Multinational development of a questionnaire assessing patient satisfaction with anticoagulant treatment: the 'Perception of Anticoagulant Treatment Questionnaire' (PACT-Q)

Deferring diagnostic evaluation of suspected deep vein thrombosis using direct oral anticoagulant or low-molecular-weight heparin as a single dose anticoagulant: A prospective real-world study in a regionwide care pathway

BACKGROUND

Patients with suspected deep vein thrombosis (DVT) are typically referred to the emergency department for immediate evaluation. To enhance efficiency, our hospital implemented a regional, general practitioner (GP)-driven DVT care pathway, deferring diagnostic evaluation to a scheduled outpatient DVT clinic appointment the following day. Patients receive a single dose anticoagulant from their GP to prevent thrombosis progression while awaiting diagnostic workup. This prospective study aimed to evaluate the safety and patient preferences regarding the DVT care pathway and the type of single dose anticoagulant (low-molecular-weight heparin (LMWH) vs. direct oral anticoagulant (DOAC)).

METHODS

Patients enrolled in the DVT care pathway between June 2021 and July 2023 were eligible. Until July 2022, LMWH was administered, and thereafter, the protocol recommended DOAC as the single dose anticoagulant. Patients completed questionnaires, incorporating patient-reported outcome and experience measures (PROMs/PREMs), during their DVT clinic visit and after five days. The primary endpoint was bleeding events within 72 h of receiving the single dose anticoagulant.

RESULTS

Of 460 included patients, 229 received LMWH and 231 received DOAC as the single dose anticoagulant. DVT was confirmed in 24.8 % of patients. No major or clinically relevant non-major bleeding were reported. LMWH was associated with more minor bleedings (22.3 % vs. DOAC 13.4 %), primarily attributed to injection site hematomas. Patients reported high satisfaction with the DVT care pathway (96.5 %) and generally preferred DOAC over LMWH.

CONCLUSION

Deferring diagnostic evaluation for DVT using a single dose of either LMWH or DOAC in a real-world population is deemed safe. Considering practical advantages, patient preferences, and fewer skin hematomas, we favor DOACs as the single dose anticoagulant in this care pathway.

Treatment Satisfaction and Convenience for Patients With Atrial Fibrillation on Edoxaban or Vitamin K Antagonists After Transcatheter Aortic Valve Replacement: A Post Hoc Analysis from the ENVISAGE-TAVI AF Trial

ENVISAGE-TAVI AF (Edoxaban versus Standard of Care and Their Effects on Clinical Outcomes in Patients Having Undergone Transcatheter Aortic Valve Implantation-Atrial Fibrillation; NCT02943785) was a prospective, randomized, open-label trial comparing non-vitamin K oral anticoagulant (NOAC) edoxaban with vitamin K antagonists (VKAs) in patients with atrial fibrillation after successful transcatheter aortic valve replacement (TAVR). The effect of edoxaban- or VKA-based therapy on patient-reported outcomes remains unknown, as most studies focus on efficacy and safety. Pre-TAVR patient-reported expectations and post-TAVR Treatment Satisfaction and Convenience with edoxaban or VKA treatment (at months 3 and 12) were analyzed using the Perception of Anticoagulation Treatment Questionnaire (PACT-Q). This analysis included randomized and dosed patients with an evaluable PACT-Q1 assessment at baseline and ≥1 postbaseline assessment (PACT-Q2). Subanalyses included patients stratified by pre-TAVR anticoagulant (NOAC, VKA, no NOAC/VKA). Edoxaban- (n = 585) and VKA-treated (n = 522) patients had similar baseline characteristics and treatment expectations. Pre-TAVR anticoagulant use did not affect treatment expectations. After TAVR, edoxaban-treated patients had significantly higher Treatment Satisfaction and Convenience scores compared with VKA-treated patients at all time points (p <0.001 for all). Among edoxaban-treated patients, those who received VKAs pre-TAVR were significantly more satisfied with treatment than those who received NOACs (p <0.001) or no NOACs/VKAs (p = 0.003); however, there was no significant difference in the perception of convenience (p = 0.927 and p = 0.092, respectively). Conversely, among VKA-treated patients, the type of anticoagulant used pre-TAVR did not affect Treatment Satisfaction or Convenience scores post-TAVR. In conclusion, patients with atrial fibrillation who received edoxaban post-TAVR reported significantly higher Treatment Satisfaction and Convenience scores compared with those who received VKAs, resulting in a clinically meaningful difference between treatment groups.

Can we collect health-related quality of life information from anticoagulated atrial fibrillation participants who have recently experienced a bleed? An observational feasibility study in primary and secondary care in Wales and through a UK online forum

OBJECTIVE

To evaluate the feasibility of recruiting participants diagnosed with atrial fibrillation (AF) taking oral anticoagulation therapies (OATs) and recently experiencing a bleed to collect health-related quality of life (HRQoL) information.

DESIGN

Observational feasibility study. The study aimed to determine the feasibility of recruiting participants with minor and major bleeds, the most appropriate route for recruitment and the appropriateness of the patient-reported outcome measures (PROMs) selected for collecting HRQoL information in AF patients, and the preferred format of the surveys.

SETTING

Primary care, secondary care and via an online patient forum.

PARTICIPANTS

The study population was adult patients (≥18) with AF taking OATs who had experienced a recent major or minor bleed within the last 4 weeks.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes - PROMs: EuroQol 5 Dimensions-5 Levels, Perception of Anticoagulant Treatment Questionnaire, part 2 only (part 2), atrial fibrillation effect on quality of life. Secondary outcomes - Location of bleed, bleed severity, current treatment, patient perceptions of HRQoL in relation to bleeding events.

RESULTS

We received initial expressions of interest from 103 participants. We subsequently recruited 32 participants to the study-14 from primary care and 18 through the AF forum. No participants were recruited through secondary care. Despite 32 participants consenting, only 26 initial surveys were completed. We received follow-up surveys from 11 participants (8 primary care and 3 AF forum). COVID-19 had a major impact on the study.

CONCLUSIONS

Primary care was the most successful route for recruitment. Most participants recruited to the study experienced a minor bleed. Further ways to recruit in secondary care should be explored, especially to capture more serious bleeds.

TRIAL REGISTRATION NUMBER

The study is registered in the Clinicaltrials.gov database, NCT04921176.

