVE: To report primary nonadherence in NVAF patients who are newly prescribed DOACs and identify associated factors. METHODS: This observational retrospective cohort study used a large primary care database in Catalonia. Patients with NVAF who were newly prescribed a DOAC between January 2009 and December 2015 were identified, and primary nonadherence was measured by comparing prescribing records to pharmacy claims data. Multivariable logistic regression was used to determine associated factors. RESULTS: A total of 12,257 patients met the inclusion and exclusion criteria; of these, 1,276 (10.4%) were primary nonadherent. Primary nonadherence was found to be 12.8% for apixaban, 8.6% for dabigatran, and 10.8% for rivaroxaban. Multivariable logistic regression indicated higher odds of primary nonadherence with apixaban and rivaroxaban compared to dabigatran (apixaban: OR = 1.61, 95% CI = 1.39-1.87; rivaroxaban: OR = 1.28, 95% CI = 1.11-1.47). Patients aged at least 80 years showed lower odds of primary nonadherence compared to those aged less than 65 years (OR = 0.78, 95% CI = 0.66-0.93). A diagnosis of chronic kidney disease was associated with primary nonadherence (OR = 1.27, 95% CI = 1.08-1.50). Whereas, diabetes (OR = 0.85, 95% CI = 0.74-0.97), hypertension (OR = 0.79, 95% CI = 0.70-0.91), and stroke/transient ischemic attack (OR = 0.70, 95% C I =0.59-0.82) were inversely associated with primary nonadherence. CONCLUSIONS: Overall, 10.4% of patients prescribed DOACs were primary nonadherent, failing to collect the first prescription. The percentage could have serious implications for patient outcomes and the real-world cost-effectiveness of prescribing DOACs in NVAF. Rates of primary nonadherence and associated factors may provide useful information for the design and evaluation of adherence interventions. DISCLOSURES: No outside funding was received for this study. The data for this study came from the European Medicines Agency PE-PV project (Grant/Award Number EMA/2015/27/PH). The authors have nothing to disclose. A preliminary version of this work was presented at the European Drug Utilisation Research Group (EuroDURG) Conference, Szeged, Hungary, March 5, 2020.
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Affiliation(s)
- Alethea Charlton
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron, Barcelona, Spain; Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany; and Pettenkofer School of Public Health, Munich, Germany
| | - Xavier Vidal
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron; Autonomous University of Barcelona; and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Mònica Sabaté
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron; Autonomous University of Barcelona; and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Elena Bailarín
- Fundació Institut Català de Farmacologia (FICF) and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Lina María Leguízamo Martínez
- Autonomous University of Barcelona and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Luisa Ibáñez
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron; Autonomous University of Barcelona; and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
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de Castro KP, Chiu HH, De Leon-Yao RC, Almelor-Sembrana L, Dans AM. A Patient Decision Aid for Anticoagulation Therapy in Patients With Nonvalvular Atrial Fibrillation: Development and Pilot Study. JMIR Cardio 2021; 5:e23464. [PMID: 34385138 PMCID: PMC8391739 DOI: 10.2196/23464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 04/06/2021] [Accepted: 06/02/2021] [Indexed: 12/21/2022] Open
Abstract
Background Atrial fibrillation (AF) is one of the most common predisposing factors for ischemic stroke worldwide. Because of this, patients with AF are prescribed anticoagulant medications to decrease the risk. The availability of different options for oral anticoagulation makes it difficult for some patients to decide a preferred choice of medication. Clinical guidelines often recommend enhancing the decision-making process of patients by increasing their involvement in health decisions. In particular, the use of patient decision aids (PDAs) in patients with AF was associated with increased knowledge and increased likelihood of making a choice. However, the majority of available PDAs are from Western countries. Objective We aimed to develop and pilot test a PDA to help patients with nonvalvular AF choose an oral anticoagulant for stroke prevention in the local setting. Outcomes were (1) reduction in patient decisional conflict, (2) improvement in patient knowledge, and (3) patient and physician acceptability. Methods We followed the International Patient Decision Aid Standards (IPDAS) to develop a mobile app–based PDA for anticoagulation therapy in patients with nonvalvular AF. Focus group discussions identified decisional needs, which were subsequently incorporated into the PDA to compare choices for anticoagulation. Based on recommendations, the prototype PDA was rendered by at least 30 patients and 30 physicians. Decisional conflict and patient knowledge were tested before and after the PDA was implemented. Patient acceptability and physician acceptability were measured after each encounter. Results Anticoagulant options were compared by the PDA using three factors that were identified (impact on stroke and bleeding risk, and price). The comparisons were presented as tables and graphs. The prototype PDA was rendered by 30 doctors and 37 patients for pilot testing. The mean duration of the encounters was 15 minutes. The decisional conflict score reduced by 35 points (100-point scale; P<.001). The AF knowledge score improved from 10 to 15 (P<.001). The PDA was acceptable for both patients and doctors. Conclusions Our study showed that an app-based PDA for anticoagulation therapy in patients with nonvalvular AF (1) reduced patient decisional conflict, (2) improved patient knowledge, and (3) was acceptable to patients and physicians. A PDA is potentially acceptable and useful in our setting. A randomized controlled trial is warranted to test its effectiveness compared to usual care. PDAs for other conditions should also be developed.
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Affiliation(s)
- Kim Paul de Castro
- Department of Medicine, Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Harold Henrison Chiu
- Department of Medicine, Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Ronna Cheska De Leon-Yao
- Department of Medicine, Philippine General Hospital, University of the Philippines, Manila, Philippines
| | | | - Antonio Miguel Dans
- Division of Adult Medicine, Department of Medicine, Philippine General Hospital, University of the Philippines, Manila, Philippines
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Medication non-adherence in chronic kidney disease: a mixed-methods review and synthesis using the theoretical domains framework and the behavioural change wheel. J Nephrol 2021; 34:1091-1125. [PMID: 33559850 DOI: 10.1007/s40620-020-00895-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/28/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Medication non-adherence is a well-recognised issue in chronic diseases but data in patients with chronic kidney disease (CKD) not receiving kidney replacement therapy (KRT) remains limited. This review summarised the prevalence of medication non-adherence and assessed determinants and outcomes associated with it in adults with CKD, not on KRT. METHOD We searched PubMed, Embase, PsychInfo, Web of Science, and Cochrane (CENTRAL) for studies published until January 2020. Pooled prevalence of medication non-adherence was reported. Determinants of adherence-identified from quantitative and qualitative studies-were mapped into the theoretical domains framework and interventions proposed using the behavioural change wheel. RESULTS Twenty-seven studies (22 quantitative and 5 qualitative) were included. The pooled prevalence of medication non-adherence was 39% (95% CI 30-48%). Nine studies reported association between non-adherence and outcomes, including blood pressure, disease progression, adverse events, and mortality. Modifiable determinants of non-adherence were mapped into 11 of the 14 Theoretical Domains Framework-of which, six appeared most relevant. Non-adherence decisions were usually due to lack of knowledge on CKD, comorbidities, and medications; polypharmacy and occurrence of medication side effects; changes in established routines such as frequent medication changes; higher medication cost, poor accessibility to medications, services and facilities; inadequate patient-healthcare professional communication; and forgetfulness. Using the behavioural change wheel, we identified several areas where interventions can be directed to improve medication adherence. CONCLUSION Medication non-adherence is common in adults with CKD, not on KRT and may lead to poor outcomes. Evidence synthesis using mixed study designs was crucial in identifying determinants of non-adherence, drawing on a parsimonious approach from behaviour science. PROSPERO REGISTRATION CRD42020149983.
