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Khettar S, Jacquin Courtois S, Luaute J, Decullier E, Bin S, Dupuis M, Derex L, Mechtouff L, Nighoghossian N, Dussart C, Rode G, Janoly-Dumenil A. Multiprofessional intervention to improve adherence to medication in stroke patients: a study protocol for a randomised controlled trial (ADMED AVC study). Eur J Hosp Pharm 2022; 29:169-175. [PMID: 32978218 PMCID: PMC9047932 DOI: 10.1136/ejhpharm-2020-002425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Adherence to secondary preventive medications is often suboptimal in patients with stroke, exposing them to an increased risk of recurrent cerebral and/or cardiovascular events. Effective actions in the long term to improve adherence to medication are needed. The study will evaluate the efficacy of a collaborative multiprofessional patient-centred intervention conducted by a pharmacist on adherence to secondary preventive medication in stroke survivors. METHODS AND ANALYSIS This is a multicentre cluster-randomised controlled trial. Two groups of 91 patients (intervention vs standard care) will be recruited. The clinical pharmacist intervention targeting secondary preventive medication will consist of three parts over 1 year: (1) an individual semi-structured interview at hospital discharge; (2) follow-up telephone interviews at 3, 6 and 9 months after discharge; and (3) a final individual semi-structured interview 1 year after discharge. Information on patient follow-up will be shared with the general practitioner and the community pharmacist by sending a report of each interview. The primary outcome is adherence to medication during the 12 months after hospital discharge, assessed using a composite endpoint: the medication possession ratio associated with a self-administered questionnaire. ETHICS AND DISSEMINATION The local ethics committee, the national committee for use of personal data in medical research and the national data protection agency approved the study. The sponsor has no role in study design; collection, analysis and interpretation of data; or report writing. DISCUSSION This pharmacist-led educational programme has the potential to significantly improve adherence to medication in stroke survivors which could lead to a decrease in recurrent cerebral and/or cardiovascular events. TRIAL REGISTRATION NUMBER NCT02611440.
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Affiliation(s)
- Sophie Khettar
- Department of Pharmacy, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- EA 4129 P2S Parcours Santé Systémique, Claude Bernard University Lyon 1, Lyon, France
| | - Sophie Jacquin Courtois
- Physical medicine and rehabilitation department, Henry Gabrielle Hospital, Hospices Civils de Lyon, Saint-Genis-Laval, France
- INSERM U1028, CNRS UMR5292, Lyon Neuroscience Research Center, ImpAct Team, Claude Bernard University Lyon 1, Bron, France
| | - Jacques Luaute
- Physical medicine and rehabilitation department, Henry Gabrielle Hospital, Hospices Civils de Lyon, Saint-Genis-Laval, France
- INSERM U1028, CNRS UMR5292, Lyon Neuroscience Research Center, ImpAct Team, Claude Bernard University Lyon 1, Bron, France
| | - Evelyne Decullier
- Public Health Center, Research and Clinical Epidemiology, Hospices Civils de Lyon, Lyon, France
| | - Sylvie Bin
- Public Health Center, Research and Clinical Epidemiology, Hospices Civils de Lyon, Lyon, France
| | - Marine Dupuis
- Public Health Center, Research and Clinical Epidemiology, Hospices Civils de Lyon, Lyon, France
| | - Laurent Derex
- EA 7425 HESPER Health Services and Performance Research, Claude Bernard University Lyon1, Lyon, France
- Stroke center, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Bron, France
| | - Laura Mechtouff
- Stroke center, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Bron, France
- INSERM U1060, CarMeN laboratory, Claude bernard University Lyon 1, Villeurbanne, France
| | - Norbert Nighoghossian
- Stroke center, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Bron, France
- INSERM U1044, CNRS UMR 5220, CREATIS, Claude Bernard University Lyon 1, Villeurbanne, France
| | - Claude Dussart
- EA 4129 P2S Parcours Santé Systémique, Claude Bernard University Lyon 1, Lyon, France
| | - Gilles Rode
- Physical medicine and rehabilitation department, Henry Gabrielle Hospital, Hospices Civils de Lyon, Saint-Genis-Laval, France
- INSERM U1028, CNRS UMR5292, Lyon Neuroscience Research Center, ImpAct Team, Claude Bernard University Lyon 1, Bron, France
| | - Audrey Janoly-Dumenil
- Department of Pharmacy, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- EA 4129 P2S Parcours Santé Systémique, Claude Bernard University Lyon 1, Lyon, France
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Westberg A, Sjölander M, Glader EL, Gustafsson M. Primary Non-Adherence to Preventive Drugs and Associations with Beliefs About Medicines in Stroke Survivors. Patient Prefer Adherence 2022; 16:343-352. [PMID: 35177898 PMCID: PMC8844454 DOI: 10.2147/ppa.s351001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/12/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Medication non-adherence is a common problem in clinical practice. Little is known about stroke survivors' primary non-adherence to preventive drugs, and we hypothesised that their beliefs about medicines are associated with primary non-adherence. The objective was to describe primary non-adherence among stroke survivors and to assess associations between primary non-adherence to preventive drugs and beliefs about medicines. METHODS Questionnaires were sent to 797 individuals 3 months after stroke to assess beliefs about medicines through the Beliefs about Medicines Questionnaire (BMQ). All participants were registered in the Swedish Stroke Register (Riksstroke), and prescriptions for new preventive drugs during the hospital stay were identified through data from Riksstroke. Primary non-adherers were those who failed to fill one or more new prescriptions within 1 month of hospital discharge based on data from the Swedish Prescribed Drug Register. Differences between primary non-adherers and adherers were assessed by 2 tests and associations between the BMQ subscales and primary non-adherence were analysed using independent two-sample t-tests and multivariable logistic regression models. RESULTS A total of 594 individuals responded to the survey, of which 452 received new prescriptions of preventive drugs. Overall, 53 (12%) participants were classified as primary non-adherent. Primary non-adherers were more often dependent on help or support from next of kin (p=0.032) and had difficulties with memory more often (p=0.002) than the primary adherent individuals. No statistically significant differences in BMQ subscale-scores were found between the two groups (p>0.05). CONCLUSION Primary non-adherence to preventive drugs was low, and no associations were found between primary non-adherence and beliefs about medicines. Associations with cognitive impairments such as difficulties with memory and need for help from next of kin suggest that more effort is needed to help stroke survivors to start important preventive drug treatments after discharge from hospital.
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Affiliation(s)
- Annica Westberg
- Department of Integrative Medical Biology, Umeå University, Umeå, 901 87, Sweden
| | - Maria Sjölander
- Department of Integrative Medical Biology, Umeå University, Umeå, 901 87, Sweden
| | - Eva-Lotta Glader
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, 901 87, Sweden
| | - Maria Gustafsson
- Department of Integrative Medical Biology, Umeå University, Umeå, 901 87, Sweden
- Correspondence: Maria Gustafsson, Department of Integrative Medical Biology, Umeå University, Umeå, SE-901 87, Sweden, Email
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Kim SJ, Kwon OD, Choi HC, Lee EJ, Cho B, Yoon DH. Prevalence and associated factors of premature discontinuation of antiplatelet therapy after ischemic stroke: a nationwide population-based study. BMC Neurol 2021; 21:349. [PMID: 34507550 PMCID: PMC8431917 DOI: 10.1186/s12883-021-02384-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/24/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND We tried to evaluate the prevalence of premature discontinuation of antiplatelets and its affecting factors after ischemic stroke using large-sized representative national claims data. METHODS Patients aged 20 years or older with newly confirmed ischemic stroke who started aspirin or clopidogrel for the first time were selected from 2003 to 2010 National Health Insurance Service-National Sample Cohort (NHIS-NSC) of South Korea (n = 4621), a randomly collected sample which accounts for 2.2% (n = 1,017,468) of total population (n = 46,605,433). The prevalence of discontinuation of antiplatelets was measured every 6 months until the 24 months since the first prescription. Then we classified the participants into 2 groups according to the discontinuation status at 12 months and assessed the factors influencing premature discontinuation of antiplatelets within 12 months. RESULTS Among total participants, 35.5% (n = 1640) discontinued antiplatelets within 12 months and 58.5% (n = 2704) discontinued them within 24 months. The remaining 41.5% (n = 1917) continued them for 24 months or more. In the multivariate logistic regression analysis, initiating treatment with aspirin monotherapy [adjusted OR (aOR), 2.66, 95% CI 2.17-3.25] was the most prominent determinant of premature discontinuation within 12 months followed by CCI score ≥ 6 (aOR 1.50, 95% CI 1.31-1.98), and beginning treatment with clopidogrel monotherapy (aOR 1.41, 95% CI 1.15-1.72). Rural residency (aOR 1.36, 95% CI 1.14-1.62), < 4 total prescribed drugs (aOR 1.24, 95% CI 1.05-1.47), lower income (aOR 1.20, 95% CI 1.03-1.40 for middle income class and OR 1.21, 95% CI 1.02-1.45 for low income class), and ages ≥70 years (aOR 1.15, 95% CI 1.00-1.31) were also significantly associated with premature discontinuation of antiplatelets within 12 months. CONCLUSIONS The prevalence of premature discontinuation of antiplatelets after ischemic stroke was quite high. Thus, by understanding factors associated with premature discontinuation, a more strategic approach is required for the physicians to improve persistence with antiplatelets.