Oral anticoagulant switching in patients with atrial fibrillation: a scoping review

INTRODUCTION

Oral anticoagulants (OACs) prevent stroke in patients with atrial fibrillation (AF). Several factors may cause OAC switching.

OBJECTIVES

To examine the phenomenon of OAC switching in patients with AF, including all available evidence; frequency and patterns of switch, clinical outcomes, adherence, patient-reported outcomes, reasons for switch, factors associated with switch and evidence gaps.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, Embase and Web of Science, up to January 2022.

RESULTS

Of the 116 included studies, 2/3 examined vitamin K antagonist (VKA) to direct-acting OAC (DOAC) switching. Overall, OAC switching was common and the definition of an OAC switch varied across. Switching from VKA to dabigatran was the most prevalent switch type, but VKA to apixaban has increased in recent years. Patients on DOAC switched more to warfarin than to other DOACs. OAC doses involved in the switches were hardly reported and patients were often censored after the first switch. Switching back to a previously taken OAC (frequently warfarin) occurred in 5%-21% of switchers.The risk of ischaemic stroke and gastrointestinal bleeding in VKA to DOAC switchers compared with non-switchers was conflicting, while there was no difference in the risk of other types of bleeding. The risk of ischaemic stroke in switchers from DOAC versus non-switchers was conflicting. Studies evaluating adherence found no significant changes in adherence after switching from VKA to DOAC, however, an increase in satisfaction with therapy were reported. Reasons for OAC switch, and factors associated with OAC switch were mostly risk factors for stroke and bleeding. Clinical outcomes, adherence and patient-reported outcomes were sparse for switches from DOACs.

CONCLUSIONS

OAC switching is common in patients with AF and patients often switch back to an OAC they have previously been on. There are aspects of OAC switching that have received little study, especially in switches from DOACs.

Investigating the feasibility of recruitment to an observational, quality-of-life study of patients diagnosed with atrial fibrillation (AF) who have experienced a bleed while anticoagulated: EQUAL-AF feasibility study protocol

Background

Oral anticoagulation therapies (OATs) are often prescribed in conjunction with medications to restore normal heart rate rhythm which can limit the risk of an atrial fibrillation (AF) related stroke and systemic thromboembolism. However, they are associated with the serious side effect of bleeding. Both clinically relevant nonmajor bleeding (CRNMB) and major bleeding while anticoagulated are believed to have a significant impact on patient quality of life (QoL). There is currently limited research into the effect bleeding has on QoL. The aim of this study is to evaluate the feasibility of identifying and recruiting patients diagnosed with AF, who are taking OATs and have recently experienced a bleed and collecting information on their QoL.

Methods

We will recruit a minimum of 50 patients to this cross-sectional, observational study. We will recruit from general practices, secondary care, and through an online AF forum. We will ask participants to complete three validated patient-reported outcome measures (PROMs), EQ5D, AFEQT, and PACT-Q, approximately 4 weeks following a bleed and again 3 months later. We will randomly select a subset of 10 participants (of those who agree to be interviewed) to undergo a structured interview with a member of the research team to explore the impact of bleeding on their QoL and to gain feedback on the three PROMs used. We will undertake a descriptive analysis of the PROMs and demographic data. We will analyse the qualitative interviews thematically to identify key themes.

Discussion

We aim to establish if it is possible to recruit patients and use PROMs to collect information regarding how patient QoL is affected when they experience either a clinically relevant non-major bleed (CRNMB) or major bleed while taking OATs for the management of AF. We will also explore the appropriateness, or otherwise, of the three identified PROMs for assessing quality of life following a bleed.

PROMs

Three PROMs were selected following a literature review of similar QoL studies and using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist for comparison. A review of the current literature produced no suitable validated PROM to record QoL experiences in patients who have been diagnosed with AF and have experienced a bleed while anticoagulated. As such, the EQ5D, AFEQT, and PACT-Q (part 2) were deemed most appropriate for use in this feasibility study.

Trial registration

The trial has been adopted onto the NIHR Portfolio (ID no. 47771) and registered with www.ClinicalTrials.gov (no. NCT04921176) retrospectively registered in June 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01135-8.

The Influence of Frailty Syndrome and Dementia on the Convenience and Satisfaction with Oral Anticoagulation Treatment in Elderly Patients with Atrial Fibrillation

Background: The impact of frailty syndrome (FS) and dementia on the convenience and satisfaction with oral anticoagulation (OAC) treatment in atrial fibrillation (AF) patients is not well-known. Aim: Assessment the impact of FS and dementia on the convenience and satisfaction with OAC treatment in 116 elderly (mean age 75.2, SD = 8.2) patients with AF. Methodology: A self-administered questionnaire was used in the study to collect basic socio-demographic and clinical data. Tilburg Frailty Indicator (TFI) questionnaire was used to assess the presence of FS, Mini Mental State Examination (MMSE) to assess cognitive impairment (CI), The Perception of Anticoagulant Treatment Questionnaire Part 2 (PACT-Q2) to assess convenience and satisfaction with OAC treatment, and the Arrhythmia-Specific Questionnaire in Tachycardia and Arrhythmia (ASTA) to assess quality of life (QoL). Results: Multivariable analysis as a significant, negative predictor of the convenience and satisfaction domain showed the occurrence of dementia (β = −0.34; p < 0.001, β = −0.41; p < 0.001, respectively) and prior major bleeding (β = −0.30; p < 0.001, β = −0.33; p < 0.001, respectively). Analysis showed a significant relationship between convenience and satisfaction and the overall result of the ASTA (r = −0.329; p < 0.001, r = −0.372; p < 0.001, respectively). Conclusions: Elements of geriatric syndrome, such as FS and dementia, adversely affect treatment convenience and satisfaction with OAC treatment in AF. It has been shown that better convenience and satisfaction with OAC treatment translates into better QoL. There were no differences between satisfaction and convenience and the type of OAC treatment (vitamin K antagonists (VKA) vs. novel oral anticoagulants (NOAC).

The relationship between self-efficacy and treatment satisfaction among patients with anticoagulant therapy: a cross-sectional study from a developing country

BACKGROUND

Thromboembolic events are a common complicated health problem. Although anticoagulants have several positive effects on these conditions, they also have several characteristics that strongly affect compliance and satisfaction. The purpose of this investigation is to explore the association between treatment satisfaction and self-efficacy in a sample of patients using anticoagulation therapy and determine the influence of sociodemographic and clinical factors on both aspects.