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Henry M, Wosnitza M, Thate-Waschke IM, Bauersachs R, Ueng KC, Chang KC, Wilke T. Country-based Comparison of Atrial Fibrillation Patients' Preferences for Oral Anticoagulation: An Evaluation of Discrete Choice Experiments in Five Different Countries. J Cardiovasc Pharmacol 2021; 77:100-106. [PMID: 33165142 DOI: 10.1097/fjc.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/13/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT The aim of this study was to examine atrial fibrillation (AF) patients' preferences regarding oral anticoagulation (OAC) characteristics and to investigate differences across 5 different countries. A multicenter discrete choice experiment was conducted in Germany, Sweden, Switzerland, Spain, and Taiwan. Study sites enrolled patients with nonvalvular AF who received continuous OAC therapy. The discrete choice experiment design considered the following 4 attributes with 2 attribute levels each: need for bridging (yes/no), interactions with food/alcohol (yes/no), need for regular international normalized ratio (INR) assessments, and frequency of intake (once/twice daily). Generally, patients (n = 1391) preferred treatment alternatives that were characterized by "no need of bridging," "no need for regular INR controls," "no interactions with food/alcohol," and "once daily intake." For this desired treatment regimen, patients were willing to accept a substantially higher travel distance/time. German patients with AF were strongly impacted in their hypothetical treatment decision by the frequency of intake (37.5%). Swedish patients on the other hand gave little importance to intake frequency (12.6%). In Switzerland, patients were especially concerned with food/alcohol interactions of the medication (34.7%), whereas this was the least important attribute for Taiwanese patients (18.9%), who ascribed the most homogenous importance to the different treatment attributes overall. In Spain, the need for regular INR assessments especially impacted the patient's treatment decision (31.9%). Patients of all countries attributed a moderate importance to the need for bridging (25.9%-34.2%). These findings may facilitate country-specific consideration of patients' preferences regarding OAC therapy, potentially increasing treatment acceptance on the patient's side with the ultimate goal of improving treatment adherence and persistence.
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Impact of adherence to warfarin therapy during 12 weeks of pharmaceutical care in patients with poor time in the therapeutic range. J Thromb Thrombolysis 2020; 51:1043-1049. [PMID: 32974757 DOI: 10.1007/s11239-020-02280-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 01/17/2023]
Abstract
Poor adherence to warfarin treatment is a contributor to poor quality of treatment, which increases the risk of bleeding and thromboembolic events. This study aims to evaluate the impact of adherence to warfarin therapy on anticoagulation quality during 12 weeks of pharmaceutical care and after 1 year of follow-up for patients with atrial fibrillation and with poor TTR. The Arrhythmia Unit of tertiary hospital in Brazil. We included 262 patients with AF and poor quality of anticoagulation therapy with warfarin (TTR < 50%). Pharmacist-driven therapy management was performed for 12 weeks and patients were also evaluated 1 year after the end of the follow-up with a pharmacist. Adherence was classified into high adherence, medium adherence and low adherence. Impact of adherence to warfarin therapy after pharmaceutical care. Of the 262 patients, 160 were high adherence, 71 were medium adherence and 31 were low adherence. No statistically significant difference is found between adherence groups in demographic and clinical variables. The TTR basal means were not different among adherence groups (p = 0.386). However, the means of TTR 12 weeks and TTR 1 year after the end of protocol were statistically different among adherence groups (p < 0.001 and p = 0.002, respectively). When we compared TTR values at different times within the adherence group, we observed that there is a statistical difference between the three TTR means (basal versus 12 weeks versus 1 year after) within the adherence group (p < 0.001). Patients with poor anticoagulation control, who adhered to the treatment with warfarin during the pharmaceutical care had better anticoagulation quality compared to those who did not adhere to the therapy with warfarin.
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Pham Nguyen TP, Chen Y, Thibault D, Leonard CE, Hennessy S, Willis A. Does hospitalization for thromboembolism improve oral anticoagulant adherence in patients with atrial fibrillation? J Am Pharm Assoc (2003) 2020; 60:986-992.e2. [PMID: 32883621 DOI: 10.1016/j.japh.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/21/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND It is not known how medication adherence changes after hospitalization for a sentinel thromboembolic event. OBJECTIVE The purpose of this study was to examine the impact of hospitalization for ischemic stroke or thromboembolism on postdischarge adherence to oral anticoagulants in patients with atrial fibrillation. METHODS We conducted a quasi-experimental pre-post observational study using a large U.S. commercial insurance health care claims database. Adult patients with atrial fibrillation taking oral anticoagulants with a random hospitalization for a nonbleeding-related reason occurring after the first observed oral anticoagulant prescription fill, with no other admissions within the preceding and following 6 months, were identified in Optum Clinformatics (Eden Prairie, MN) from 2009 to 2016. Adherence was estimated by the proportion of days covered within 6 and 12 months before and after hospitalization. Difference-in-difference analysis using a generalized linear model was employed to compare pre- and post-hospitalization proportions of days covered (PDCs) by reasons for hospitalization (i.e., ischemic stroke or thromboembolism vs. other nonbleeding-related reasons), adjusting for imbalanced baseline characteristics. RESULTS Of the 21,400 individuals meeting inclusion criteria, 5.4% were hospitalized for ischemic stroke or thromboembolism and 94.6% for other nonbleeding-related reasons. Baseline characteristics were quite similar between groups, except for a few covariables such as age or CHA2DS2-VASc score. Minority race or ethnicity individuals had 0.7% lower overall PDC than whites (P = 0.006). After covariate adjustment, 6-month adherence declined by 1.1% less in individuals hospitalized for ischemic stroke or thromboembolism, compared with other nonbleeding reasons, although the difference was not statistically significant (P = 0.17). Similar results were observed for the 12-month window. CONCLUSION This real-world study suggests that more effective strategies are needed to improve adherence to oral anticoagulant, particularly after a thromboembolic event.