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Affiliation(s)
- Seung Jae Kim
- International Healthcare Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
- Department of Family Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | | | - Ho Chun Choi
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, 06236, Republic of Korea.
- Nuvizen, Palo Alto, California, 94303, USA.
| | - Eung-Joon Lee
- Institute of Public Health and Medical Care, Seoul National University Hospital, Seoul, 03080, Republic of Korea.
- Department of Neurology, Seoul National University Hospital, Seoul, 03080, Republic of Korea.
| | - BeLong Cho
- Department of Family Medicine, Seoul National University Hospital, Seoul, 03080, Republic of Korea
| | - Dae Hyun Yoon
- Department of Psychiatry, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, 06236, Republic of Korea
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Prevention of Non-Cardiogenic Ischemic Stroke: Towards Personalized Stroke Care. Stroke 2021. [DOI: 10.36255/exonpublications.stroke.personalizedcare.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Wawruch M, Murin J, Tesar T, Paduchova M, Petrova M, Celovska D, Havelkova B, Trnka M, Aarnio E. Non-Persistence With Antiplatelet Medications Among Older Patients With Peripheral Arterial Disease. Front Pharmacol 2021; 12:687549. [PMID: 34093210 PMCID: PMC8170080 DOI: 10.3389/fphar.2021.687549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/04/2021] [Indexed: 12/24/2022] Open
Abstract
Introduction: Antiplatelet therapy needs to be administered life-long in patients with peripheral arterial disease (PAD). Our study was aimed at 1) the analysis of non-persistence with antiplatelet medication in older PAD patients and 2) identification of patient- and medication-related characteristics associated with non-persistence. Methods: The study data was retrieved from the database of the General Health Insurance Company. The study cohort of 9,178 patients aged ≥ 65 years and treated with antiplatelet medications was selected from 21,433 patients in whom PAD was newly diagnosed between 01/2012 and 12/2012. Patients with a 6 months treatment gap without antiplatelet medication prescription were classified as non-persistent. Characteristics associated with non-persistence were identified using the Cox regression. Results: At the end of the 5 years follow-up, 3,032 (33.0%) patients were non-persistent. Age, history of ischemic stroke or myocardial infarction, clopidogrel or combination of aspirin with clopidogrel used at the index date, higher co-payment, general practitioner as index prescriber and higher overall number of medications were associated with persistence, whereas female sex, atrial fibrillation, anxiety disorders, bronchial asthma/chronic obstructive pulmonary disease, being a new antiplatelet medication user (therapy initiated in association with PAD diagnosis), and use of anticoagulants or antiarrhythmic agents were associated with non-persistence. Conclusion: In patients with an increased probability of non-persistence, an increased attention should be paid to improvement of persistence.
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Affiliation(s)
- Martin Wawruch
- Institute of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Jan Murin
- 1st Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Tomas Tesar
- Department of Organization and Management of Pharmacy, Faculty of Pharmacy, Comenius University, Bratislava, Slovakia
| | | | - Miriam Petrova
- Institute of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Denisa Celovska
- 1st Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | | | - Michal Trnka
- Institute of Medical Physics, Biophysics, Informatics and Telemedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Emma Aarnio
- Institute of Biomedicine, University of Turku, Turku, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
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Kim SJ, Kwon OD, Choi HC, Lee EJ, Cho B. Effect of antiplatelet persistence on long-term mortality and predictors of non-persistence in ischemic stroke patients 75 years and older: a nationwide cohort study. BMC Geriatr 2021; 21:232. [PMID: 33827445 PMCID: PMC8028245 DOI: 10.1186/s12877-021-02171-4] [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: 12/02/2020] [Accepted: 03/19/2021] [Indexed: 11/30/2022] Open
Abstract
Background We aimed to provide real-world evidence on the benefit of persistence with antiplatelet therapy (APT) on long-term all-cause mortality (ACM) in ischemic stroke patients aged 75 years and older. Methods Newly diagnosed ischemic stroke patients aged 75 years and older who initiated aspirin or clopidogrel for the first time were chosen from 2003 to 2010 National Health Insurance Service-National Sample Cohort (NHIS-NSC) of Korea (n = 887), a random cohort sample accounting for 2.2% (n = 1,017,468) of total population (n = 46,605,433). Then subjects were divided into persistent (n = 556) and non-persistent (n = 321) groups according to the persistent status at 6 months. Survivor analysis was performed between the two groups and predictors of non-persistence were analyzed by multivariate logistic regression analysis. Patients were followed up until death or December 31, 2013. Results Non-persistence with APT was significantly associated with increased risk of ACM (adjusted hazard ration [aHR] 2.13, 95% confidence interval [CI] 1.72–2.65), cerebro-cardiovascular disease (CVD) mortality (aHR 2.26, 95% CI 1.57–3.24), and non-CVD mortality (aHR 2.06, 95% CI 1.5702.70). More comorbidities (Charlson comorbidity index score ≥ 6) (adjusted odds ratio [aOR], 2.56, 95% CI 1.43–4.55), older age (aOR 1.52, 95% CI 1.11–2.09 for 80–84 years, aOR 1.73, 95% CI 1.17–2.57 for ≥85 years), and less than 4 total prescribed drugs (aOR 1.54, 95% CI 1.08–2.21) were independent predictors of non-persistence. Conclusions Persistent with APT after ischemic stroke featured long-term mortality benefit even in patients aged 75 years and older. Thus, improving APT persistence for ischemic stroke patients in this age group is also recommended by understanding factors associated with non-persistence.
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Affiliation(s)
- Seung Jae Kim
- Department of Family Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,International Healthcare Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Oh Deog Kwon
- Republic of Korea Navy 2nd Fleet Medical Corps, Pyeongtaek-si, Gyeonggi-do, Republic of Korea
| | - Ho Chun Choi
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, 39th Floor, Gangnam Finance Center, 152 Teheran-ro, Gangnam-gu, Seoul, 06236, Republic of Korea.
| | - Eung-Joon Lee
- Department of Neurology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - BeLong Cho
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Kim SJ, Kwon OD, Choi HC, Lee EJ, Cho B. Non-persistence with anti-platelet therapy and long-term mortality after ischemic stroke: A nationwide study. PLoS One 2021; 16:e0244718. [PMID: 33561124 PMCID: PMC7872250 DOI: 10.1371/journal.pone.0244718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/15/2020] [Indexed: 11/22/2022] Open
Abstract
Background We tried to investigate the effect of non-persistence with antiplatelets after ischemic stroke on long-term all-cause mortality (ACM). Methods and findings We selected newly diagnosed ischemic stroke patients aged ≥20years who were newly treated with aspirin or clopidogrel from 2003–2010 Korean National Health Insurance Service-National Sample Cohort, a random sample of 2.2% of total population. Subjects were divided into two pairs of groups according to persistence with antiplatelets at 6 and 12 months: those who discontinued antiplatelets within 6 months (DA6M) and those who continued them for 6 or months or more (CA6M); and those who discontinued antiplatelets within 12 months (DA12M) and those who continued them for 12 months or more (CA12M). Those who died within 6 months among DA6M and those who died within 12 months among DA12M were excluded along with those with medication possession ratio<80% among CA6M and CA12M. Subjects were followed-up until death or December 31, 2013. Among 3,559 total subjects, DA6M were 1,080 and CA6M were 2,479 while, out of 3,628 total patients, DA12M were 1,434 and CA12M were 2,194. The risks of ACM [adjusted hazard ratio (aHR), 2.25; 95% confidence interval (CI), 1.94–2.61], cerebro-cardiovascular disease (CVD) death (aHR, 2.52; 95% CI, 1.96–3.24) and non-CVD death (aHR, 2.11; 95% CI, 1.76–2.64) of DA6M were all significantly increased compared to CA6M. DA12M also had significantly higher risks of ACM (aHR, 1.93; 95% CI, 1.65–2.25), CVD mortality (aHR, 2.13; 95% CI; 1.63–2.77) and non-CVD mortality (aHR, 1.83;95% CI 1.51–2.22) than DA12M but aHRs were lower than that between DA6M and CA6M. The difference rates of ACM, CVD death, and non-CVD death between non-persistent and persistent groups all continuously widened over time but the degree of difference was gradually decreased. Conclusions Maintaining antiplatelets for the first 12 months after ischemic stroke reduces long-term risks of both CVD death and non-CVD death.