METHODS

This was a cross-sectional exploratory study carried out in Palestine. The Arabic version of the Anti-Coagulant Treatment Satisfaction Scale (ACTS) assessed treatment satisfaction. In addition, the Arabic version of the 6-Item Self-Efficacy for Managing Chronic Diseases (SES6C) was used to assess self-efficacy.

RESULTS

A total of 300 patients using anticoagulants (average age 51.95 and SD 17.98) were included. There is a modest correlation between treatment satisfaction and self-efficacy (r = 0.345; p <  0.001). The mean and median self-efficacy scores were 38.41 ± 9.88 and 39.00 (interquartile range: 33.00-46.00), respectively. Overall, patients reported a moderate burden and benefit score. The mean and median of the acting burden were 43.30 ± 10.45, and 43.30 (interquartile range: 36.00 to 51.00), respectively. The results showed that young age, higher education, employment, use of fewer medications, and having fewer diseases were significantly associated with higher self-efficacy behaviors. The results also showed that new oral anti-coagulants (NOACs) had a higher degree of self-efficacy and ACTS benefit scores (41.00 (33.75-47.00), p = 0.002; 13.00 (12.00-15.00), p <  0.001, respectively), than vitamin k antagonists (VKA).

CONCLUSIONS

The results demonstrated a significant relationship between treatment satisfaction and self-efficacy, and certain sociodemographic and clinical characteristics influence both. We found that there is a higher degree of self-efficacy and treatment satisfaction among patients who use NOACs than those who use UFH / VKA. Therefore, patients should be motivated to increase their knowledge about anticoagulant therapy. Healthcare providers should play an active role in educating patients, increasing their self-esteem, and awareness about anticoagulant drugs. Importantly, this study was an explanatory one, and it includes a low proportion of patients with venous thromboembolism. This encourages future research on a large scale of patients, considering the indications of anticoagulant therapy.

Patient perception and treatment convenience of dabigatran versus vitamin K antagonist when used for stroke prophylaxis in atrial fibrillation: Real-world Evaluation of Long-term Anticoagulant Treatment Experience (RE-LATE) study

Purpose

Dabigatran is a direct thrombin inhibitor approved for stroke prophylaxis in patients with non-valvular atrial fibrillation (NVAF). Real-world data about patient preference, satisfaction and convenience in patients in Asia are not available. The study aimed to explore the perception of patients with newly diagnosed NVAF regarding dabigatran versus vitamin K antagonists (VKAs), when used for stroke prevention.

Patients and methods

This was a multinational, multicentre, non-interventional study involving 49 sites across 5 countries in South East Asia and South Korea where 934 patients newly diagnosed with NVAF were initiated on either dabigatran (N=591) or VKA (N=343). Data were collected at baseline and over two follow-up visits across 6 months. Treatment satisfaction and patient convenience were evaluated using the Perception on Anticoagulant Treatment Questionnaire-2 (PACT-Q2).

Results

The mean age of the patients was 65.9±10.4 years, and 64.2% were male. Mean CHA₂DS₂-VASc score was 2.4±1.5, and mean HAS-BLED score was 1.2±0.9. At baseline, patients initiated on dabigatran had higher stroke risk, bleeding risk, creatinine clearance and proportion of patients with concomitant illnesses compared with patients initiated on VKAs. Treatment convenience was perceived to be significantly better with dabigatran versus VKAs at visits 2 and 3 (p=0.0423 and 0.0287, respectively). Treatment satisfaction was significantly better with dabigatran compared with VKAs at visit 3 (p=0.0300).

Conclusion

In this study, dabigatran is associated with better patient perception in terms of treatment convenience and satisfaction compared with VKAs when used for stroke prevention in newly diagnosed NVAF patients from South East Asia and South Korea.

Trial registration number

NCT02849509.

Plain language summary

Patient satisfaction with dabigatran versus VKAs in South East Asia. Patients with atrial fibrillation are at high risk of stroke and require anticoagulants for stroke prevention. Two such anticoagulants are dabigatran and VKAs. We wanted to compare the extent of satisfaction and treatment convenience among newly diagnosed patients with atrial fibrillation from the South East Asian region when they were given either dabigatran or VKAs. Consenting patients filled out a standardised questionnaire called the PACT-Q2 over three visits after they were started on either dabigatran (591 patients) or VKAs (343 patients). We found that satisfaction and convenience were significantly higher when patients received dabigatran than when they received VKAs.

Patient perceptions of anticoagulant treatment with dabigatran or a vitamin K antagonist for stroke prevention in atrial fibrillation according to region and age: an exploratory analysis from the RE-SONANCE study

Background

The oral anticoagulant dabigatran offers an effective alternative to vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF), yet patient preference data are limited. The prospective observational RE-SONANCE study demonstrated that patients with AF, newly initiated on dabigatran, or switching to dabigatran from long-term VKA therapy, reported improved treatment convenience and satisfaction compared with VKA therapy. This pre-specified sub-study aimed to assess the impact of country and age on patients’ perceptions of dabigatran or VKA therapy in AF.

Methods

RE-SONANCE was an observational, prospective, multi-national study (NCT02684981) that assessed treatment satisfaction and convenience in patients switching from VKAs to dabigatran (Cohort A), or newly diagnosed with AF receiving dabigatran or VKAs (Cohort B), using the PACT-Q questionnaire. Pre-specified exploratory outcomes: variation in PACT-Q2 scores by country and age (< 65, 65 to < 75, ≥ 75 years) (both cohorts); variation in PACT-Q1 responses at baseline by country and age (Cohort B).

Results

Patients from 12 countries (Europe/Israel) were enrolled in Cohort A (n = 4103) or B (n = 5369). In Cohort A, mean (standard deviation) PACT-Q2 score increase was highest in Romania (convenience: 29.6 [23.6]) and Hungary (satisfaction: 26.0 [21.4]) (p < 0.001). In Cohort B, mean (standard error) increase in PACT-Q2 scores between dabigatran and VKAs was highest in Romania (visit 3: 29.0 [1.3]; 24.5 [0.9], p < 0.001). Mean PACT-Q2 score increase by age (all p < 0.001) was similar across ages. PACT-Q1 responses revealed lowest expectations of treatment success in Romania and greatest concerns about payment in Estonia, Latvia, and Romania, but were similar across ages.