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Speed V, Patel RK, Byrne R, Roberts LN, Arya R. A perfect storm: Root cause analysis of supra-therapeutic anticoagulation with vitamin K antagonists during the COVID-19 pandemic. Thromb Res 2020; 192:73-74. [PMID: 32425265 PMCID: PMC7229971 DOI: 10.1016/j.thromres.2020.05.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/15/2022]
Affiliation(s)
- V Speed
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Institute of Pharmaceutical Sciences, King's College London, London, UK.
| | - R K Patel
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - R Byrne
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Institute of Pharmaceutical Sciences, King's College London, London, UK
| | - L N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - R Arya
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
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Boon GJAM, van Rein N, Bogaard HJ, Ende-Verhaar YM, Huisman MV, Kroft LJM, van der Meer FJM, Meijboom LJ, Symersky P, Vonk Noordegraaf A, Klok FA. Quality of initial anticoagulant treatment and risk of CTEPH after acute pulmonary embolism. PLoS One 2020; 15:e0232354. [PMID: 32343741 PMCID: PMC7188241 DOI: 10.1371/journal.pone.0232354] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/13/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pathophysiology of chronic thromboembolic pulmonary hypertension (CTEPH) is not fully understood. Poor-quality anticoagulation may contribute to a higher risk of CTEPH after acute pulmonary embolism (PE), partly explaining the transition from acute PE to CTEPH. We assessed the association between the time in therapeutic range (TTR) of vitamin-K antagonist (VKA) treatment and incidence of CTEPH after a PE diagnosis. METHODS Case-control study in which the time spent in, under and above therapeutic range was calculated in 44 PE patients who were subsequently diagnosed with CTEPH (cases). Controls comprised 150 consecutive PE patients in whom echocardiograms two years later did not show pulmonary hypertension. All patients were treated with VKA for at least 6 months after the PE diagnosis. Time in (TTR), under and above range were calculated. Mean differences between cases and controls were estimated by linear regression. RESULTS Mean TTR during the initial 6-month treatment period was 72% in cases versus 78% in controls (mean difference -6%, 95%CI -12 to -0.1), mainly explained by more time above the therapeutic range in the cases. Mean difference of time under range was 0% (95%CI -6 to 7) and 2% (95CI% -3 to 7) during the first 3 and 6 months, respectively. In a multivariable model, adjusted odds ratios (ORs) for CTEPH were around unity considering different thresholds for 'poor anticoagulation', i.e. TTR <50%, <60% and <70%. CONCLUSION Subtherapeutic initial anticoagulation was not more prevalent among PE patients diagnosed with CTEPH than in those who did not develop CTEPH.
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Affiliation(s)
- Gudula J. A. M. Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke van Rein
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Yvonne M. Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J. M. Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Felix J. M. van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lilian J. Meijboom
- Department of Radiology and Nuclear medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Petr Symersky
- Department of Cardiac Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
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Tzikas A, Samaras A, Kartas A, Vasdeki D, Fotos G, Dividis G, Paschou E, Forozidou E, Tsoukra P, Kotsi E, Goulas I, Karvounis H, Giannakoulas G. Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with non-valvular Atrial Fibrillation (MISOAC-AF): a randomized clinical trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:f63-f71. [PMID: 32339234 DOI: 10.1093/ehjcvp/pvaa039] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/05/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022]
Abstract
AIMS We aimed to assess the impact of an educational, motivational intervention on the adherence to oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (AF). METHODS AND RESULTS Hospitalized patients with non-valvular AF who received OAC were randomly assigned to usual medical care or a proactive intervention, comprising motivational interviewing, and tailored counselling on medication adherence. The primary study outcome was adherence to OAC at 1 year, which was evaluated according to proportion of days covered (PDC) by OAC regimens and was assessed through nationwide registers of prescription claims. Secondary outcomes included the rate of persistence to OAC, gaps in treatment, and clinical events. A total of 1009 patients were randomized, 500 in the intervention group and 509 in the control group. At 1-year follow-up, 77.2% (386/500) of patients in the intervention group were adherent (PDC > 80%), compared with 55% (280/509) in the control group [adjusted odds ratio (aOR) 2.84, 95% confidence interval (CI) 2.14-3.75; P < 0.001]. Mean PDC ± standard deviation was 0.85 ± 0.26 and 0.75 ± 0.31, respectively (P < 0.001). Patients that received the intervention were more likely to persist in their OAC therapy at 1 year (aOR 2.42, 95% CI 1.71-3.41; P < 0.001). Usual medical care was associated with more major (≥3 months) treatment gaps (aOR 2.39, 95% CI 1.76-3.26; P < 0.001). Clinical events over a median follow-up period of 2 years did not differ among treatment groups. CONCLUSION In patients receiving OAC therapy for non-valvular AF, a multilevel motivational intervention significantly improved medication adherence and rate of therapy persistence, and reduced major gaps in treatment. No significant impact on clinical outcomes was observed. TRIAL REGISTRATION NUMBER NCT02941978.
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Affiliation(s)
- Apostolos Tzikas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece.,Department of Cardiology, Interbalkan European Medical Center, Asklipiou 10, Pylaia, Thessaloniki 55535, Greece
| | - Athanasios Samaras
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Anastasios Kartas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Dimitra Vasdeki
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - George Fotos
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - George Dividis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Eleni Paschou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Evropi Forozidou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Paraskevi Tsoukra
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Eleni Kotsi
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Ioannis Goulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Haralambos Karvounis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
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Roseau C, Richard C, Renet S, Kowal C, Eliahou L, Rieutord A, Chaumais MC. Evaluation of a program of pharmaceutical counseling for French patients on oral anticoagulant therapy. Int J Clin Pharm 2020; 42:685-694. [PMID: 31933106 DOI: 10.1007/s11096-020-00964-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
Abstract
Background Oral anticoagulants are widely used for treatment and prevention of thromboembolic diseases. We set up a pharmaceutical counseling program for both direct oral anticoagulant and vitamin K antagonist drugs in our hospital in 2015. Objective Evaluate patient satisfaction and the evolution of their knowledge throughout the pharmaceutical counseling program on anticoagulants and identify knowledge variability factors. Setting Cardiology Inpatient Unit from the University Antoine Béclère Hospital, France. Methods Evaluation was based on data collection of patients surveyed between 2015 and 2018. Inpatients in the cardiology department on oral anticoagulants were eligible. The learning process was designed to enhance patient knowledge and understanding based on 10 cognitive or self-management skills, relating to the optimization of oral anticoagulant therapy management. It consisted in 2 face-to-face interviews during hospitalization and 2 additional phone interviews one and six months after discharge. The median patient score was evaluated at each step of the process as well as the mean score for each item from the global population. A sub-analysis was run on the less well-acquired skills in order to identify risk factors for limited knowledge. The association between those factors and the level of knowledge (score ≥ 7 or < 7) was assessed using Chi square test followed by multivariate analysis. Main outcome measure Patient knowledge of anticoagulation therapy depending on specific factors. Results Of the 880 patients eligible for pharmaceutical counseling, 319 entered the process and 102 completed it. Median knowledge scores were 8/10 and 9/10 after the first and the final interviews respectively with a significant improvement (p = 0.0003). The least well-acquired items at each step were surveillance and under-dosing management. The sub-analysis showed the use of vitamin K antagonist to be linked to an enhanced understanding related to treatment surveillance (p = 0.029). Patients suffering from atrial fibrillation were found to have a worse understanding of under-dosing management (p = 0.013). Finally, patients evaluated the process as helpful and suitable for their conditions. Conclusion Pharmaceutical counseling is appropriate for patients, improving and maintaining knowledge of oral anticoagulants. Our evaluation highlights the need to focus on patient-specific profiles to reach a satisfactory level of knowledge.