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Affiliation(s)
- Seung Jae Kim
- Department of Family Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Oh Deog Kwon
- Republic of Korea Navy 2nd Fleet Medical Corps, Pyeongtaek-si, Gyeonggi-do, Republic of Korea
| | - Ho Chun Choi
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea
- Nuvizen, Palo Alto, CA, United States of America
- * E-mail: (HCC); (EJL)
| | - Eung-Joon Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
- * E-mail: (HCC); (EJL)
| | - BeLong Cho
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Stroke patients' support: evaluation of knowledge, practices and training needs of French community pharmacists. Int J Clin Pharm 2021; 43:980-989. [PMID: 33387187 DOI: 10.1007/s11096-020-01204-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
Background Stroke represents a major Public Health issue in industrialized countries because of its frequency and severity. In secondary stroke prevention, treatment efficacy is correlated to medication adherence. However, it remains suboptimal in stroke patients. Community pharmacists, in light of their positioning in the care pathway and proximity to patients, can play an essential role in patient support and improving treatment adherence. However, it is currently unknown whether pharmacists are ready to perform this task. Objective Evaluate knowledge, practices and training needs for community pharmacists in therapeutic stroke management to improve long term care for stroke patients. Setting Community pharmacies in the Rhone Alpes region (France). Method We conducted a cross sectional study via a standardized self-assessment questionnaire consisting of 40 questions divided into three parts. The latter was designed by a multidisciplinary team and distributed electronically to community pharmacists of the Rhône-Alpes region (France). Main outcome measure (a) global knowledge score on the pathology, risk factors and clinical care management, (b) description of the support practices for stroke patients, (c) training needs for pharmacists. Results The 104 participants presented a moderate level of knowledge (global score: 12/20 ± 3). Topics best mastered were: pathophysiology, target blood pressure and place of antiplatelets in the therapeutic strategy. Knowledge items that needed improvement were: warning signs correctly identified by 44% of participants, time delay for thrombolysis for which 14% answered correctly, target glycated hemoglobin levels were correct for 41%, and the 3 recommended antihypertensive drug classes were only identified by 5% of participants. Patient education received from pharmacists concerned dosage (89%), treatment adherence (88%), benefits (66%) and administration modalities of medicines (64%), management of risk factors (75% for diet, 73% for physical activity, 70% for smoking and 53% for alcohol). All pharmacists wanted additional training on risk factors and clinical management guidelines. Conclusion Based on this small study, the fragmented knowledge and varied practices promote the need for further training for pharmacists to optimize support of stroke patients. This study promotes the elaboration of training systems adapted to pharmacists' needs. This will help support the development of a targeted pharmaceutical care approach for stroke patients.
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Viprey M, Gouillet M, Puppo C, Termoz A, Della Vecchia C, Derex L, Haesebaert J, Schott AM, Préau M. A Qualitative Study of Barriers and Facilitators to Adherence to Secondary Prevention Medications Among French Patients Suffering from Stroke and Transient Ischemic Attack. Patient Prefer Adherence 2020; 14:1213-1223. [PMID: 32801652 PMCID: PMC7382755 DOI: 10.2147/ppa.s257323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/23/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Secondary prevention medications (SPM) reduce the risk of ischemic stroke (IS) and transient ischemic attack (TIA) recurrence. However, approximately one-third of patients are estimated to be non-adherent. This qualitative study aimed to explore barriers and facilitators to adherence to SPM after IS or TIA. PATIENTS AND METHODS Thirty-six face-to-face semi-structured interviews were conducted with 14 TIA patients and 22 IS patients who self-administered their treatment 12 months after IS/TIA. A thematic analysis was performed. RESULTS Major facilitators to good adherence to SPM were the fear of stroke recurrence and the high level of trust in the prescribing physician. Barriers included a perceived lack and/or inappropriate timing of information about SPM, practical difficulties of taking some SPM (eg, inadequate packaging) and of implementing routines into their daily life. CONCLUSION Information on SPM is inadequate in terms of quantity and timing both during the acute IS/TIA period and over the long term. Providing more tailor-made information at an opportune moment, in particular by promoting discussion with their general practitioner (GP) throughout the course of illness and recovery, is essential to ensure that patients are not left alone in the decision-making process regarding adherence to SPM.
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Affiliation(s)
- Marie Viprey
- Public Health Department, Hospices Civils de Lyon, Lyon, France
- HESPER EA 7425, University of Lyon, University Claude Bernard Lyon 1, Lyon, France
| | | | | | - Anne Termoz
- Public Health Department, Hospices Civils de Lyon, Lyon, France
- HESPER EA 7425, University of Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Claire Della Vecchia
- HESPER EA 7425, University of Lyon, University Claude Bernard Lyon 1, Lyon, France
- GRePS, Lyon 2 University, Lyon, France
| | - Laurent Derex
- HESPER EA 7425, University of Lyon, University Claude Bernard Lyon 1, Lyon, France
- Comprehensive Stroke Center, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Bron, France
| | - Julie Haesebaert
- Public Health Department, Hospices Civils de Lyon, Lyon, France
- HESPER EA 7425, University of Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Anne-Marie Schott
- Public Health Department, Hospices Civils de Lyon, Lyon, France
- HESPER EA 7425, University of Lyon, University Claude Bernard Lyon 1, Lyon, France
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Jang DE, Zuñiga JA. Factors associated with medication persistence among ischemic stroke patients: a systematic review. Neurol Res 2020; 42:537-546. [PMID: 32321382 DOI: 10.1080/01616412.2020.1754640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE An investigation of the prevalence of medication persistence and associated factors in order to inform effective strategies for improving medication persistence. METHODS A systematic review of the literature from 2010 to the present was performed, using the PRISMA protocol. Primary and empirical observational studies of adult ischemic stroke or transient ischemic attack patients were included. PubMed, CINAHL, Web of Science, Cochrane Library, and PsycInfo databases were searched using the key terms stroke, ischemic stroke, medication persistence, medication adherence, and patient compliance. RESULTS Of four hundred twenty-eight journal articles retrieved, a final 18 articles were included. Short-term medication persistence was 46.2-96.7%, and long-term medication persistence was 41.7-93.0%. Identified hospital-related factors for medication persistence were stroke unit care, in-hospital medical complications, and early follow-up visit. Demographic factors for medication persistence were older age, and high/adequate financial status; disease-related factors were disease history, stroke subtype, and symptom severity. Age less than 75, female sex, comorbidity, antiplatelet medication switch, and polypharmacy were identified as factors of medication nonpersistence. CONCLUSIONS Stroke patients' medication persistence decreases over time, and persistence on antiplatelets, anticoagulants, and statin was poor. Several factors were associated with medication persistence, and these factors should be considered in future secondary preventative strategies.
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Affiliation(s)
- Dong Eun Jang
- School of Nursing, The University of Texas at Austin , Austin, TX, USA
| | - Julie Ann Zuñiga
- School of Nursing, The University of Texas at Austin , Austin, TX, USA
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Yeo SH, Toh MPHS, Lee SH, Seet RCS, Wong LY, Yau WP. Impact of medication nonadherence on stroke recurrence and mortality in patients after first-ever ischemic stroke: Insights from registry data in Singapore. Pharmacoepidemiol Drug Saf 2020; 29:538-549. [PMID: 32190948 DOI: 10.1002/pds.4981] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 11/13/2019] [Accepted: 02/09/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE This retrospective cohort study aims to examine adherence to secondary stroke preventive medications and their association with risk of stroke recurrence and mortality in patients after first-ever ischemic stroke. METHODS Using data from the National Healthcare Group and Singapore Stroke Registry, patients with first-ever ischemic stroke between 2010 and 2014 were included, and categorized based on antithrombotic or statin adherence using the proportion of days covered: high (≥75%), intermediate (50%-74%), low (25%-49%), and very low (<25%). The primary outcome was first recurrent ischemic stroke within a year after hospital discharge, while the secondary composite outcomes were (a) stroke recurrence and all-cause mortality and (b) stroke recurrence and cardiovascular mortality. The Cox proportional hazard model was used to examine the association between medication adherence and outcomes. Adjusted hazard ratios (aHRs) and the corresponding 95% confidence intervals (CIs) were reported. RESULTS Among ischemic stroke patients prescribed with antithrombotics (n = 1139) or statins (n = 1160) at hospital discharge, about one-third were highly adherent to their medications. Patients with lower medication adherence tended to be younger, were admitted to private ward classes, and were without hypertension. Compared with the patients with high medication adherence, the risk of stroke recurrence was higher in patients with very low antithrombotic (aHR = 4.65; 95% CI: 1.45-14.89) or statin (aHR = 3.44; 95% CI: 0.93-12.74) adherence. Similar findings were observed for the secondary outcomes. CONCLUSIONS Poor adherence to antithrombotic and statin treatment increases the risk of recurrent stroke and mortality in patients after first-ever ischemic stroke. Further measures are needed to improve medication adherence among stroke survivors.