Conclusions

Treatment satisfaction and convenience tended to favor dabigatran over VKAs. Regional differences in treatment expectations exist across Europe.

Trial and clinical registry

Trial registration number: ClinicalTrials.gov NCT02684981.

Trial registration date: February 18, 2016.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11239-021-02450-2.

Real-world evaluation of perception, convenience and anticoagulant treatment satisfaction of patients with atrial fibrillation switched from long-term vitamin K antagonist treatment to dabigatran

Background and purpose

Real-world data about treatment convenience and satisfaction in Asian non-valvular atrial fibrillation (NVAF) patients after switching from vitamin K antagonists (VKAs) to non-VKA oral anticoagulants were evaluated.

Methods

In this non-interventional study involving 49 sites across five countries in Southeast Asia and South Korea, 379 stable NVAF patients who switched from VKA therapy to dabigatran during routine clinical practice were recruited and followed up for 6 months. Treatment convenience and satisfaction were evaluated using Perception on Anticoagulant Treatment Questionnaire-2 (PACT-Q2). Through post hoc analysis, factors associated with improved treatment convenience scores at visit 2 were described.

Results

Treatment convenience and satisfaction significantly improved after switching from VKAs to dabigatran at visit 2 and visit 3 (convenience: p<0.001 each vs baseline; satisfaction: p=0.0174 (visit 2), p=0.0004 (visit 3) compared with baseline). Factors predictive of higher (>80th percentile) response on treatment convenience were female sex, younger age (<75 years), higher baseline stroke risk, higher creatinine clearance and absence of concomitant hypertension, stroke or gastrointestinal diseases.

Conclusion

Dabigatran was associated with a significant improvement in treatment convenience and satisfaction after switching from VKAs when used for stroke prevention in NVAF patients from Southeast Asia and South Korea.

Satisfaction of Patients with Nonvitamin K Anticoagulants Compared to Vitamin K Antagonists: a Systematic Review and Meta-analysis

OBJECTIVE

 To undertake a systematic review and meta-analysis to assess the satisfaction of patients receiving nonvitamin K anticoagulants (NOACs), compared with vitamin K antagonists (VKAs).

METHODS

 We searched CENTRAL, MEDLINE, Embase, and Clinicaltrials.gov for randomized controlled trials (RCTs) and observational studies. Two reviewers screened, extracted, and appraised data independently. We pooled data using a random-effects model. Outcome included treatment satisfaction, which was assessed by scores of Duke Anticoagulation Satisfaction Scale (DASS), Anticlot Treatment Scale (ACTS), Perception of Anticoagulant Treatment Questionnaire 2 (PACT-Q2), or Treatment Satisfaction Questionnaire for Medication version II (TSQM-VII) and their domains reported with 95% confidence intervals (95% CIs). We followed MOOSE and PRISMA guidelines.

RESULTS

 We included four RCTs and 16 observational studies, enrolling 18,684 participants overall. Compared with VKAs, treatment with NOACs improved the ACTS Burdens score by 4.21 points (95% CI: 2.99-5.43, I ² = 95%, combined n = 6,180), and ACTS Benefits by 0.49 points (95% CI: 0.18-0.81, I ² = 85%, combined n = 6,171). Switching from VKAs to NOACs improved the ACTS Burdens score by 5.33 points (95% CI: 3.53-7.14, combined n = 3,097). Compared with VKAs, treatment with NOACs improved the TSQM-VII Global Satisfaction score by 6.86 points (95% CI: 3.00-10.73, combined n = 5,535).

CONCLUSION

 In patients with nonvalvular atrial fibrillation or venous thromboembolism, NOAC treatment is associated with greater satisfaction compared with VKAs. The switch from VKAs to NOACs was associated with improved patients' satisfaction. These effects were largely due to a lower degree of treatment burden with NOAC treatment.

Patients' satisfaction associated with portable coagulometers for warfarin monitoring: a cross-sectional study

BACKGROUND

The use of point-of-care (POC) coagulometers for monitoring patients on vitamin K antagonist (VKA) treatment makes international normalised ratio (INR) results immediately available. The aim of this study was to compare patients' satisfaction with VKA treatment in two settings characterised by distinct ways of monitoring: POC INR versus laboratory INR.

MATERIALS AND METHODS

We recruited adult patients on long-term warfarin treatment (July 2017-February 2018) from the Anticoagulation Clinics at five district health centres (namely Cospicua, Floriana, Mosta, Qormi, Rabat-POC INR) and at Mater Dei Hospital (Msida - Laboratory INR) in Malta. We administered two psychometric questionnaires: the Duke Anticoagulation Satisfaction Scale (DASS) (range 25-175, lower scores corresponding to higher satisfaction) and the Perception of Anticoagulation Treatment Questionnaire (PACT-Q2) (range 0-100, higher scores corresponding to higher satisfaction).

RESULTS

We analysed 313 questionnaires (POC INR n=159, laboratory INR n=154). In the POC INR cohort, median age was 72 years and 59.1% were males; in the laboratory INR cohort, median age was 70.5 years and 46.1% were males. The POC INR cohort obtained significantly lower overall DASS score (p<0.001) and significantly higher PACT-Q2 scores (p<0.001 for the subscale "convenience"; p=0.039 for the subscale "anticoagulant treatment satisfaction") than the laboratory INR cohort. In multiple regression analysis, the use of POC coagulometers was significantly associated with the overall DASS score (p=0.013) and the PACT-Q2 convenience score (p=0.012).

DISCUSSION

Patients on warfarin treatment were generally satisfied. Patients monitored with the POC INR with a dedicated time slot reported less inconvenience and burdens and better psychological impact than patients monitored with the traditional laboratory INR.

