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Handoko ML, de Man FS, Brugts JJ, van der Meer P, Rhodius-Meester HFM, Schaap J, van de Kamp HJR, Houterman S, van Veghel D, Uijl A, Asselbergs FW. Embedding routine health care data in clinical trials: with great power comes great responsibility. Neth Heart J 2024; 32:106-115. [PMID: 38224411 PMCID: PMC10884372 DOI: 10.1007/s12471-023-01837-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 01/16/2024] Open
Abstract
Randomised clinical trials (RCTs) are vital for medical progress. Unfortunately, 'traditional' RCTs are expensive and inherently slow. Moreover, their generalisability has been questioned. There is considerable overlap in routine health care data (RHCD) and trial-specific data. Therefore, integration of RHCD in an RCT has great potential, as it would reduce the effort and costs required to collect data, thereby overcoming some of the major downsides of a traditional RCT. However, use of RHCD comes with other challenges, such as privacy issues, as well as technical and practical barriers. Here, we give a current overview of related initiatives on national cardiovascular registries (Netherlands Heart Registration, Heart4Data), showcasing the interrelationships between and the relevance of the different registries for the practicing physician. We then discuss the benefits and limitations of RHCD use in the setting of a pragmatic RCT from a cardiovascular perspective, illustrated by a case study in heart failure.
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Affiliation(s)
- M Louis Handoko
- Department of Cardiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands.
- Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
| | - Frances S de Man
- Department of Pulmonary Medicine, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Thorax Centre, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Hanneke F M Rhodius-Meester
- Department of Internal Medicine, Geriatrics Section, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Department of Neurology, Alzheimer Centre Amsterdam, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Department of Geriatric Medicine, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Jeroen Schaap
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
- Dutch Network for Cardiovascular Research, Utrecht, The Netherlands
| | | | | | | | - Alicia Uijl
- Department of Cardiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Folkert W Asselbergs
- Department of Cardiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Institute of Cardiovascular Science and Institute of Health Informatics, Faculty of Population Health Sciences, University College London, London, UK
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Voorhout L, Pisters R, Geurts CHPH, Oostindjer A, van Doorn S, Rila H, Fuijkschot WW, Verheugt F, Hemels MEW. Screening over 100 000 patients in 39 general practices in the Netherlands for anticoagulation underprescription in atrial fibrillation: a descriptive, cross-sectional study. BMJ Open 2023; 13:e072655. [PMID: 37597862 PMCID: PMC10441057 DOI: 10.1136/bmjopen-2023-072655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/06/2023] [Indexed: 08/21/2023] Open
Abstract
OBJECTIVES To investigate the underprescription of oral anticoagulation (OAC) in individual atrial fibrillation (AF) patients in primary care. SETTING Screening of patient records in 39 participating general practitioners (GPs) across the Netherlands. PARTICIPANTS We screened 101 207 patient records identifying 2375 non-valvular AF patients. METHODS Using electronic patient files, we were able to screen the entire GP population for AF, CHA2DS2-VASc stroke risk scores, and the use of guidelines recommended OAC prescription. In case of a deviation from guidelines recommended OAC prescription, we checked the electronic patient file for any documented reason. Additionally, 6 weeks following the screening, we asked all GPs to provide information on any actions taken for the underprescribed patients. RESULTS We found a mean CHA2DS2-VASc score of 3.2. OAC prescription consisted of direct OAC in 1342/1984 (68%) and vitamin K-antagonists in the remainder of patients. OAC underprescription was present in 93/944 (9.9%) females and 101/1374 (9.7%) in males, respectively. In 111/146 (76.0%) of the underprescribed AF patients, no reason to withhold OAC was reported. Reported reasons to withhold OAC were patient refusal (n=10), cardiologist advice (n=7) and high risk of bleeding (n=7). Data regarding actions following the identification of OAC underprescription were available for 92/194 (47%) of the OAC underprescribed cases. After consultation OAC was initiated in 9/92 (10%) only. CONCLUSIONS In this large Dutch study among GPs, we observed 9.8% underprescription of OAC in AF patients. In 76% of the AF patients lacking a prescription for OAC, no documentation for deviating from the guidelines was found. Only in a minority of cases detection of OAC underprescription lead to OAC initiation.
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Affiliation(s)
- Leonard Voorhout
- Department of Cardiology, Research, Hospital Rijnstate, Arnhem, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Research, Hospital Rijnstate, Arnhem, The Netherlands
| | | | | | - Sander van Doorn
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | | | | | - Freek Verheugt
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Research, Hospital Rijnstate, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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van Hulst M, Tieleman RG, Zwart LAR, Pomp M, Jacobs MS, Meeder JG, van Ofwegen-Hanekamp CEE, Hollander M, Smits P, Hemels MEW. Health economic evaluation of nation-wide screening programmes for atrial fibrillation in the Netherlands. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022:qcac042. [PMID: 35881482 DOI: 10.1093/ehjqcco/qcac042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
AIMS Screening for atrial fibrillation (AF) is recommended by the European Society of Cardiology guideline to prevent strokes. Cost-effectiveness analyses of different screening programs for AF are difficult to compare, because of varying settings and models used. We compared the impact and cost-effectiveness of various AF screening programs in the Netherlands. METHODS AND RESULTS The base case economic analysis was conducted from the societal perspective. Health effects and costs were analysed using a Markov model. The main model inputs were derived from the ARISTOTLE, RE-LY and ROCKET AF trial combined with Dutch observational data. Univariate, probabilistic sensitivity and various scenario analyses were performed. The maximum number of newly detected AF patients in The Netherlands ranged from 4554 to 39 270, depending on the screening strategy used. Adequate treatment with anticoagulation would result in a maximum of more than 3000 strokes prevented using single time point AF screening. Compared with no screening, screening 100 000 persons provided a gain in QALYs ranging from 984 to 8727, and a mean cost difference ranging from -6650 000€ to 898 000€, depending on the screening strategy used. Probabilistic sensitivity analysis (PSA) demonstrated a 100% likelihood that screening all patients ≥ 75 years visiting the Geriatric outpatient clinic was cost-saving. Four out of six strategies were cost-saving in ≥ 74% of the PSA simulations. Out of these, opportunistic screening of all patients ≥ 65 years visiting the GPs office had the highest impact on strokes prevented. CONCLUSION Most single-time point AF screening strategies are cost-saving and have an important impact on stroke prevention.