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Affiliation(s)
- See-Hwee Yeo
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
| | - Matthias Paul Han Sim Toh
- Chronic Disease Epidemiology, Population Health, National Healthcare Group, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Sze Haur Lee
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Raymond Chee Seong Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Neurology, National University Health System, Singapore
| | - Lai Yin Wong
- Chronic Disease Epidemiology, Population Health, National Healthcare Group, Singapore
| | - Wai-Ping Yau
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
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12
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Kim DY, Kwon H, Nam KW, Lee Y, Kwon HM, Chung YS. Remote Management of Poststroke Patients With a Smartphone-Based Management System Integrated in Clinical Care: Prospective, Nonrandomized, Interventional Study. J Med Internet Res 2020; 22:e15377. [PMID: 32130140 PMCID: PMC7068458 DOI: 10.2196/15377] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 10/24/2019] [Accepted: 12/15/2019] [Indexed: 12/11/2022] Open
Abstract
Background Advances in mobile health (mHealth) have enabled systematic and continuous management of patients with chronic diseases. Objective We developed a smartphone-based mHealth system and aimed to evaluate its effects on health behavior management and risk factor control in stroke patients. Methods With a multifaceted stroke aftercare management system that included exercise, medication, and educational materials, we performed a 12-week single-arm intervention among eligible poststroke patients in the stroke clinic from September to December 2016. The intervention consisted of (1) regular blood pressure (BP), blood glucose, and physical activity measurements; (2) stroke education; (3) an exercise program; (4) a medication program; and (5) feedback on reviewing of records by clinicians. Clinical assessments consisted of the stroke awareness score, Beck Depression Inventory-II (BDI), EuroQol-5 Dimensions (EQ-5D), and BP at visit 1 (baseline), visit 2 (4 weeks), and visit 3 (12 weeks). Temporal differences in the parameters over 12 weeks were investigated with repeated-measures analysis of variance. Changes in medication adherence at visit 1-2 (from visit 1 to visit 2) and visit 2-3 (from visit 2 to visit 3) were compared. System satisfaction was evaluated with a self-questionnaire using a 5-point Likert scale at visit 3. Results The study was approved by the Institutional Review Board in September 2016, and participants were enrolled from September to December 2016. Among the 110 patients enrolled for the study, 99 were included in our analyses. The mean stroke awareness score (baseline: 59.6 [SD 18.1]; 4 weeks: 67.6 [SD 16.0], P<.001; 12 weeks: 74.7 [SD 14.0], P<.001) and BDI score (baseline: 12.7 [SD 10.1]; 4 weeks: 11.2 [SD 10.2], P=.01; 12 weeks: 10.7 [SD 10.2], P<.001) showed gradual improvement; however, no significant differences were found in the mean EQ-5D score (baseline: 0.66 [SD 0.33]; 4 weeks: 0.69 [SD 0.34], P=.01; 12 weeks: 0.69 [SD 0.34], P<.001). Twenty-six patients who had uncontrolled BP at baseline had −13.92 mmHg (P=.001) and −6.19 mmHg (P<.001) reductions on average in systolic and diastolic BP, respectively, without any antihypertensive medication change. Medication compliance was better at visit 2-3 (60.9% [SD 37.2%]) than at visit 1-2 (47.8% [SD 38.7%], P<.001). Conclusions Awareness of stroke, depression, and BP was enhanced when using the smartphone-based mHealth system. Emerging mHealth techniques have potential as new nonpharmacological secondary prevention methods because of their ubiquitous access, near real-time responsiveness, and comparatively lower cost.
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Affiliation(s)
- Do Yeon Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Medical Corps, Republic of Korea Navy, Jeju Island, Republic of Korea
| | - Hee Kwon
- LifeSemantics, Corp, Seoul, Republic of Korea
| | - Ki-Woong Nam
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yongseok Lee
- Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Hyung-Min Kwon
- Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Young Seob Chung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
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13
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Kaufman BG, O'Brien EC, Stearns SC, Matsouaka R, Holmes GM, Weinberger M, Song PH, Schwamm LH, Smith EE, Fonarow GC, Xian Y. The Medicare Shared Savings Program and Outcomes for Ischemic Stroke Patients: a Retrospective Cohort Study. J Gen Intern Med 2019; 34:2740-2748. [PMID: 31452032 PMCID: PMC6854149 DOI: 10.1007/s11606-019-05283-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 04/10/2019] [Accepted: 07/25/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Post-stroke care delivery may be affected by provider participation in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) through systematic changes to discharge planning, care coordination, and transitional care. OBJECTIVE To evaluate the association of MSSP with patient outcomes in the year following hospitalization for ischemic stroke. DESIGN Retrospective cohort SETTING: Get With The Guidelines (GWTG)-Stroke (2010-2014) PARTICIPANTS: Hospitalizations for mild to moderate incident ischemic stroke were linked with Medicare claims for fee-for-service beneficiaries ≥ 65 years (N = 251,605). MAIN MEASURES Outcomes included discharge to home, 30-day all-cause readmission, length of index hospital stay, days in the community (home-time) at 1 year, and 1-year recurrent stroke and mortality. A difference-in-differences design was used to compare outcomes before and after hospital MSSP implementation for patients (1) discharged from hospitals that chose to participate versus not participate in MSSP or (2) assigned to an MSSP ACO versus not or both. Unique estimates for 2013 and 2014 ACOs were generated. KEY RESULTS For hospitals joining MSSP in 2013 or 2014, the probability of discharge to home decreased by 2.57 (95% confidence intervals (CI) = - 4.43, - 0.71) percentage points (pp) and 1.84 pp (CI = - 3.31, - 0.37), respectively, among beneficiaries not assigned to an MSSP ACO. Among discharges from hospitals joining MSSP in 2013, beneficiary ACO alignment versus not was associated with increased home discharge, reduced length of stay, and increased home-time. For patients discharged from hospitals joining MSSP in 2014, ACO alignment was not associated with changes in utilization. No association between MSSP and recurrent stroke or mortality was observed. CONCLUSIONS Among patients with mild to moderate ischemic stroke, meaningful reductions in acute care utilization were observed only for ACO-aligned beneficiaries who were also discharged from a hospital initiating MSSP in 2013. Only 1 year of data was available for the 2014 MSSP cohort, and these early results suggest further study is warranted. REGISTRATION None.
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Affiliation(s)
- Brystana G Kaufman
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Sally C Stearns
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - G Mark Holmes
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paula H Song
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lee H Schwamm
- Neurology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Eric E Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Gregg C Fonarow
- Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ying Xian
- Duke Clinical Research Institute, Durham, NC, USA
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14
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Geary L, Hasselström J, Carlsson AC, Eriksson I, von Euler M. Secondary prevention after stroke/transient ischemic attack: A randomized audit and feedback trial. Acta Neurol Scand 2019; 140:107-115. [PMID: 31017305 DOI: 10.1111/ane.13109] [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] [Received: 02/08/2019] [Revised: 03/10/2019] [Accepted: 04/12/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The clinical benefits of use of secondary preventive pharmacotherapy in ischemic stroke/TIA have been previously demonstrated. A potential target for facilitating the use of recommended medications is primary care physicians. Therefore, we carried out an audit and feedback intervention aimed at primary care centers. The aim was to improve the use of secondary preventive stroke medications and diagnosis recording in ischemic stroke/TIA. MATERIALS AND METHODS The intervention consisted of structured, healthcare database-derived quality reports on secondary preventive medication use and diagnosis recording, sent in 2015 to half of the primary care centers in Stockholm County, with information specific to each primary care center. Medication dispensation (primary outcome) for statins, antihypertensives, antiplatelets, and anticoagulants, as well as diagnosis recording (secondary outcome), was compared between intervention centers and control centers in the 18 months following the intervention. Outcome data were derived from the healthcare databases of Stockholm County (VAL). RESULTS Dispensation of medications to the 12 766 patients analyzed in the study was high. Over 77% of patients used antihypertensives and antithrombotics, and 65%-68% used statins. After the intervention, no differences in medication dispensation were seen between the intervention and control centers, even after adjusting for potential confounders. CONCLUSIONS A simple audit and feedback intervention directed toward physicians in primary care did not improve medication dispensation to ischemic stroke/TIA patients 18 months later. Any future audit and feedback intervention aimed at improving adherence to guidelines for secondary prevention in primary care should consider multiple and continuous reminders, the graphical appeal, and widening the recipients to include patients.