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Affiliation(s)
- C Roseau
- AP-HP, Service de pharmacie, DHU Thorax Innovation, Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, 92141, Clamart Cedex, France
| | - C Richard
- AP-HP, Service de pharmacie, DHU Thorax Innovation, Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, 92141, Clamart Cedex, France
| | - S Renet
- Service de Pharmacie, Groupe Hospitalier Paris Saint-Joseph, Paris, France.,Univ. Paris-Sud, Faculté de Pharmacie, Université Paris-Saclay, Châtenay Malabry, France
| | - C Kowal
- AP-HP, Service de pharmacie, Hôpital Albert Chenevier, Creteil, France
| | - L Eliahou
- AP-HP, Service de cardiologie, Hôpital Antoine Béclère, Clamart, France
| | - A Rieutord
- AP-HP, Service de pharmacie, DHU Thorax Innovation, Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, 92141, Clamart Cedex, France
| | - M-C Chaumais
- AP-HP, Service de pharmacie, DHU Thorax Innovation, Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, 92141, Clamart Cedex, France. .,Univ. Paris-Sud, Faculté de Pharmacie, Université Paris-Saclay, Châtenay Malabry, France. .,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.
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Murphy A, Kirby A, Bradley C. Monitoring of atrial fibrillation in primary care patients prescribed direct oral anticoagulants for stroke prevention. Ir J Med Sci 2020; 189:961-966. [PMID: 31900842 DOI: 10.1007/s11845-019-02150-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 11/20/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are widely marketed as medicines that do not require routine laboratory monitoring. However, they do have complex pharmacological properties and side effects; hence prescribing and monitoring guidelines, such as the European Heart Rhythm Association (EHRA) guidelines, have emerged. These advocate monitoring for renal and hepatic impairment; bleeding episodes; liver function; co-medication; circulation, and occurrence of side effects. Though 3 to 6 month follow-up is advocated, this is currently not routine, and its implementation creates a potential obligation for general practitioners (GPs) managing atrial fibrillation (AF) patients in the community. AIMS This study investigates the frequency, the type of follow-up, and the factors that influenced follow-up among Irish GPs, who prescribed DOACs to patients with AF, to prevent strokes in 2015. METHODS The frequency and type of follow-up care is estimated, and a count model regression analysis is applied to determine the GP and practice characteristics that are associated with the implementation of follow-up. RESULTS The EHRA guidelines most frequently followed were those pertaining to renal function (82%), bleeding episodes (71%), liver function (69%), circulation (54%), and side effects (55%). The regression analysis revealed that female GPs (P = 0.05) and GPs who follow all seven guidelines (P = 0.06) practice more frequent follow-up while those in training practices (P = 0.09) provide less frequent follow-up. CONCLUSIONS Results show that there was incomplete adherence to the 2013 EHRA prescribing guidelines with only 24% adhering to all seven guidelines, and patient follow-up was less frequent than has been suggested.
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Affiliation(s)
- Aileen Murphy
- Department of Economics, Cork University Business School, University College Cork, Aras na Laoi, Western Rd., Cork, Ireland.
| | - Ann Kirby
- Department of Economics, Cork University Business School, University College Cork, Aras na Laoi, Western Rd., Cork, Ireland
| | - Colin Bradley
- Department of General Practice, School of Medicine, Western Gateway Building, University College Cork, Cork, Ireland
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Zielinski GD, van Rein N, Teichert M, Klok FA, Rosendaal FR, van der Meer FJM, Huisman MV, Cannegieter SC, Lijfering WM. Persistence of oral anticoagulant treatment for atrial fibrillation in the Netherlands: A surveillance study. Res Pract Thromb Haemost 2020; 4:141-153. [PMID: 31989096 PMCID: PMC6971315 DOI: 10.1002/rth2.12261] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/18/2019] [Accepted: 08/26/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In contrast to vitamin K antagonists (VKA), direct oral anticoagulants (DOAC's) are not strictly monitored and dose titrated by anticoagulation clinics in the Netherlands. This may affect drug persistence of atrial fibrillation (AF) patients, whom often require lifelong treatment. OBJECTIVES To assess persistence of DOACs and of VKAs in patients with AF. METHODS Dispensing data from the Dutch Foundation of Pharmaceutical Statistics were used to monitor persistence of AF patients to DOAC from 1 January 2012-1 April 2016. In addition, we estimated the persistence of AF patients to VKA between 1 January 2004 and 1 January 2012 in data from the Anticoagulation Clinic Leiden. Non-persistence was defined as the cumulative incidence of patients who completely stopped DOAC, switched to another oral anticoagulant or stopped their VKA. RESULTS DOAC users (n = 77 333) were younger than VKA users (n = 10 079; 70 vs 73 years). Non-Persistence to DOAC (ie stopping with any oral anticoagulant) was 34% at 1 and 64% at 4 years, compared to 22% at one and 36% at 4 years for VKA. Approximately a Twenty-five percent of those who had stopped their initial DOAC switched to another anticoagulant (VKA or another DOAC). Multivariable analyses revealed that young age, female sex, no concomitant drug use and non-adherence were predictors for non-persistence of DOAC. CONCLUSIONS Persistence to DOAC was low and in line with other observational studies, and higher for VKA. Our results show a clear correlation between age <60 years and worse persistence, as well as with female and non-adherence to DOAC.
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Affiliation(s)
- Gilda Denise Zielinski
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Nienke van Rein
- Department of Clinical Pharmacy & ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - Martina Teichert
- Department of Clinical Pharmacy & ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and HaemostasisLeiden University Medical CenterThe Netherlands
| | - Frits R. Rosendaal
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | | | - Menno V. Huisman
- Department of Thrombosis and HaemostasisLeiden University Medical CenterThe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Thrombosis and HaemostasisLeiden University Medical CenterThe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
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Cognitive Impairment Is Independently Associated with Non-Adherence to Antithrombotic Therapy in Older Patients with Atrial Fibrillation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16152698. [PMID: 31362337 PMCID: PMC6696263 DOI: 10.3390/ijerph16152698] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/24/2019] [Accepted: 07/27/2019] [Indexed: 12/17/2022]
Abstract
Atrial Fibrillation (AF) patients could reduce their risk of stroke by using oral antithrombotic therapy. However, many older people with AF experience cognitive impairment and have limited health literacy, which can lead to non-adherence to antithrombotic treatment. This study aimed to investigate the influence of cognitive impairment and health literacy on non-adherence to antithrombotic therapy. The study performed a secondary analysis of baseline data from a cross-sectional survey of AF patients’ self-care behaviors at a tertiary university hospital in 2018. Data were collected from a total of 277 AF patients aged 65 years and older, through self-reported questionnaires administered by face-to-face interviews. Approximately 50.2% of patients were non-adherent to antithrombotic therapy. Multiple logistic regression analysis revealed that cognitive impairment independently increased the risk of non-adherence to antithrombotic therapy (odds ratio = 2.628, 95% confidence interval = 1.424–4.848) after adjustment for confounding factors. However, health literacy was not associated with non-adherence to antithrombotic therapy. Cognitive impairment is a significant risk factor for poor adherence to antithrombotic therapy. Thus, health professionals should periodically assess both cognitive function after AF diagnosis and adherence to medication in older patients. Further studies are needed to identify the factors that affect cognitive decline and non-adherence among AF patients.