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Affiliation(s)
- Marinus van Hulst
- Department of Clinical Pharmacy and Toxicology, Martini Hospital (Groningen, The Netherlands)
- Department of Health Sciences, University of Groningen, University Medical Center, Groningen, the Netherlands (Groningen, The Netherlands)
| | - Robert G Tieleman
- Department of Cardiology, Martini Hospital (Groningen, The Netherlands)
- Department of Cardiology, University Medical Center Groningen (Groningen, The Netherlands)
| | - Lennaert A R Zwart
- Department of Geriatric Medicine, Northwest Clinics, Alkmaar, The Netherlands
- Aging and Later Life, Amsterdam and Public Health department, Amsterdam University Medical Center, The Netherlands
- Department of Geriatric Medicine, Dijklander Hospital, Hoorn, The Netherlands
| | - Marc Pomp
- Amsterdam Business School, University of Amsterdam, The Netherlands
| | - Maartje S Jacobs
- Department of Clinical Pharmacy and Toxicology, Martini Hospital (Groningen, The Netherlands)
| | - Joan G Meeder
- Department of Cardiology, VieCurie Medical Center (Venlo, The Netherlands)
| | | | - Monika Hollander
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Paul Smits
- De Hoedt Medical Center (Zoetermeer, The Netherlands)
| | - Martin E W Hemels
- Department of Cardiology, Rijnstate Hospital (Arnhem, The Netherlands)
- Department of Cardiology, Radboud University Medical Centre (Nijmegen, The Netherlands)
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Seelig J, Chu G, Trinks-Roerdink EM, Pisters R, de Vries TA, Cate HT, Geersing GJ, Rutten FH, Huisman MV, Hemels ME. Unequal prescription of anticoagulants among females and males with atrial fibrillation and similar stroke risk - should we omit sex category from the CHA2DS2-VASc score? Heart Rhythm 2022; 19:860-861. [PMID: 35033666 DOI: 10.1016/j.hrthm.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/05/2022] [Accepted: 01/10/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Jaap Seelig
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Gordon Chu
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Emmy M Trinks-Roerdink
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands
| | - Tim Ac de Vries
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands; Department of Cardiology, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, the Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands; Department of Internal Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Geert-Jan Geersing
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Martin Ew Hemels
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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Moudallel S, van Laere S, Cornu P, Dupont A, Steurbaut S. Assessment of adherence, treatment satisfaction and knowledge of direct oral anticoagulants in atrial fibrillation patients. Br J Clin Pharmacol 2021; 88:2419-2429. [PMID: 34907577 DOI: 10.1111/bcp.15180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/29/2021] [Accepted: 12/02/2021] [Indexed: 11/28/2022] Open
Abstract
AIM The direct oral anticoagulants (DOACs) are increasingly used for stroke prevention in atrial fibrillation (AF). However, little is known about the association between medication adherence, patient satisfaction and treatment knowledge. The objective was to determine patients' DOAC adherence and their treatment satisfaction over time. Furthermore, we respectively investigated possible associations of treatment satisfaction and treatment knowledge in relation to adherence. METHODS Longitudinal study conducted in AF patients hospitalized in 2019 in a tertiary university hospital. DOAC adherence, treatment satisfaction and knowledge were assessed with validated questionnaires. Mixed effects logistic regression was modelled to investigate the effect of both treatment satisfaction and knowledge on DOAC adherence over time. RESULTS In total, 164 patients participated of which 128 and 101 patients could be recontacted after a period of respectively 3 (first contact) and 6 months (second contact) to assess adherence and treatment satisfaction. Suboptimal adherence was observed in 40.6% of the patients after 3 months and in 42.6% after 6 months (p=0.78). There was no significant difference (p=0.29) in the total score for treatment satisfaction between the first (79.2%) and the second contact (80.6%). DOAC adherence was not affected by time (p=0.71) nor by total knowledge score (p=0.61) or treatment satisfaction score (p=0.34). Nonetheless, a strong correlation between treatment satisfaction and knowledge was found (p=0.004). CONCLUSION DOAC adherence was suboptimal. Treatment satisfaction and knowledge were not associated with DOAC adherence over a 6 month period. Knowledge gaps were identified that could be remediated through patient education and follow-up.
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Affiliation(s)
- Souad Moudallel
- Research Group Clinical Pharmacology and Clinical Pharmacy; Vrije Universiteit Brussel, Brussel, Belgium
| | - Sven van Laere
- Research Group of Biostatistics and Medical Informatics, Department of Public Health (GEWE), Vrije Universiteit Brussel, Brussel, Belgium
| | - Pieter Cornu
- Research Group Clinical Pharmacology and Clinical Pharmacy; Vrije Universiteit Brussel, Brussel, Belgium
| | - Alain Dupont
- Research Group Clinical Pharmacology and Clinical Pharmacy; Vrije Universiteit Brussel, Brussel, Belgium
| | - Stephane Steurbaut
- Research Group Clinical Pharmacology and Clinical Pharmacy; Vrije Universiteit Brussel, Brussel, Belgium
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