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Affiliation(s)
- Lukas Geary
- Karolinska Institutet Stroke Research Network at Södersjukhuset Stockholm Sweden
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
- Unit of Medicine Capio S:t Görans Sjukhus Stockholm Sweden
| | - Jan Hasselström
- Department of Neurobiology, Care Sciences and Society, Section of Family Medicine and Primary Care Karolinska Institutet Stockholm Sweden
- Academic Primary Health Care Center Stockholm County Council Stockholm Sweden
| | - Axel Carl Carlsson
- Department of Neurobiology, Care Sciences and Society, Section of Family Medicine and Primary Care Karolinska Institutet Stockholm Sweden
| | - Irene Eriksson
- Department of Healthcare Development Stockholm County Council Stockholm Sweden
- Department of Medicine Solna Karolinska Institutet Stockholm Sweden
| | - Mia von Euler
- Karolinska Institutet Stroke Research Network at Södersjukhuset Stockholm Sweden
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
- Department of Medicine Solna Karolinska Institutet Stockholm Sweden
- Department of Clinical Pharmacology Karolinska University Hospital Stockholm Sweden
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15
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Deshpande CG, Kogut S, Laforge R, Willey C. Impact of medication adherence on risk of ischemic stroke, major bleeding and deep vein thrombosis in atrial fibrillation patients using novel oral anticoagulants. Curr Med Res Opin 2018; 34:1285-1292. [PMID: 29334815 DOI: 10.1080/03007995.2018.1428543] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Our study examined the impact of adherence to novel oral anticoagulants [NOACs - dabigatran and rivaroxaban] on ischemic-stroke (IS), major-bleeding (MB), deep-vein-thrombosis and pulmonary-embolism (DVTPE) risk in a large, nationwide, propensity-matched sample. METHODS A retrospective cohort study utilized data from a US commercial managed-care database (2010-2012). Adult patients with ≥1 diagnosis of atrial fibrillation/flutter (ICD-9 427.31/32), >1 prescription of NOACs and CHA2DS2-VASc score ≥1 were included. Patients were categorized as adherent versus nonadherent (using proportion of days covered [PDC ≥80%]) based on their NOAC use up to 6 months and those continued its use up to 12 months. The patients were matched using propensity score (based on inverse probability treatment weighting) and the risk of IS, MB, DVTPE outcomes was evaluated for the matched cohorts' post-adherence (exposure) assessment using multivariable Cox regression. RESULTS A total of 3,629 and 1,946 patients with at least 6 and 12 months of NOAC use were included. Based on a PDC threshold of ≥80%, adherence rates at 6 and 12 month usage were 77% and 76%, respectively. Patients with lowest adherence were from the South, had low stroke risk and EPO/HMO insurance. Using Cox models with matched cohorts, nonadherence within the first 6 months' use was significantly associated with higher risk of IS and DVTPE (IS: hazard ratio [HR] = 1.82, p = .002; DVTPE: HR = 2.12, p = .010) and the risk increased with nonadherence for the prolonged period of 12 months' use (IS: HR = 2.08, p = .022; DVTPE: HR = 5.39, p = .003). The risk of MB was not different (p > .05) between adherent and nonadherent groups for both 6 month and 12 month cohorts. CONCLUSION Adherence to NOACs for both 6 months and prolonged use (up to 12 months) was associated with a reduction in IS and DVTPE risk, but did not substantially increase risk of MB. Further studies on newer, individual NOACs and older populations are warranted.
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Affiliation(s)
- Chinmay G Deshpande
- a Department of Pharmacy Practice , College of Pharmacy, University of Rhode Island , Kingston , RI , USA
| | - Stephen Kogut
- a Department of Pharmacy Practice , College of Pharmacy, University of Rhode Island , Kingston , RI , USA
| | - Robert Laforge
- b Department of Psychology , University of Rhode Island , Kingston , RI , USA
| | - Cynthia Willey
- a Department of Pharmacy Practice , College of Pharmacy, University of Rhode Island , Kingston , RI , USA
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16
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Mechtouff L, Haesebaert J, Viprey M, Tainturier V, Termoz A, Porthault-Chatard S, David JS, Derex L, Nighoghossian N, Schott AM. Secondary Prevention Three and Six Years after Stroke Using the French National Insurance Healthcare System Database. Eur Neurol 2018; 79:272-280. [PMID: 29758555 DOI: 10.1159/000488450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 03/14/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Secondary prevention is inadequate in the first 2 years after stroke but what happens after that is less documented. The aim of this study was to assess the use and the adherence to preventive drugs 3 and 6 years after experiencing a transient ischemic attack (TIA) or an ischemic stroke (IS). METHODS The population study was from the AVC69 cohort (IS or TIA admitted in an emergency or stroke unit in the Rhône area, France, for an IS or a TIA during a 7-month period). Medication use was defined as ≥1 purchase during the studied year and adherence as Continuous Measure of Medication Acquisition ≥0.8 using the French medical insurance health care funding database. RESULTS The study population consisted of 210 patients at 3 years and 163 patients at 6 years. Medication use at 3 and 6 years was, respectively, 80.9 and 79.8% for antithrombotics, 69.1 and 66.3% for antihypertensives, 60.5 and 55.2% for statins and 48.6 and 46.6% for optimal treatment defined as the treatment achieved by the use of the 3 drugs. Adherence to each class was good at 3 years and tends to decrease at 6 years. CONCLUSIONS More than one patient out of 2 do not use the optimal preventive treatment.
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Affiliation(s)
- Laura Mechtouff
- Stroke Unit, Hôpital Pierre Wertheimer, Hospices Civils de, Lyon, France
| | - Julie Haesebaert
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Marie Viprey
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Valérie Tainturier
- Département de Recherche et d'Informations Médicalisées (DRIM), Direction Régionale du Service Médical de Rhône-Alpes (DRSM RA), Lyon, France
| | - Anne Termoz
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | | | - Jean-Stéphane David
- Service d'Anesthésie-Réanimation-Urgence, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Laurent Derex
- Stroke Unit, Hôpital Pierre Wertheimer, Hospices Civils de, Lyon, France
| | - Norbert Nighoghossian
- Stroke Unit, Hôpital Pierre Wertheimer, Hospices Civils de, Lyon, France.,CREATIS, CNRS UMR 5220, INSERM U1044, University Lyon 1, Lyon, France
| | - Anne-Marie Schott
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
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17
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Wawruch M, Zatko D, Wimmer G, Luha J, Wimmerova S, Kukumberg P, Murin J, Hloska A, Tesar T, Shah R. Non-persistence with antiplatelet therapy in elderly patients after a transient ischemic attack. Aging Clin Exp Res 2017; 29:1121-1127. [PMID: 28284002 DOI: 10.1007/s40520-017-0745-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/21/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Antiplatelet therapy following a transient ischemic attack (TIA) constitutes an important secondary prevention measure. AIMS The study was aimed at evaluating the development of non-persistence with antiplatelet therapy in elderly patients after a TIA and identifying patient-related characteristics associated with the probability of non-persistence during the follow-up period. METHODS The study cohort (n = 854) was selected from the database of the largest health insurance provider of the Slovak Republic. It included patients aged ≥65 years, in whom antiplatelet medication was initiated following a TIA diagnosis during the period between 1 January 2010 and 31 December 2010. Each patient was followed for a period of 3 years from the date of the first antiplatelet medication prescription associated with TIA diagnosis. Patients in whom there was a treatment gap of at least 6 months without antiplatelet medication prescription were defined as "non-persistent". The factors predicting non-persistence were identified in the Cox proportional hazards model. RESULTS At the end of the follow-up period, 345 (40.4%) patients were non-persistent with antiplatelet medication. Protective factors decreasing a patient´s likelihood of becoming non-persistent were age ≥75 years [hazard ratio (HR) = 0.75], polypharmacy (concurrent use of ≥6 drugs) (HR = 0.79), arterial hypertension (HR = 0.68), diabetes mellitus (HR = 0.74), hypercholesterolemia (HR = 0.75), and antiplatelet medication switching during the follow-up period (HR = 0.73). CONCLUSIONS It is concluded that following a TIA, elderly patients aged <75 years or those with normal serum cholesterol levels, without certain comorbid conditions and polypharmacy may benefit from special counselling to encourage persistence with secondary preventive medication.