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30
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Pamela J B, Joseph H, Matthew K, Thomas G B, Lee N, Judith M K, Jamie M R, Frank M S. Warfarin Use and Mortality, Stroke, and Bleeding Outcomes in a Cohort of Elderly Patients with non-Valvular Atrial Fibrillation. J Atr Fibrillation 2019; 12:2155. [PMID: 31687068 DOI: 10.4022/jafib.2155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/14/2018] [Accepted: 12/10/2018] [Indexed: 12/25/2022]
Abstract
Aims To determine exposure to warfarin and the associated outcomes in a population of older patients with non-valvular atrial fibrillation (NVAF). Methods Cohort study of patients aged 65-89 years admitted to hospital July 2003-December 2008 with newly-diagnosed or pre-existing AF. Outcomes at three years among one-year survivors post-index admission (landmark date) were all-cause mortality, stroke/systemic thromboembolism (stroke/TE) and bleeding. Multivariate Cox models were used to identify factors associated with each outcome. Results AF was the principal diagnosis for 27.5% of 17,336 index AF admissions. Of 14,634 (84.4%) patients alive at one-year 1,384 (9.5%) died in the following year. Vascular disease (42%) was the most frequent cause of death.Warfarin use, prior to the index admission and/or the 1-year landmark, did not exceed 40%.Compared to non-exposure or discontinuation at the index admission, initiation or persistence with warfarin prior to the landmark date was associated with reduced risk for all-cause mortality, a statistically non-significant reduction in risk for stroke/TE, and an increased risk for bleeding. Higher CHA2DS2-VASc scores were associated with increased risk for each outcome. Conclusions In a population-based cohort of hospitalised NVAF patients, the initiation and persistent use of warfarin was associated with lower all-cause mortality risk to three years, although reduction in risk for stroke/TE did not reach statistical significance. The apparent under-use of warfarin in this older, high-risk cohort reinforces the opportunity for further reduction in stroke/TE with the uptake of non-vitamin K oral anti-coagulants (NOACs) among those not prescribed, or not persistent with, warfarin.
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Affiliation(s)
- Bradshaw Pamela J
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia
| | - Hung Joseph
- School of Medicine, Sir Charles Gairdner Hospital Unit, The University of Western Australia, Perth, Western Australia
| | - Knuiman Matthew
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia
| | - Briffa Thomas G
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia
| | - Nedkoff Lee
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia
| | - Katzenellebogen Judith M
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia
| | - Rankin Jamie M
- Cardiology Department, Fiona Stanley Hospital, Murdoch, Western Australia
| | - Sanfilippo Frank M
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia
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Fawzy AM, Yang WY, Lip GY. Safety of direct oral anticoagulants in real-world clinical practice: translating the trials to everyday clinical management. Expert Opin Drug Saf 2019; 18:187-209. [PMID: 30712419 DOI: 10.1080/14740338.2019.1578344] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) may be regarded as some of the most successful innovations in recent times. These drugs which were specifically developed to overcome the challenges posed by warfarin did just that and in the process, have changed the outlook towards stroke prevention with anticoagulation. The decade of experience with these drugs that has resulted in the availability of large scale data on their safety profile has aided this. Areas covered: This review examines existing real-world studies (RWS) and their interpretation to better appreciate how they either complement or contradict findings from the hallmark trials. Specific focus has been made on the safety of DOACs, on their risks of major bleeding, intra-cranial haemorrhage (ICH), gastro-intestinal (GI) bleeding and all-cause mortality compared to warfarin and each other. DOAC use in the elderly and other sub-groups are briefly discussed. Expert opinion: Results for safety outcomes according to 'real world evidence' (RWE) are in-keeping with randomised controlled trials (RCTs) and currently, all 4 DOACs have been deemed at least as effective as warfarin, while demonstrating superiority in some aspects. While real world studies act as a complementary source of knowledge, traditional RCTs remain the gold standard for determining cause-effect relationships.
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Affiliation(s)
- Ameenathul M Fawzy
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK
| | - Wang-Yang Yang
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,b Department of Cardiology, Beijing AnZhen Hospital, National Clinical Research Centre for Cardiovascular Diseases , Capital Medical University , Beijing , China
| | - Gregory Yh Lip
- c Liverpool Centre for Cardiovascular Science , University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK
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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: 205] [Impact Index Per Article: 41.0] [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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Reading SR, Black MH, Singer DE, Go AS, Fang MC, Udaltsova N, Harrison TN, Wei RX, Liu ILA, Reynolds K. Risk factors for medication non-adherence among atrial fibrillation patients. BMC Cardiovasc Disord 2019; 19:38. [PMID: 30744554 PMCID: PMC6371431 DOI: 10.1186/s12872-019-1019-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 02/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background Atrial fibrillation (AF) patients are routinely prescribed medications to prevent and treat complications, including those from common co-occurring comorbidities. However, adherence to such medications may be suboptimal. Therefore, we sought to identify risk factors for general medication non-adherence in a population of patients with atrial fibrillation. Methods Data were collected from a large, ethnically-diverse cohort of Kaiser Permanente Northern and Southern California adult members with incident diagnosed AF between January 1, 2006 and June 30, 2009. Self-reported questionnaires were completed between May 1, 2010 and September 30, 2010, assessing patient socio-demographics, health behaviors, health status, medical history and medication adherence. Medication adherence was assessed using a previously validated 3-item questionnaire. Medication non-adherence was defined as either taking medication(s) as the doctor prescribed 75% of the time or less, or forgetting or choosing to skip one or more medication(s) once per week or more. Electronic health records were used to obtain additional data on medical history. Multivariable logistic regression analyses examined the associations between patient characteristics and self-reported general medication adherence among patients with complete questionnaire data. Results Among 12,159 patients with complete questionnaire data, 6.3% (n = 771) reported medication non-adherence. Minority race/ethnicity versus non-Hispanic white, not married/with partner versus married/with partner, physical inactivity versus physically active, alcohol use versus no alcohol use, any days of self-reported poor physical health, mental health and/or sleep quality in the past 30 days versus 0 days, memory decline versus no memory decline, inadequate versus adequate health literacy, low-dose aspirin use versus no low-dose aspirin use, and diabetes mellitus were associated with higher adjusted odds of non-adherence, whereas, ages 65–84 years versus < 65 years of age, a Charlson Comorbidity Index score ≥ 3 versus 0, and hypertension were associated with lower adjusted odds of non-adherence. Conclusions Several potentially preventable and/or modifiable risk factors related to medication non-adherence and a few non-modifiable risk factors were identified. These risk factors should be considered when assessing medication adherence among patients diagnosed with AF.
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Affiliation(s)
- Stephanie R Reading
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA
| | - Mary Helen Black
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA
| | - Daniel E Singer
- Department of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.,Departments of Epidemiology, Biostatistics and Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Margaret C Fang
- Division of Hospital Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA
| | - Rong X Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA
| | - In-Lu Amy Liu
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA.