Patients' perceptions with dabigatran in patients with atrial fibrillation previously treated with vitamin K antagonists

Aim: To analyze the perception of anticoagulation with dabigatran in patients with nonvalvular atrial fibrillation previously treated with vitamin K antagonists over a 6-month period. Materials & methods: This is a prospective, noninterventional, noncontrolled, multicenter study. To assess patients' perceptions, PACT-Q2 questionnaire was completed. Results: Six hundred and fifty nine patients (73.1 ± 9.4 years, CHA₂DS₂-VASc 3.6 ± 1.6) were included. At baseline, the convenience and satisfaction scores were 60.9 ± 24.9 and 49.9 ± 17.7, respectively. The scores significantly increased along the study. Convenience score was higher in males and in patients with low-moderate thromboembolic risk. Satisfaction score was higher in females. Only 8.0% of patients discontinued dabigatran (3.7% due to side effects). Conclusion: Convenience and satisfaction scores for nonvalvular atrial fibrillation patients treated with dabigatran at 6 months were significantly better than with previous vitamin K antagonists.

Patient perception of anticoagulant treatment for stroke prevention (RE-SONANCE study)

Objective

We evaluated atrial fibrillation (AF) patients' perceptions of anticoagulation treatment with dabigatran or a vitamin K antagonist (VKA) for stroke prevention, according to accepted indications.

Methods

The RE-SONANCE observational, prospective, multicentre, international study used the validated Perception on Anticoagulant Treatment Questionnaire (PACT-Q) to assess patients with AF already taking a VKA who were switched to dabigatran (cohort A), and newly diagnosed patients initiated on either dabigatran or a VKA (cohort B). Visit 1 (V1) was at baseline, and visit 2 (V2) and visit 3 (V3) were at 30-45 and 150-210 days after baseline, respectively. Primary outcomes were treatment satisfaction and convenience in cohort A at V2 and V3 versus baseline, and in cohort B for dabigatran and a VKA at V2 and V3.

Results

The main analysis set comprised 4100 patients in cohort A and 5365 in cohort B (dabigatran: 3179; VKA: 2186). In cohort A, PACT-Q2 improved significantly (p<0.001 for all) for treatment convenience (mean change V1 vs V2=20.72; SD=21.50; V1 vs V3=24.54; SD=22.85) and treatment satisfaction (mean change V1 vs V2=17.60; SD=18.76; V1 vs V3=21.04; SD=20.24). In cohort B, mean PACT-Q2 scores at V2 and V3 were significantly higher (p<0.001 for all) for dabigatran versus a VKA for treatment convenience (V2=18.38; SE =0.51; V3=23.34; SE=0.51) and satisfaction (V2=15.88; SE=0.39; V3=19.01; SE=0.41).

Conclusions

Switching to dabigatran from long-term VKA therapy or newly initiated dabigatran is associated with improved patient treatment convenience and satisfaction compared with VKA therapy.

Veterans Perceptions of Satisfaction and Convenience with Anticoagulants for Atrial Fibrillation: Warfarin versus Direct Oral Anticoagulants

BACKGROUND

Atrial fibrillation (AFib) is associated with high morbidity and mortality. Traditionally, AFib was treated with warfarin, yet recent evidence suggests patients may favor direct oral anticoagulants (DOACs). Variation in preferences is common and we explored patients' perceptions of satisfaction and convenience of DOACs versus warfarin within the Veterans Health Administration (VA).

PATIENTS AND METHODS

We administered a cross-sectional survey, the Perception of Anticoagulant Treatment Questionnaire 2 (PACT-Q2), to Veterans residing in New England, age ≥65, diagnosed with AFib, and actively taking anticoagulant medication in fiscal year 2018. Survey recipients were randomly selected among patients on warfarin (n=200) or DOACs (n=200). A selection of survey respondents agreed to a follow-up semi-structured interview (n=16) to further investigate perceptions of satisfaction and convenience.

RESULTS

Of 400 patients, 187 completed the PACT-Q2 survey (49% on DOACs; 51% on warfarin). DOACs received significantly higher convenience ratings than warfarin (87.6, SD 13.5 vs 81.1, SD 18.8; p=0.007); there was no difference in satisfaction (64.2, SD 20.5 SD, warfarin vs, 67.3, SD 19.4, DOACs). Interview results showed that participants perceived their treatment to be convenient. However, participants expressed challenges related to the convenience of taking warfarin or DOACs, such as warfarin users having to follow dietary recommendations or DOAC users desiring some additional monitoring to answer questions or concerns. Overall, warfarin and DOAC users reported satisfaction with ongoing monitoring methods, although a few DOAC users expressed uncertainties with the frequency of monitoring. For most participants, concerns about side effects did not differ by anticoagulant type nor affect satisfaction.

CONCLUSION

Our survey and interview results showed variable patient satisfaction and perceptions of convenience with both DOACs and warfarin. Although DOACs are increasingly prescribed for AFib, some Veterans felt that regular follow-up on warfarin was advantageous. Our findings demonstrate the importance of patient-centered decision-making in AFib treatment in the VA patient population.

Validation and psychometric properties of the Maltese version of the Duke Anticoagulation Satisfaction Scale (DASS)

Purpose

Assessing treatment satisfaction can guide specific interventions to improve anticoagulation adherence and reduce adverse outcomes. We aimed to assess the psychometric properties (reliability and validity) of the Maltese translation of the Duke Anticoagulation Satisfaction Scale (DASS).

Patients and methods

The DASS explores three dimensions (limitations, hassles/burdens, psychological impact). The translation process included forward and backward translations. Reliability was evaluated through internal consistency and reproducibility. Validity was evaluated through floor/ceiling effect, convergent/discriminant validity, construct validity, and known-group validity.

Results

The Maltese version of the DASS, administered to 174 patients on warfarin for different clinical indications, showed good reliability (Cronbach’s alpha 0.87; intraclass correlation coefficient for test–retest 0.73). Floor effect was identified mainly in the limitations and hassles/burdens subscales. Significant positive correlations were found between the DASS total score and its subscales (limitations 0.80, hassles/burdens 0.85, psychological impact 0.68). Female sex, shorter warfarin treatment duration (≤5 years), previous hospitalization and history of bleeding were associated with lower satisfaction.

Conclusion

Psychometric properties of the Maltese DASS were comparable to the original English version. The Maltese version of the DASS is a valid and reliable instrument that can be used by health care professionals to assess the level of satisfaction of Maltese-speaking anticoagulated patients.

A systematic review of patient-reported outcomes associated with the use of direct-acting oral anticoagulants

AIMS

Patient-reported outcomes (PROs) are a distinctive method of evaluating patient response to health care or treatment. This systematic review aimed to analyse the impact of PROs in patients on direct oral anticoagulant (DOAC) treatment, prescribed for any indication (e.g. venous thromboembolism treatment or atrial fibrillation) using controlled trials (CT) and real-world observational studies (OS).