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Affiliation(s)
- Martin Wawruch
- Institute of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Comenius University, Sasinkova 4, 811 08, Bratislava, Slovakia.
| | - Dusan Zatko
- General Health Insurance Company, Panónska cesta 2, 851 04, Bratislava, Slovakia
| | - Gejza Wimmer
- Institute of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Comenius University, Sasinkova 4, 811 08, Bratislava, Slovakia
| | - Jan Luha
- Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University, Sasinkova 4, 811 08, Bratislava, Slovakia
| | - Sona Wimmerova
- Department of Biophysics, Informatics and Biostatistics, Faculty of Public Health, Slovak Medical University, Limbová 12, 833 03, Bratislava, Slovakia
| | - Peter Kukumberg
- 2nd Department of Neurology, Faculty of Medicine, Comenius University, Limbová 5, 833 05, Bratislava, Slovakia
| | - Jan Murin
- 1st Department of Internal Medicine, Faculty of Medicine, Comenius University, Mickiewiczova 13, 813 69, Bratislava, Slovakia
| | - Adam Hloska
- Department of Pharmacology, Jessenius Faculty of Medicine in Martin, Comenius University, Mala Hora 11161, 036 01, Martin, Slovakia
| | - Tomas Tesar
- Department of Organisation and Management of Pharmacy, Faculty of Pharmacy, Comenius University, Kalinciakova 8, 832 32, Bratislava, Slovakia
| | - Rashmi Shah
- Rashmi Shah, Pharmaceutical Consultant, 8 Birchdale, Gerrards Cross, Bucks, SL9 7JA, UK
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18
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Dahlgren C, Geary L, Hasselström J, Rehnberg C, Schenck-Gustafsson K, Wändell P, Euler MV. Recording a diagnosis of stroke, transient ischaemic attack or myocardial infarction in primary healthcare and the association with dispensation of secondary preventive medication: a registry-based prospective cohort study. BMJ Open 2017; 7:e015723. [PMID: 28939569 PMCID: PMC5623465 DOI: 10.1136/bmjopen-2016-015723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES The aim of this study was to explore whether recording in primary care of a previously recorded hospital diagnosis was associated with increased patient utilisation of recommended medications. DESIGN Registry-based prospective cohort study. SETTING AND PARTICIPANTS 19 072 patients with a hospital discharge diagnosis of transient ischaemic attack (TIA), stroke or acute coronary syndrome from hospitals in Stockholm County 2010-2013 were included in the study. MAIN OUTCOME MEASURE The outcome of the study was medication dispensation as a marker of adherence to recommended medications. Adherence was defined as having had at least two filled prescriptions in the third year following hospital discharge. RESULTS Recording a diagnosis was associated with higher utilisation of all recommended medications with the exception of antihypertensives in patients with TIA. The differences between the groups with and without a recorded diagnosis remained after adjusting for age, sex, index year and visits to private practitioners. Dispensation of antithrombotics was high overall, 80%-90% in patients without a recorded diagnosis and 90%-94% for those with a diagnosis. Women with recorded ischaemic stroke/TIA/acute coronary syndrome were dispensed more statins (56%-71%) than those with no recorded diagnosis (46%-59%). Similarly, 68%-83% of men with a recorded diagnosis were dispensed statins (57%-77% in men with no recorded diagnosis). The rate of diagnosis recording spanned from 15% to 47% and was especially low in TIA (men 15%, women 16%). CONCLUSION Recording a diagnosis of TIA/stroke or acute coronary syndrome in primary care was found to be associated with higher dispensation of recommended secondary preventive medications. Further study is necessary in order to determine the mechanisms underlying our results and to establish the utility of our findings.
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Affiliation(s)
- Cecilia Dahlgren
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Stockholms Läns Landsting, Center for Health Economics, Informatics and Healthcare Research, Stockholm, Sweden
| | - Lukas Geary
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Unit of Medicine, Capio S:t Görans Sjukhus, Stockholm, Sweden
| | - Jan Hasselström
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Stockholms Läns Landsting, Academic Primary Care Center, Stockholm, Sweden
| | - Clas Rehnberg
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Karin Schenck-Gustafsson
- Department of Medicine, Cardiac Unit, Center for Gender Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Per Wändell
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
| | - Mia von Euler
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Clinical Pharmacology Unit Solna, Karolinska Institutet, Stockholm, Sweden
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19
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Vyas A, Bash LD, Patel MD, Simpson RJ. Changes in Treatment Patterns and Incremental Health Care Utilization Due to P2Y12-Associated Complications in Patients with Acute Coronary Syndrome. J Manag Care Spec Pharm 2017; 23:947-956. [PMID: 28854078 PMCID: PMC10398233 DOI: 10.18553/jmcp.2017.23.9.947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND P2Y12 antiplatelet therapy (APT) is highly efficacious in reducing the incidence of ischemic events in patients with acute coronary syndrome (ACS); however, it is associated with several adverse complications. Data on P2Y12-associated complications and adherence to APT are sparse. OBJECTIVE To describe the characteristics, frequency of P2Y12-associated complications, adherence and persistence to P2Y12 APT, and health care utilization among ACS patients on P2Y12 APT. METHODS This retrospective observational study of the MarketScan Commercial Claims and Encounters Database identified patients aged ≥ 18 years who were discharged from an ACS hospitalization in 2012-2014 and initiated P2Y12 APT (ticagrelor, prasugrel, or clopidogrel). The proportion of patients within each treatment group who experienced P2Y12-associated complications within 1 year and who were adherent to APT were determined. Frequencies of all-cause health care utilization (i.e., hospitalization, length of stay, emergency room [ER] visits, outpatient visits, cardiac events, and transfusions) were evaluated for each treatment group. Poisson regressions were conducted to evaluate the association between nonad-herence with P2Y12 APT and health care utilization, after adjusting for demographics (age and gender), health insurance type, and comorbidities. RESULTS Among 11,629 ACS patients, most were male; 44.6% had hypertension; 20.6% had diabetes; and 53.4% had hyperlipidemia. Clopidogrel use was common (62.6%), with ticagrelor use less common (9.0%). Among all groups, approximately one third experienced P2Y12-associated complications. One-year adherence to APT was suboptimal (68% overall), with 73.3% adherence among prasugrel users, followed by 71.4% adherence among ticagrelor users and 65.6% adherence among clopidogrel users. Switching was most common with ticagrelor users. Inpatient hospitalizations, cardiac events, and transfusions were more common in clopidogrel users compared with prasugrel and ticagrelor users. Nonadherent patients experienced significantly more hospitalizations, ER visits, and transfusions (1.34, 1.09, and 1.85 [P < 0.05], respectively) compared with adherent patients. These trends of association remained consistent across all treatment groups. Also, patients not adherent to ticagrelor experienced 1.9 times as many cardiac events as adherent patients. However, this association was not significant for clopidogrel and prasugrel users. Patients not adherent to P2Y12 APT experienced significantly lower outpatient visits compared with adherent patients. CONCLUSIONS Complications associated with P2Y12 in ACS patients treated with P2Y12 APT were common, with dyspnea, heart block, and major or life-threatening bleeding as the most common. Adherence was significantly associated with lower health care utilization. Increased adherence to secondary prevention therapy among these very high-risk patients is crucial. Disease management strategies to improve adherence and reduce treatment-associated adverse events through individualized patient care, alternative secondary treatment options, and physician awareness should be designed, implemented, and sustained. DISCLOSURES Data analysis was conducted by Merck & Co., the manufacturer of vorapaxar (ZONTIVITY). At the time of this study, Vyas was an employee of Rutgers University, which received grant funding from Merck & Co. for this study, and is now employed with the University of Rhode Island. Patel was employed by Symphony Solutions and the University of North Carolina during the drafting and revising of the manuscript. Bash is employed by Merck & Co. Simpson received consulting fees from Merck & Co. for work on this study and has received fees for research from Amgen and Pfizer. Study concept and design were contributed by Vyas, Bash, Patel, and Simpson. Patel took the lead in data collection, assisted by the other authors. All the authors contributed equally to data analysis and manuscript preparation. The abstract for this study was presented as a poster at the American Heart Association Scientific Sessions 2016; November 12-16, 2016; New Orleans, Louisiana.
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Affiliation(s)
- Ami Vyas
- 1 Department of Epidemiology, School of Public Health, Rutgers University, Piscataway, New Jersey
| | | | | | - Ross J Simpson
- 3 Department of Medicine, University of North Carolina, Chapel Hill
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Systematic Review of Hospital Readmissions in Stroke Patients. Stroke Res Treat 2016; 2016:9325368. [PMID: 27668120 PMCID: PMC5030407 DOI: 10.1155/2016/9325368] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 08/08/2016] [Indexed: 12/21/2022] Open
Abstract
Background. Previous evidence on factors and causes of readmissions associated with high-impact users of stroke is scanty. The aim of the study was to investigate common causes and pattern of short- and long-term readmissions stroke patients by conducting a systematic review of studies using hospital administrative data. Common risk factors associated with the change of readmission rate were also examined. Methods. The literature search was conducted from 15 February to 15 March 2016 using various databases, such as Medline, Embase, and Web of Science. Results. There were a total of 24 studies (n = 2,126,617) included in the review. Only 4 studies assessed causes of readmissions in stroke patients with the follow-up duration from 30 days to 5 years. Common causes of readmissions in majority of the studies were recurrent stroke, infections, and cardiac conditions. Common patient-related risk factors associated with increased readmission rate were age and history of coronary heart disease, heart failure, renal disease, respiratory disease, peripheral arterial disease, and diabetes. Among stroke-related factors, length of stay of index stroke admission was associated with increased readmission rate, followed by bowel incontinence, feeding tube, and urinary catheter. Conclusion. Although risk factors and common causes of readmission were identified, none of the previous studies investigated causes and their sequence of readmissions among high-impact stroke users.