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Loewen PS, Bansback N, Hicklin J, Andrade JG, Kapanen AI, Kwan L, Lynd LD, McClean A, MacGillivray J, Salmasi S. Evaluating the Effect of a Patient Decision Aid for Atrial Fibrillation Stroke Prevention Therapy. Ann Pharmacother 2019; 53:665-674. [PMID: 30724102 DOI: 10.1177/1060028019828420] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Stroke prevention therapy decisions for patients with atrial fibrillation (AF) are complex and require trade-offs, but few validated patient decision aids (PDAs) are available to facilitate shared decision making. OBJECTIVE To evaluate the effects of a novel PDA on decision-making parameters for AF patients choosing stroke prevention therapy. METHODS We developed an evidence-based individualized online AF PDA for stroke prevention therapy and evaluated it in a prospective observational pilot study. The primary outcome was decisional conflict. Secondary outcomes were knowledge, usability/acceptability, patient preferences, effects on therapy choices, and participant feedback. RESULTS 37 participants completed the PDA. The PDA could be completed independently and was well accepted. It significantly decreased the mean decisional conflict score ( P < 0.001) and all its subscales and increased participant AF knowledge ( P = 0.02). 76% of participants indicated that their individualized therapy attribute ranking was congruent with their values. The PDA-generated best-match therapy was chosen by 70% of participants in decision 1 (no therapy, aspirin, or oral anticoagulant), and 17% for decision 2 (choice of anticoagulant). Among AF patients, 60% chose a different drug than that currently prescribed to them. Conclusion and Relevance: Our PDA was effective for reducing decisional conflict, increasing patient knowledge, eliciting patients' values, and presenting therapy options that aligned with patients' values and preferences. Using the PDA revealed that many patients have therapy preferences different from their currently prescribed treatment. The PDA is a practical and potentially valuable tool to facilitate decision making about stroke prevention therapy for AF.
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Affiliation(s)
- Peter S Loewen
- 1 The University of British Columbia, Vancouver, BC, Canada
| | - Nick Bansback
- 1 The University of British Columbia, Vancouver, BC, Canada.,2 Providence Health Research Institute, Vancouver, BC, Canada
| | - James Hicklin
- 1 The University of British Columbia, Vancouver, BC, Canada
| | | | | | - Leanne Kwan
- 4 Royal Columbian Hospital, New Westminster, BC, Canada
| | - Larry D Lynd
- 1 The University of British Columbia, Vancouver, BC, Canada.,2 Providence Health Research Institute, Vancouver, BC, Canada
| | - Alison McClean
- 1 The University of British Columbia, Vancouver, BC, Canada
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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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36
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Pioneering Australia’s First Atrial Fibrillation Guidelines. Heart Lung Circ 2018; 27:1391-1393. [DOI: 10.1016/j.hlc.2018.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Weernink MGM, Vaanholt MCW, Groothuis-Oudshoorn CGM, von Birgelen C, IJzerman MJ, van Til JA. Patients' Priorities for Oral Anticoagulation Therapy in Non-valvular Atrial Fibrillation: a Multi-criteria Decision Analysis. Am J Cardiovasc Drugs 2018; 18:493-502. [PMID: 30132140 PMCID: PMC6267541 DOI: 10.1007/s40256-018-0293-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction Effectiveness of oral anticoagulants (OACs) is critically dependent on patients’ adherence to intake regimens. We studied the relative impact of attributes related to effectiveness, safety, convenience, and costs on the value of OAC therapy from the perspective of patients with non-valvular atrial fibrillation. Methods Four attributes were identified by literature review and expert interviews: effectiveness (risk of ischemic stroke), safety (risk of major bleeding, minor bleeding, gastrointestinal complaints), convenience (intake frequency, diet restrictions, international normalized ratio [INR] blood monitoring, pill type/intake instructions), and out-of-pocket costs. Focus groups were held in Spain, Germany, France, Italy and the United Kingdom (N = 48) to elicit patients’ preferences through the use of the analytical hierarchy process method. Results Effectiveness (60%) and side effects (27%) have a higher impact on the perceived value of OACs than drug convenience (7%) and out-of-pocket costs (6%). As for convenience, eliminating monthly INR monitoring was given the highest priority (40%), followed by reducing diet restrictions (27%), reducing intake frequency (17%) and improving the pill type/intake instructions (15%). The most important side effect was major bleeding (75%), followed by minor bleeding (15%) and gastrointestinal complaints (10%). Furthermore, 71% of patients preferred once-daily intake to twice-daily intake. Discussion Although the relative impact of convenience on therapy value is small, patients have different preferences for options within convenience criteria. Besides considerations on safety and effectiveness, physicians should also discuss attributes of convenience with patients, as it can be assumed that alignment to patient preferences in drug prescription and better patient education could result in higher adherence. Electronic supplementary material The online version of this article (10.1007/s40256-018-0293-0) contains supplementary material, which is available to authorized users.
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Vaanholt MCW, Weernink MGM, von Birgelen C, Groothuis-Oudshoorn CGM, IJzerman MJ, van Til JA. Perceived advantages and disadvantages of oral anticoagulants, and the trade-offs patients make in choosing anticoagulant therapy and adhering to their drug regimen. PATIENT EDUCATION AND COUNSELING 2018; 101:1982-1989. [PMID: 30001822 DOI: 10.1016/j.pec.2018.06.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 06/27/2018] [Accepted: 06/29/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The objective of this study was to explore the perceived advantages and disadvantages of oral anticoagulant therapies (OAT), and the trade-offs patients make in choosing therapy and adhering to their drug regimen. METHODS Five focus group sessions were conducted across Europe among patients with atrial fibrillation to identify the most important factors impacting OAT's value and adherence. RESULTS The most frequently identified barriers to OAT were lack of knowledge; poor patient-physician relationships; distraction due to employment or social environment; prior bleeding event(s) or the fear of bleeding; and changes in routine. Factors identified as promoting adherence included patients' personality, motivation, attitudes, and medication-taking habits and routines, as well as good quality health services. Inconvenient aspects of vitamin-K antagonists, such as regular blood monitoring and diet restrictions, were not reported to influence adherence, but may trigger patients to switch to direct oral anticoagulants. CONCLUSION Most patients reported that a mixture of modifiable and non-modifiable factors helps them to take their drugs as prescribed. Individual patients' particular needs and preferences regarding OAT vary. PRACTICE IMPLICATIONS OAT adherence can be promoted if therapies are tailored to patients' needs and preferences. Patients should be supported to share their preferences with their clinician.
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Affiliation(s)
- Melissa C W Vaanholt
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.
| | - Marieke G M Weernink
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.
| | - Clemens von Birgelen
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands; Thoraxcentrum Twente, Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - Catharina G M Groothuis-Oudshoorn
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.
| | - Maarten J IJzerman
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.
| | - Janine A van Til
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.
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Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome. Blood 2018; 132:1365-1371. [DOI: 10.1182/blood-2018-04-848333] [Citation(s) in RCA: 403] [Impact Index Per Article: 67.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 07/03/2018] [Indexed: 12/21/2022] Open
Abstract
Publisher's Note: There is a Blood Commentary on this article in this issue.