METHODS

A systematic search of articles was conducted according to PRISMA guidelines using databases, with the last update in November 2018. The Cochrane Collaboration tool for assessing bias in randomized CTs and the Newcastle-Ottawa Scale adapted for cross-sectional studies were used. Outcomes evaluated were related to health-related quality of life (HRQoL), satisfaction, adherence and compliance.

RESULTS

Twenty-one original studies (6 CT, 15 OS) were included. HRQoL was assessed by 6 (1 CT, 5 OS) studies and reported that HRQoL scores were similar in patients on DOACs and warfarin. Patients prescribed DOACs presented higher HRQoL scores which were attributed to lack of intense monitoring required compared with warfarin but this was not statistically significant. The majority of studies (5 CT, 9 OS) investigated patient-reported satisfaction, indicating greater satisfaction with DOACs with significantly lower burden and increased benefit scores for patients on DOACs. Patient-reported expectations, compliance and adherence were similar for patients on DOACs and warfarin.

CONCLUSION

Patients appear to prefer treatment with DOACs vs warfarin. This is shown by the higher quality of life, satisfaction and adherence described in the studies. However, heterogeneity in the analysed studies does not allow firm conclusions.

Reliability and validity of the Maltese version of the Perception of Anticoagulant Treatment Questionnaire (PACT-Q)

Purpose: Anticoagulant therapy has an impact on the health-related quality of life, as it is a chronic treatment for most clinical indications and also requires some lifestyle changes. Since there was no validated questionnaire available in the Maltese language, the aim of our study was to translate and validate the Perception of Anticoagulant Treatment Questionnaire (PACT-Q2). Patients and methods: The PACT-Q2 explores two dimensions (convenience and anticoagulant treatment satisfaction). Forward and backward translations were performed. The Maltese version of the PACT-Q2 was administered to 174 patients on warfarin treatment enrolled from different anticoagulation clinics in Malta. Reliability was assessed through internal consistency (Cronbach's alpha) and test-retest (intraclass correlation coefficient [ICC]). Validity was assessed through floor/ceiling effect, factor analysis (root mean square error of approximation [RMSEA], standardized root mean squared residual [SRMR], goodness-of-fit index [GFI], adjusted goodness-of-fit index [AGFI], comparative fit index [CFI]), subscales correlation and known-group validity. Results: Reliability was very good for the convenience subscale (Cronbach's alpha 0.86, ICC 0.87), but less good for the satisfaction subscale (Cronbach's alpha 0.62, ICC 0.40). Floor effect was 0%; ceiling effect was low (6.3% convenience, 1.2% satisfaction). Fit parameters were close to acceptable cut-offs (RMSEA =0.09, SRMR =0.10, GFI =0.82, AGFI =0.78, CFI =0.79). There was no correlation between the two subscales (r=0.01, p=0.83). Patients with history of bleeding showed lower convenience (r=-0.16, p=0.08) and lower satisfaction (r=-0.21, p=0.01). Conclusions: Our results support the finding that the Maltese translation of the PACT-Q2 is a valid and reliable instrument.

Comparing quality of life and treatment satisfaction between patients on warfarin and direct oral anticoagulants: a cross-sectional study

INTRODUCTION AND AIM

Patient quality of life (QOL) while on long-term oral anticoagulant therapy has been receiving greater attention in recent years due to the increase in life expectancy brought about by advances in medical care. This study aimed to compare the QOL, treatment satisfaction, hospitalization and bleeding rate in patients on long-term warfarin versus direct oral anticoagulants (DOAC).

METHODS

This was a cross-sectional study of patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE) on long-term anticoagulant therapy attending the cardiology clinic and anticoagulation clinic of the University Malaya Medical Centre from July 1, 2016, to June 30, 2018. Patient QOL was assessed by using the Short Form 12 Health Survey (SF12), while treatment satisfaction was assessed by using the Perception of Anticoagulation Treatment Questionnaire 2 (PACT-Q2).

RESULTS

A total of 208 patients were recruited; 52.4% received warfarin and 47.6% received DOAC. There was no significant difference in QOL between warfarin and DOAC based on SF12 (physical QOL, P=0.083; mental QOL, P=0.665). Nevertheless, patients in the DOAC group were significantly more satisfied with their treatment compared to the warfarin group based on PACT-Q2 (P=0.004). The hospitalisation rate was significantly higher in the warfarin group than the DOAC group (15.6% versus 3.0%, P=0.002). Clinically relevant minor bleeds and severe bleeding events were non-significantly higher in the warfarin group than the DOAC group (66.7% versus 40.0%, P=0.069).

CONCLUSION

Compared to warfarin, treatment of NVAF and VTE with DOAC showed comparable QOL, higher treatment satisfaction, lesser hospitalization, and a non-significant trend toward fewer bleeding episodes.

Adherence to Oral Anticoagulants in Atrial Fibrillation: An Australian Survey

Background:

The aim of this study was to investigate the proportion of patients who have suboptimal adherence to oral anticoagulant (OAC), identify the predictors of adherence, and determine whether patient-related factors vary across adherence levels in Australia.

Methods:

Respondents were recruited for an online survey using Facebook. Survey instruments included the Morisky Medication Adherence Scale, the Anticoagulation Knowledge Tool, the Perception of Anticoagulant Treatment Questionnaires, and a modified Cancer Information Overload scale. Predictors of medication adherence were identified using ordinal regression analysis.

Results:

Of the 386 responses eligible for analysis, only 54.9% reported a high level of adherence. Participants aged 65 years or younger were less likely to have high adherence compared to older participants (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.33-0.88; P = .013), while females were more likely to be highly adherent compared to males (OR, 1.69; 95% CI, 1.08-2.64; P = .023). The analyses showed that age, gender, treatment satisfaction, information overload, concerns about making mistake when taking OACs, and cost of medication were significant predictors of adherence.

Conclusion:

Self-reported suboptimal adherence to OAC is common among patients with atrial fibrillation. A focus on supporting people who are at higher risk of suboptimal adherence is needed to maximize the benefit of OAC therapy in this population.