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Kubica A, Obońska K, Fabiszak T, Kubica J. Adherence to antiplatelet treatment with P2Y12 receptor inhibitors. Is there anything we can do to improve it? A systematic review of randomized trials. Curr Med Res Opin 2016; 32:1441-51. [PMID: 27112628 DOI: 10.1080/03007995.2016.1182901] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antiplatelet therapy is the cornerstone of treatment for patients with acute coronary syndromes (ACS) and/or undergoing percutaneous coronary interventions. Non-adherence to medication after ACS may lead to increased morbidity, mortality, and costs to the healthcare system due to elevated risk of stent thrombosis, myocardial infarction or death. Medication adherence is an issue of growing concern regarding the improvement of health system performance. Promoting medication adherence offers a rare opportunity to simultaneously improve health outcomes while reducing costs of treatment in patients with coronary artery disease (CAD). The aim of this systematic review was to critically discuss adherence to antiplatelet treatment with P2Y12 receptor inhibitors in CAD patients. After a systematic investigation of the literature in databases including PubMed, CENTRAL and Google Scholar, using appropriate keywords, and considering clinical randomized, prospective observational and retrospective studies, reporting on adherence to treatment with inhibitors of P2Y12 platelet receptors or educational interventions aimed to improve medication adherence in patients with CAD, seven articles were considered eligible for inclusion in this systematic review. Reported adherence to clopidogrel, despite catastrophic consequences of its premature discontinuation, is low. We identified several determinants of low adherence and early discontinuation of clopidogrel. We also present data on the usefulness, utilization and credibility of different methods of medication adherence assessment, and suggest and critically discuss available interventions aimed at improvement of adherence to clopidogrel, still showing the need for innovative approaches to achieve enhanced medication adherence and improve health outcomes after acute myocardial infarction.
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Affiliation(s)
- Aldona Kubica
- a Department of Health Promotion, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Karolina Obońska
- b Department of Cardiology and Internal Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Tomasz Fabiszak
- b Department of Cardiology and Internal Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Jacek Kubica
- b Department of Cardiology and Internal Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
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Al AlShaikh S, Quinn T, Dunn W, Walters M, Dawson J. Predictive factors of non-adherence to secondary preventative medication after stroke or transient ischaemic attack: A systematic review and meta-analyses. Eur Stroke J 2016; 1:65-75. [PMID: 29900404 PMCID: PMC5992740 DOI: 10.1177/2396987316647187] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/06/2016] [Indexed: 11/30/2022] Open
Abstract
Purpose Non-adherence to secondary preventative medications after stroke is
relatively common and associated with poorer outcomes. Non-adherence can be
due to a number of patient, disease, medication or institutional factors.
The aim of this review was to identify factors associated with non-adherence
after stroke. Method We performed a systematic review and meta-analysis of studies reporting
factors associated with medication adherence after stroke. We searched
MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL and Web of Knowledge. We followed
PRISMA guidance. We assessed risk of bias of included studies using a
pre-specified tool based on Cochrane guidance and the Newcastle–Ottawa
scales. Where data allowed, we evaluated summary prevalence of non-adherence
and association of factors commonly reported with medication adherence in
included studies using random-effects model meta-analysis. Findings From 12,237 titles, we included 29 studies in our review. These included
69,137 patients. The majority of included studies (27/29) were considered to
be at high risk of bias mainly due to performance bias. Non-adherence rate
to secondary preventative medication reported by included studies was 30.9%
(95% CI 26.8%–35.3%). Although many factors were reported as related to
adherence in individual studies, on meta-analysis, absent history of atrial
fibrillation (OR 1.02, 95% CI 0.72–1.5), disability (OR 1.27, 95% CI
0.93–1.72), polypharmacy (OR 1.29, 95% CI 0.9–1.9) and age (OR 1.04, 95% CI
0.96–1.14) were not associated with adherence. Discussion This review identified many factors related to adherence to preventative
medications after stroke of which many are modifiable. Commonly reported
factors included concerns about treatment, lack of support with medication
intake, polypharmacy, increased disability and having more severe
stroke. Conclusion Understanding factors associated with medication taking could inform
strategies to improve adherence. Further research should assess whether
interventions to promote adherence also improve outcomes.
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Affiliation(s)
- Sukainah Al AlShaikh
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Terry Quinn
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - William Dunn
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Matthew Walters
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Wawruch M, Zatko D, Wimmer G, Luha J, Kuzelova L, Kukumberg P, Murin J, Hloska A, Tesar T, Kallay Z, Shah R. Factors Influencing Non-Persistence with Antiplatelet Medications in Elderly Patients After Ischaemic Stroke. Drugs Aging 2016; 33:365-73. [DOI: 10.1007/s40266-016-0365-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Ostergaard K, Pottegård A, Hallas J, Bak S, dePont Christensen R, Gaist D. Discontinuation of antiplatelet treatment and risk of recurrent stroke and all-cause death: a cohort study. Neuroepidemiology 2014; 43:57-64. [PMID: 25323533 DOI: 10.1159/000365732] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 07/02/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We wished to examine the impact of antiplatelet drug discontinuation on recurrent stroke and all-cause mortality. METHODS We identified a cohort of incident ischaemic stroke patients in a Danish stroke registry, 2007-2011. Using population-based registries we assessed subjects' drug use and followed them up for stroke recurrence, or all-cause death. Person-time was classified by antiplatelet drug use into current use, recent use (≤150 days after last use), and non-use (>150 days after last use). Lipid-lowering drug (LLD) use was classified by the same rules. We used Cox proportional hazard models to calculate the adjusted hazard ratio (HR) and corresponding 95% confidence intervals (CIs) for the risk of recurrent stroke or death associated with discontinuation of antiplatelet or LLD drugs. RESULTS Among 4,670 stroke patients followed up for up a median of 1.5 years, 237 experienced a second stroke and 600 died. Compared with current antiplatelet drug use, both recent use (1.3 (0.8-2.0)), and non-use (1.3 (0.8-1.9)) were associated with increased recurrent stroke risk. The corresponding HRs of death were 1.9 (1.4-2.5) for recent and 1.8 (1.4-2.3) for non-use of antiplatelet drugs. Recent statin use was associated with markedly increased risk of death (2.1 (1.7-2.6)), and only marginally with recurrent stroke (1.2 (0.9-1.6)). CONCLUSIONS Antiplatelet drug discontinuation may be associated with an increased recurrent stroke risk. Our results on death risk indicate that non-pharmacological biases, such as 'sick stopper', may threaten the validity of this risk estimate.
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Bauler S, Jacquin-Courtois S, Haesebaert J, Luaute J, Coudeyre E, Feutrier C, Allenet B, Decullier E, Rode G, Janoly-Dumenil A. Barriers and facilitators for medication adherence in stroke patients: a qualitative study conducted in French neurological rehabilitation units. Eur Neurol 2014; 72:262-70. [PMID: 25277833 DOI: 10.1159/000362718] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 04/06/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe the perceptions of French patients, caregivers and healthcare professionals on stroke and secondary preventive medications. METHOD A qualitative study was conducted, based on four predetermined topics: stroke, secondary prevention medications, patient's experience, relationship between patient/caregiver and healthcare team. RESULTS Twenty-six interviews were conducted. Difficulties in taking medications, lack of knowledge on stroke and medication benefits, fear of over medication were identified as barriers for adherence in patients. Doubts about generic drugs were expressed by caregivers. Healthcare professionals reported lack of knowledge and absence of clinical symptoms as barriers. On the other hand, support from caregivers and healthcare professional support is essential for compliance in all participants. Patients and caregivers expressed that fear of recurrence was a facilitator for treatment compliance. CONCLUSION This study highlights the barriers and facilitators for stroke treatment adherence and underlines the similarities and differences between the perceptions of patients, caregivers and healthcare professionals. These results must be integrated into the future French educational programs to improve medication adherence.