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40
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An Update on the “Novel” and Direct Oral Anticoagulants, and Long-Term Anticoagulant Therapy. Clin Chest Med 2018; 39:583-593. [DOI: 10.1016/j.ccm.2018.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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41
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Brieger D, Amerena J, Attia JR, Bajorek B, Chan KH, Connell C, Freedman B, Ferguson C, Hall T, Haqqani HM, Hendriks J, Hespe CM, Hung J, Kalman JM, Sanders P, Worthington J, Yan T, Zwar NA. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018. Med J Aust 2018; 209:356-362. [DOI: 10.5694/mja18.00646] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/12/2018] [Indexed: 02/02/2023]
Affiliation(s)
| | | | - John R Attia
- University of Newcastle, Newcastle, NSW
- John Hunter Hospital, Newcastle, NSW
| | | | - Kim H Chan
- Royal Prince Alfred Hospital, Sydney, NSW
- University of Sydney, Sydney, NSW
| | - Cia Connell
- National Heart Foundation of Australia, Melbourne, VIC
| | | | - Caleb Ferguson
- Western Sydney University, Sydney, NSW
- Blacktown and Mount Druitt Hospital, Sydney, NSW
| | | | | | - Jeroen Hendriks
- Royal Adelaide Hospital, Adelaide, SA
- University of Adelaide, Adelaide
| | | | | | - Jonathan M Kalman
- University of Melbourne, Melbourne, VIC
- Royal Melbourne Hospital, Melbourne, VIC
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Bartoli‐Abdou JK, Patel JP, Xie R, Dzahini O, Vadher B, Brown A, Roberts LN, Patel RK, Arya R, Auyeung V. Associations between illness beliefs, medication beliefs, anticoagulation-related quality of life, and INR control: Insights from the Switching Study. Res Pract Thromb Haemost 2018; 2:497-507. [PMID: 30046754 PMCID: PMC6046584 DOI: 10.1002/rth2.12116] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/23/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Anticoagulation control with vitamin-K antagonists (VKAs) in patients with atrial fibrillation (AF) or venous thromboembolism (VTE) can be measured using time in therapeutic range (TTR), where TTR >65% is considered good and low TTR may be associated with low adherence. METHODS This cross-sectional observational study compared illness beliefs, treatment beliefs, and treatment satisfaction of patients with TTR >75% and TTR <50% using validated tools to determine their association with TTR. Adults requiring chronic VKA therapy were recruited from 2 hospital anticoagulation clinics in London, UK. RESULTS 311 patients with TTR >75% and 214 with TTR <50% were recruited. TTR >75% patients had been taking warfarin on average over 2 years longer than TTR <50% patients (P < .001). Statistically significant differences in beliefs were found in all subscales other than in treatment control, general harm, and general overuse. Cluster analysis determined there were 4 distinct clusters of beliefs among patients. Multivariate binary logistic regression found VTE patients were least likely to have poor TTR (OR = 0.49; 95% CI 0.29, 0.77). Patients in the "cautious of therapy and fearful of illness" cluster were most likely to have low TTR (OR = 4.75; 95% CI 2.75, 8.77). CONCLUSION Illness perceptions, medication beliefs and treatment satisfaction were associated with INR control. VTE patients and those who were accepting of both illness and treatment were most likely to have optimal INR control.
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Affiliation(s)
- John K. Bartoli‐Abdou
- Institute of Pharmaceutical ScienceKing’s College LondonLondonUK
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
| | - Jignesh P. Patel
- Institute of Pharmaceutical ScienceKing’s College LondonLondonUK
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
| | - Rosa Xie
- Institute of Pharmaceutical ScienceKing’s College LondonLondonUK
- Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Olubanke Dzahini
- Institute of Pharmaceutical ScienceKing’s College LondonLondonUK
- Department of PharmacySouth London & Maudsley NHS Foundation TrustLondonUK
| | - Bipin Vadher
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
| | - Alison Brown
- King’s Thrombosis CentreDepartment of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
| | - 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
| | - Vivian Auyeung
- Institute of Pharmaceutical ScienceKing’s College LondonLondonUK
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Dronkers CEA, Lijfering WM, Teichert M, van der Meer FJM, Klok FA, Cannegieter SC, Huisman MV. Persistence to direct oral anticoagulants for acute venous thromboembolism. Thromb Res 2018; 167:135-141. [PMID: 29843087 DOI: 10.1016/j.thromres.2018.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/29/2018] [Accepted: 05/13/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Currently, direct oral anticoagulants (DOACs) are the treatment of choice for venous thromboembolism (VTE) in the Netherlands. The main advantages of DOACs over vitamin K antagonists (VKAs) are that they are safer than VKA and that neither monitoring nor dose titrations are needed. A main drawback is a potential risk of lower drug persistence, as compared with VKA treatment, which is strictly controlled by anticoagulation clinics in the Netherlands. OBJECTIVES The primary aim of this study was to audit the persistence to DOAC treatment for acute VTE during the first 2 months in daily clinical practice. METHODS Dispensing data from the Dutch Foundation of Pharmaceutical Statistics were used to monitor persistence to DOAC for treatment of VTE from 1 January 2012-1 April 2016. Non-persistence was defined as the cumulative incidence of patients who completely stopped DOAC or VKA treatment. In addition, we estimated the persistence to VKA treatment for VTE in data from the Anticoagulation Clinic Leiden. RESULTS 1834 patients were selected as DOAC users for the indication VTE. The 2-month cumulative incidence of completely stopping DOAC was 20% (95% confidence interval [CI] 18-24). In the population of 4910 VKA users, 9.1% (95%CI 8.3-9.9) stopped prematurely with VKA. CONCLUSION The stopping rate of 20% we found is in line with other cardiovascular treatments. Further research into the reasons and consequences of prematurely stopping DOAC treatment for acute VTE is urgently needed.
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Affiliation(s)
- Charlotte E A Dronkers
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martina Teichert
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Felix J M van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne C Cannegieter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Bartoli-Abdou JK, Patel JP, Crawshaw J, Vadher B, Brown A, Roberts LN, Patel RK, Arya R, Auyeung V. Exploration of adherence and patient experiences with DOACs one year after switching from vitamin-K antagonists- insights from the switching study. Thromb Res 2018; 162:62-68. [DOI: 10.1016/j.thromres.2017.12.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/30/2017] [Accepted: 12/29/2017] [Indexed: 01/13/2023]
Affiliation(s)
- John K Bartoli-Abdou
- Institute of Pharmaceutical Science, King's College London, London, United Kingdom; King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom.
| | - Jignesh P Patel
- Institute of Pharmaceutical Science, King's College London, London, United Kingdom; King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jacob Crawshaw
- Institute of Pharmaceutical Science, King's College London, London, United Kingdom
| | - Bipin Vadher
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Alison Brown
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Raj K Patel
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Roopen Arya
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Vivian Auyeung
- Institute of Pharmaceutical Science, King's College London, London, United Kingdom
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Abstract
Anticoagulant drugs are widely used in hospital and community settings. Anticoagulation is the first-line treatment for venous thromboembolism, and anticoagulant drugs have an important role in the treatment and prevention of blood clots. However, maintaining the equilibrium between clotting and bleeding can be challenging and anticoagulants have been identified as a class of drug associated with preventable patient harm. Direct oral anticoagulants (DOACs) have become the first-line treatment for many patients requiring an anticoagulant, removing the burden of frequent tests and the many food and drug interactions associated with vitamin K antagonists such as warfarin sodium. However, DOACs have increased the complexity of decision-making regarding treatment, which also increases the risk of drug errors. This article discusses the uses, modes of action and potential side effects of anticoagulants, to improve nurses' understanding and enable them to have an active role in limiting the risk of harm from these drugs.