Anticoagulation knowledge in patients with atrial fibrillation: An Australian survey

BACKGROUND

Atrial fibrillation (AF) is the most commonly diagnosed arrhythmia in clinical practice, and is associated with a significant medical and economic burden. Anticoagulants reduce the risk of stroke and systemic embolism by approximately two-thirds compared with no therapy. Knowledge regarding anticoagulant therapy can influence treatment outcomes in patients with AF.

OBJECTIVE

To measure the level of anticoagulation knowledge in patients with AF taking oral anticoagulants (OACs), investigate the association between patient-related factors and anticoagulation knowledge, and compare these results in patients taking warfarin and direct-acting oral anticoagulant (DOACs).

METHODS

Participants were recruited for an online survey via Facebook. Survey components included the Anticoagulation Knowledge Tool, the Perception of Anticoagulant Treatment Questionnaires (assessing treatment expectations, convenience and satisfaction), a modified Cancer Information Overload scale and the Morisky Medication Adherence Scale. Treatment groups were compared and predictors of OAC knowledge were identified.

RESULTS

Participants taking warfarin had a higher knowledge score compared with those taking DOACs (n = 386, 73% ± 13% vs 66% ± 14%, P<.001). Advancing age, type of OAC, health information overload and ease of OAC use (treatment expectation) were significant predictors of knowledge. Treatment expectation, including the belief that OAC treatment would cause bleeding side effects, varied significantly between participants taking warfarin and DOACs (P = .011).

CONCLUSION

The study identified knowledge gaps in patients taking OACs, and these deficiencies appeared to be greater in participants taking DOACs. Knowledge assessment should be integrated into patient counselling sessions to help identify and resolve knowledge deficits.

Real-life experience of quality of life, treatment satisfaction, and adherence in patients receiving oral anticoagulants for atrial fibrillation

INTRODUCTION

Direct oral anticoagulants (DOACs) have shown noninferiority to vitamin K antagonists (VKA) in stroke prevention in patients with atrial fibrillation. DOAC treatment may be less demanding than VKA, improving quality of life. To date, there have been no studies of the real-life experience of outpatients receiving anticoagulation therapy for atrial fibrillation in France.

METHODS

An observational descriptive real-life epidemiological study used three validated questionnaires (EQ-5D, PACT-Q2, and MMAS-8 French Translation) to assess quality of life, treatment satisfaction, and adherence, respectively, in 200 patients managed on an outpatient basis for atrial fibrillation who were receiving anticoagulation therapy by VKA or DOAC for at least 3 months. Patients were distributed between four groups: primary VKA (P-VKA), switch from VKA to DOAC (S-DOAC), primary DOAC (P-DOAC), and switch from DOAC to VKA (S-VKA).

RESULTS

Two hundred patients responded to the questionnaires: 89, 50, 52, and 9 in the P-VKA, S-DOAC, P-DOAC and S-VKA groups, respectively. Only the first three groups were compared statistically, because of the small size of the S-VKA group. Quality of life and satisfaction were good in all three groups, with no significant difference in quality of life but significantly greater satisfaction with respect to the "convenience" and "satisfaction" dimensions for DOACs (S-DOAC and P-DOAC groups versus P-VKA group; p<0.001, for both dimensions). Adherence did not significantly differ between groups.

CONCLUSION

The experience of patients under oral anticoagulation therapy for atrial fibrillation managed on an outpatient basis was good, with comparable quality of life under DOACs and VKA, and significantly greater satisfaction under DOACs, without impact on adherence. Taking account of patient preference in "shared decision-making" for the choice of type of anticoagulant could improve the patients' experience of treatment.

Patient-reported treatment satisfaction with oral rivaroxaban versus standard therapy in the treatment of acute symptomatic deep-vein thrombosis

Rivaroxaban, an oral, direct factor Xa inhibitor, has been approved for the treatment of deep-vein thrombosis (DVT) and pulmonary embolism (PE) and the prevention of recurrent DVT and PE as a fixed-dose, single-drug regimen that does not require initial heparinisation, routine coagulation monitoring or dose adjustment. This study evaluated patient-reported treatment satisfaction in EINSTEIN DVT - a large, open-label, randomised study that compared rivaroxaban with enoxaparin/ vitamin K antagonist (VKA) therapy in patients with acute symptomatic DVT without PE. As part of EINSTEIN DVT, a total of 1,472 patients in seven countries were asked to complete a new, validated measure of treatment satisfaction - the Anti-Clot Treatment Scale (ACTS) - at scheduled visits throughout 12 months of treatment. ACTS scores were compared between study groups in the intentionto- treat population. Patients reported greater satisfaction in the rivaroxaban group compared with the enoxaparin/VKA group, with higher mean ACTS scores across visits. Mean ACTS Burdens scores were 55.2 vs 52.6 (p<0.0001) in favour of rivaroxaban, equivalent to a moderate effect size of 0.42. The treatment effect was consistent over time, with the mean score difference ranging from 2.18 (month 2) to 3.18 (month 12). Overall mean ACTS Benefits scores were 11.7 vs 11.5 in favour of rivaroxaban (p=0.006). This was associated with a small overall effect size of 0.12. The improvement in ACTS Benefits for rivaroxaban became apparent at month 2 and subsequent visits. Rivaroxaban results in improved treatment satisfaction compared with enoxaparin/VKA among patients with DVT, particularly in reducing patient-reported anticoagulation burden.

Assessment of quality of life, satisfaction with anticoagulation therapy, and adherence to treatment in patients receiving long-course vitamin K antagonists or direct oral anticoagulants for venous thromboembolism

INTRODUCTION

Direct oral anticoagulants (DOACs) have shown non-inferiority and ease of use compared to vitamin K antagonists (VKA) in the treatment of venous thromboembolism (VTE). No study so far has been directed toward real-life experience of outpatients receiving anticoagulants for VTE in France.

METHODS

This is an observational descriptive real-life epidemiological study, using three validated questionnaires (Morisky Medication Adherence Scale-8, EQ-5D, and part 2 of the Perception of Anticoagulant Treatment Questionnaire), to assess adherence, quality of life, and satisfaction in 100 VTE outpatients receiving anticoagulation therapy by VKA (primary or switched from DOAC to VKA) or by DOAC (primary or switched from VKA to DOAC).