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Affiliation(s)
- Stephanie Bauler
- Pôle de Rééducation et de Réadaptation Fonctionnelles, Hôpital Henry Gabrielle, Hospices Civils de Lyon, Saint Genis Laval, France
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Østergaard K, Madsen C, Liu ML, Bak S, Hallas J, Gaist D. Long-term use of antiplatelet drugs by patients with transient ischaemic attack. Eur J Clin Pharmacol 2013; 70:241-8. [PMID: 24247641 DOI: 10.1007/s00228-013-1609-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 10/31/2013] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine the degree of long-term non-persistence to antiplatelet drugs in patients with transient ischaemic attack (TIA) and identify determinants of this drug-use pattern. METHODS We used community-based prescription registry data to determine antiplatelet drug use in TIA patients presenting to a Danish neurology department in the period 2006-2010. Non-persistence was defined as failure to present a prescription for antiplatelet drugs within 180 days after the dosage of a previous prescription had run out. We used Cox regression to calculate the hazard ratio (HR) for non-persistence and the corresponding 95 % confidence interval (CI) by potential determinants, including a stroke risk score (ABCD2 score). Adherence during follow-up [80 % medication possession ratio (MPR80)] was calculated for antiplatelets, statins and antihypertensive drugs. RESULTS The cohort comprised 594 (84 % evaluated as in-patients) TIA patients. During follow-up (median 1.7 years, interquartile range 0.9-3.0 years), 140 (23.6 %) patients became non-persistent. Non-persistence was associated with younger age (<55 years: HR 1.9, 95 % CI 1.3-2.8) and delay between TIA onset and neurological evaluation (7+ days: HR 2.0, 95 % CI 1.0-4.1). Among admitted patients, a higher ABCD2 score (4+: HR 1.3, 95 % CI 0.8-2.1) was also indicative of non-persistence. Non-persistent users were less adherent to other preventive medication (MPR80: statins 31.8 vs. 75.3 %, p value < 0.001; antihypertensives 64.3 vs. 79.5 %, p value: 0.02) than persistent users. CONCLUSION Long-term antiplatelet non-persistence was most pronounced in patients of younger age, those with delayed evaluation of symptoms and those at greater risk of stroke. It was also associated with a lower adherence to preventive medication in general.
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Affiliation(s)
- Kamilla Østergaard
- Department of Neurology, Odense University Hospital, Sdr Boulevard 29, 5000, Odense C, Denmark
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Medication persistence of HIV-infected drug users on directly administered antiretroviral therapy. AIDS Behav 2013; 17:113-21. [PMID: 22105340 DOI: 10.1007/s10461-011-0082-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Patient and regimen persistence in HIV-infected drug users are largely unknown. We evaluated patterns of medication non-persistence among HIV-infected drug users enrolled in a prospective, 6-month randomized controlled trial of directly administered antiretroviral therapy (DAART). Medication-taking behavior was assessed via direct observation and MEMS data. Of 74 participants who initiated DAART, 59 (80%) subjects were non-persistent with medication for 3 or more consecutive days. Thirty-one participants (42%) had 2 or more episodes of non-persistence. Higher depressive symptoms were strongly associated with non-persistence episodes of ≥ 3 days (AOR: 17.4, P = 0.02) and ≥ 7 days AOR: 5.4, P = 0.04). High addiction severity (AOR 3.2, P = 0.03) was correlated with non-persistence ≥ 7 days, and injection drug use (AOR: 15.2, P = 0.02) with recurrence of non-persistence ≥ 3 days. Time to regimen change was shorter for NNRTI-based regimens compared to PI-based ones (HR: 3.0, P = 0.03). There was no significant association between patterns of patient non-persistence and virological outcomes.
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Østergaard K, Hallas J, Bak S, Christensen RD, Gaist D. Long-term use of antiplatelet drugs by stroke patients: a follow-up study based on prescription register data. Eur J Clin Pharmacol 2012; 68:1631-7. [PMID: 22576729 DOI: 10.1007/s00228-012-1293-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 04/13/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE Treatment with antiplatelet drugs is a key element of secondary stroke prevention. We investigated long-term antiplatelet drug use in stroke patients with a focus on non-persistence. METHODS Population-based prescription register data were used to determine antiplatelet drug use in a cohort of stroke patients discharged from a Danish neurology department. The antiplatelet drugs comprised acetylsalicylic acid (ASA), clopidogrel and dipyridamole (if combined with ASA use). Non-persistence was defined as failure to present a prescription for antiplatelet drugs within 180 days after the dosage of a previous prescription had run out, or within 180 days after discharge. Cox regression was used to identify risk factors for non-persistence. RESULTS The cohort comprised 503 patients with ischaemic stroke discharged in 1999-2001. During follow-up (median 2.8 years, interquartile range 0.8-7.8 years), 486 of the subjects presented prescriptions for antiplatelets. Most subjects used a dual regimen of ASA and dipyridamole (N = 320). Of 110 non-persistent subjects in this group, 64 stopped using ASA, but continued to use dipyridamole in monotherapy. Overall, 181 patients (36 %) were non-persistent. Stroke severity was inversely associated with the risk of non-persistence [NIHSS score on admission 0-3 (reference); 4-6: hazard risk (HR) 0.87, 95 % confidence interval (CI) 0.61-1.25; 7+: HR 0.47, 95 % CI 0.29-0.74]. CONCLUSIONS Long-term non-persistence with antiplatelet treatment was high and more pronounced in our patients with less severe stroke. Our findings on the use of ASA and dipyridamole indicate that non-persistence may in part be amenable to simple intervention measures.
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Affiliation(s)
- Kamilla Østergaard
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark
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Rezayatmand R, Pavlova M, Groot W. The impact of out-of-pocket payments on prevention and health-related lifestyle: a systematic literature review. Eur J Public Health 2012; 23:74-9. [PMID: 22544911 DOI: 10.1093/eurpub/cks034] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Out-of-pocket payments can have a large impact on the demand for healthcare. They can be essential not only to decrease unnecessary service use, but also to encourage the use of particular preventive services provided free of charge or at a lower price. Moreover, out-of-pocket payments may increase the costs of unhealthy behaviour and provide incentives for a healthier lifestyle. METHOD This study systematically reviews empirical evidence on the effects of out-of-pocket payments on the use of preventive services and health-related lifestyle. All possible combinations of three key words 'prevention', 'patient payment' and 'health-related behaviour' were searched in PUBMED, ECONLITH, ECONPAPER and EMBASE. In total, 47 relevant publications were identified. RESULTS The results suggest that out-of-pocket payments can create a financial barrier and can decrease the use of preventive services and the uptake of preventive medications. A few studies (with contradicting empirical evidence) address the impact of cost sharing and reduced insurance coverage on a healthier lifestyle. CONCLUSION Although the great diversity of study designs (various indicators of out-of-pocket payments and preventive/health-related behaviour) makes it difficult to offer robust policy recommendations, our findings support calls to reconsider how preventive services should be financed. More research is needed to explore the actual impact of cost sharing on different aspects of health-related lifestyles, as well as to explain the role of other relevant determinants that could impact this relationship.
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Affiliation(s)
- Reza Rezayatmand
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands.
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Francis SH, Blount MA, Corbin JD. Mammalian Cyclic Nucleotide Phosphodiesterases: Molecular Mechanisms and Physiological Functions. Physiol Rev 2011; 91:651-90. [DOI: 10.1152/physrev.00030.2010] [Citation(s) in RCA: 451] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The superfamily of cyclic nucleotide (cN) phosphodiesterases (PDEs) is comprised of 11 families of enzymes. PDEs break down cAMP and/or cGMP and are major determinants of cellular cN levels and, consequently, the actions of cN-signaling pathways. PDEs exhibit a range of catalytic efficiencies for breakdown of cAMP and/or cGMP and are regulated by myriad processes including phosphorylation, cN binding to allosteric GAF domains, changes in expression levels, interaction with regulatory or anchoring proteins, and reversible translocation among subcellular compartments. Selective PDE inhibitors are currently in clinical use for treatment of erectile dysfunction, pulmonary hypertension, intermittent claudication, and chronic pulmonary obstructive disease; many new inhibitors are being developed for treatment of these and other maladies. Recently reported x-ray crystallographic structures have defined features that provide for specificity for cAMP or cGMP in PDE catalytic sites or their GAF domains, as well as mechanisms involved in catalysis, oligomerization, autoinhibition, and interactions with inhibitors. In addition, major advances have been made in understanding the physiological impact and the biochemical basis for selective localization and/or recruitment of specific PDE isoenzymes to particular subcellular compartments. The many recent advances in understanding PDE structures, functions, and physiological actions are discussed in this review.
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Affiliation(s)
- Sharron H. Francis
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee; and Department of Medicine-Renal Division, Emory University School of Medicine, Atlanta, Georgia
| | - Mitsi A. Blount
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee; and Department of Medicine-Renal Division, Emory University School of Medicine, Atlanta, Georgia
| | - Jackie D. Corbin
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee; and Department of Medicine-Renal Division, Emory University School of Medicine, Atlanta, Georgia
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