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Affiliation(s)
- Emma Gee
- Thrombosis and coagulation, King's College Hospital NHS Foundation Trust, London, England
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46
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Desteghe L, Vijgen J, Koopman P, Dilling-Boer D, Schurmans J, Dendale P, Heidbuchel H. Telemonitoring-based feedback improves adherence to non-vitamin K antagonist oral anticoagulants intake in patients with atrial fibrillation. Eur Heart J 2018; 39:1394-1403. [DOI: 10.1093/eurheartj/ehx762] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 12/11/2017] [Indexed: 01/18/2023] Open
Affiliation(s)
- Lien Desteghe
- Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, Hasselt, Belgium
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, Hasselt, Belgium
| | - Johan Vijgen
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, Hasselt, Belgium
| | - Pieter Koopman
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, Hasselt, Belgium
| | | | - Joris Schurmans
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, Hasselt, Belgium
| | - Paul Dendale
- Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, Hasselt, Belgium
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, Hasselt, Belgium
| | - Hein Heidbuchel
- Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, Hasselt, Belgium
- Department of Cardiology University of Antwerp and Antwerp University Hospital, Wilrijkstraat 10, Edegem, Belgium
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Castelli MR, Saint CA, Nuziale BT, Stern GM, Stacy ZA, Crannage AJ, Pitlick JM. Effect of a Rivaroxaban Patient Assistance Kit (R-PAK) for Patients Discharged With Rivaroxaban: A Randomized Controlled Trial. Hosp Pharm 2017; 52:496-501. [PMID: 29276279 DOI: 10.1177/0018578717721105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The combination of poor health literacy and a complex dosing regimen/transition for rivaroxaban in venous thromboembolism (VTE) treatment may increase the likelihood of negative clinical outcomes secondary to nonadherence. Objective: The aim was to determine if a Rivaroxaban Patient Assistance Kit (R-PAK) given at hospital discharge increases proper dose transition and overall patient adherence. Methods: This prospective, randomized, controlled trial was conducted at an 859-bed academic medical center. Patients were randomized into 2 groups. In the treatment group, patients received the R-PAK with counseling at discharge, whereas patients in the control group received discharge counseling alone. In addition, patients were contacted after 21 days of therapy to assess dose transition, adherence, satisfaction, and safety. The primary outcome was percentage of patients who properly transitioned to rivaroxaban once daily on day 22. Results: Twenty-five patients were enrolled; 12 received an R-PAK, whereas 13 comprised the control group. No difference in the baseline assessment of health literacy status was noted (P = 1.00). Proper transition to daily administration on day 22 was no different between the groups (P = .891). Adherence was reported in 99.8% of R-PAK patients and 97.65% of control patients (P = .074). Side effects were rarely reported. Conclusions: The use of an R-PAK for the treatment of VTE was not associated with an improvement in transition to daily administration; however, both groups had high rates of overall adherence. Pharmacist counseling/education was provided in both groups and is an important component to include in any patient discharge, especially for medications with dose transitions.
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Affiliation(s)
| | | | | | | | - Zachary A Stacy
- Mercy Hospital, St. Louis, MO, USA.,St. Louis College of Pharmacy, St. Louis, MO, USA
| | - Andrew J Crannage
- Mercy Hospital, St. Louis, MO, USA.,St. Louis College of Pharmacy, St. Louis, MO, USA
| | - Jamie M Pitlick
- Drake University College of Pharmacy and Health Sciences, Des Moines, IA, USA
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48
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Rolls CA, Obamiro KO, Chalmers L, Bereznicki LRE. The relationship between knowledge, health literacy, and adherence among patients taking oral anticoagulants for stroke thromboprophylaxis in atrial fibrillation. Cardiovasc Ther 2017; 35. [PMID: 28869793 DOI: 10.1111/1755-5922.12304] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 08/24/2017] [Accepted: 08/25/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Patients' knowledge regarding their oral anticoagulant (OAC) treatment for stroke prevention in atrial fibrillation (AF), their level of medication adherence, and health literacy are known to affect treatment outcomes. However, contemporary data regarding the relationships between these variables are lacking. OBJECTIVE To investigate the relationships between anticoagulant knowledge, health literacy, and self-reported adherence in patients taking warfarin and the directly acting oral anticoagulants. METHODS A cross-sectional survey was conducted in 48 patients with AF identified from general practices. The Anticoagulation Knowledge Tool (AKT) was used to assess anticoagulation knowledge; the Short Test of Functional Health Literacy in Adults (s-TOFHLA) for health literacy; and the 8-item Morisky Medication Adherence Scale (MMAS) for medication adherence. RESULTS Participants had mean scores of 61.6 ± 15.8, 7.2 ± 1.1, and 24.7 ± 9.5 for the AKT, MMAS-8 and s-TOFHLA, respectively. Significant correlations were observed between anticoagulation knowledge and health literacy with medication adherence (0.37, P < .01 and .30, P < .05, respectively). Participants with inadequate health literacy had a significantly lower mean knowledge score than those with adequate health literacy (55.8 ± 15.9 vs 66.1 ± 14.4, P < .05). Participants who self-reported adherence to their OAC had significantly higher knowledge scores than those who did not (67.5 ± 13.3 vs 56.1 ± 16.2, P < .05). CONCLUSION Significant correlations between health literacy, OAC knowledge, and adherence were observed, and these relationships should to be considered by health professionals responsible for monitoring patients who are prescribed anticoagulants. We also observed serious gaps in OAC knowledge. Interventions designed to optimize the outcomes of anticoagulant treatment need to address these factors.
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Affiliation(s)
- Chanelle A Rolls
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Tas, Australia
| | - Kehinde O Obamiro
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Tas, Australia
| | - Leanne Chalmers
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Tas, Australia
| | - Luke R E Bereznicki
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Tas, Australia
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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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Czuprynska J, Patel JP, Arya R. Current challenges and future prospects in oral anticoagulant therapy. Br J Haematol 2017; 178:838-851. [DOI: 10.1111/bjh.14714] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Julia Czuprynska
- Department of Haematology; King's College Hospital NHS Foundation Trust; London UK
| | - Jignesh P. Patel
- Department of Haematology; King's College Hospital NHS Foundation Trust; London UK
- Institute of Pharmaceutical Sciences; King's College London; London UK
| | - Roopen Arya
- Department of Haematology; King's College Hospital NHS Foundation Trust; London UK
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