RESULTS

Patients were very much satisfied with their treatment in both DOAC and VKA groups. Despite advantages of DOACs, therapeutic adherence was only moderate. The best adherence scores were observed in the primary VKA switched to DOAC for at least 3 months (S-DOAC) subgroup. Quality of life was better in the DOAC group mainly because of the absence of the requirement for blood testing. Most of the complaints concerned the pain/discomfort dimension in the VKA group and anxiety/depression dimension in the DOAC group.

CONCLUSION

Patients were satisfied with their anticoagulant treatment, especially when they were involved in choosing the anticoagulant, and the treatment suited them. Quality of life of patients in the DOAC group was better than in the VKA group, but adherence remains to be improved. This study highlights the importance of the physician-patient relationship, pretreatment initiation, and follow-up of any anticoagulation therapy throughout.

[Validation of satisfaction questionnaire ACTS in outpatients with atrial fibrillation treated with oral anticoagulants in Spain. ALADIN Study]

BACKGROUND AND OBJECTIVE

To validate the satisfaction questionnaire Anti-Clot-Treatment Scale (ACTS) in outpatients with nonvalvular atrial fibrillation (NVAF) treated with oral anticoagulants attended in Internal Medicine and Neurology departments in Spain.

METHODS

In this cross-sectional and multicentrer study, 1,337 outpatients aged≥18 years, with NVAF, treated with oral anticoagulants≥3 months, attended in Internal Medicine and Neurology departments in Spain were analyzed. The patients completed ACTS, Self-Assessment of Treatment Questionnaire (SAT-Q) and EuroQol-5 dimensions (EQ-5D) questionnaires. ACTS is a satisfaction tool that specifically analyzes burdens (higher score, lesser burden) and benefits (higher score, higher benefit) with anticoagulant treatment. The psychometric properties of the questionnaire were evaluated according to the classical test theory.

RESULTS

The average time to complete the questionnaire was 8.99±6.06min and 63.70% of patients needed assistance to complete it. There was a high concordance between test and retest scores. Total reliability (Cronbach's alpha) was 0.95 in the ACTS Burdens scale and 0.82 in the ACTS Benefits scale. The factorial model was pertinent. All correlations with the SAT-Q questionnaire were positive, moderate and statistically significant. With regard to the EQ-5D-3L questionnaire, correlations were positive, low and statistically significant. Patient satisfaction was higher in the individuals being treated with new direct oral anticoagulants.

CONCLUSIONS

In patients with NVAF treated with oral anticoagulants, the Spanish version of ACTS questionnaire was reliable, valid and feasible.

Low-molecular-weight heparins for cancer-associated thrombosis: Adherence to clinical practice guidelines and patient perception in TROPIQUE, a 409-patient prospective observational study

PURPOSE

Data on long-term treatment with low-molecular-weight heparins (LMWH) in cancer patients treated for venous thromboembolism are scarce. Study objectives were to document the long-term clinical use of LMWH and patient perception in this setting.

METHODS

Adult cancer patients receiving antineoplastic treatment or palliative care and LMWH for cancer associated venous thromboembolism (CAT) were eligible to participate in this prospective observational study. Main outcome was adherence to clinical practice guidelines based on recommended LMWH treatment doses for at least 3months in the absence of severe renal insufficiency. Patients' perception of the treatment was assessed in an ancillary study using the Perception Anticoagulant Treatment Questionnaire (PACT-Q).

RESULTS

Among 409 included cancer patients aged 65±12.1years, overall adherence to practice guidelines as defined in the protocol was 55.3% (226 patients). However, 98.0% of patients received a prescription for 3months or more and mean LMWH treatment duration for VTE was 6.27±0.15months which meets guidelines recommendations. Main patients' expectations scored on a 1-5 scale were blood clots prevention (mean 3.94±0.75), symptom relief (mean 3.98±1.04) and ease of use (mean 4.22±0.9). LMWH treatment appeared convenient (global score 79.7±17.1 on a 0 to 100 scale) and 69.1% of patients were satisfied or very satisfied.

CONCLUSION

Despite incomplete strict adherence to guidelines, treatment duration with LMWH was adequate showing substantial progress in the management of CAT patients. Patients expectations were high while treatment was perceived convenient with a high degree of satisfaction.

Comparison of health-related quality of life among patients using novel oral anticoagulants or warfarin for non-valvular atrial fibrillation

Objective:

The aim of this study was to compare health-related quality of life (HRQoL) measures between novel oral anticoagulants (NOACs) and warfarin-treated Turkish patients who had been started on oral anticoagulants (OACs) due to non-valvular atrial fibrillation (AF) and to determine the effects of OACs on patient’s emotional status, anxiety and depression.

Methods:

A total of 182 patients older than 18 years with non-valvular AF and being treated with OACs for at least 6 months according to current AF guidelines who were admitted to outpatient clinics between July 2014 and January 2015 were included in this cross-sectional study. The exclusion criteria were receiving OACs for conditions other than non-valvular AF and being unable to answer the questionnaire. A questionnaire was administered to all participants to evaluate HRQoL, depression and anxiety. The mean differences between the groups were compared using Student’s t-test; the Mann–Whitney U test was applied for comparisons of the medians.

Results:

The annual number of hospital admissions was significantly higher in the warfarin group (p<0.001), and all HRQoL scores were significantly lower and Hospital Anxiety and Depression Scale (HADS) score was higher in the warfarin group (p<0.001). History of any type of bleeding was significantly higher in the warfarin group (p<0.001). However, none of the patients had major bleeding. Among patients who experienced bleeding, all HRQoL scores were significantly lower and HADS score was significantly higher (p<0.001 and p=0.002, respectively).

Conclusion:

Warfarin-treated patients had higher levels of self-reported symptoms of depression and anxiety and compromised HRQoL when compared with NOAC-treated patients. The results may be explained by higher rates of bleeding episodes and higher number of hospital admissions, which may cause restrictions in life while on warfarin treatment.

Patient evaluation of outpatient venous thromboembolism prophylaxis service following lower limb injuries using a developed validated questionnaire

This paper explores patients' perceptions of a new service and protocol for managing outpatient venous thromboembolism (VTE) prophylaxis, using either subcutaneous Dalteparin or oral off-license Dabigatran in patients with lower limb injury requiring immobilisation. Establishing a patient's perspective is part of good practice as, when this is positive, it aids patient compliance and protocol dissemination. A questionnaire consisting of fifty questions was given at random to one hundred patients over a six month period when they attended the trauma clinic. Each question was scored on a five point Likert scale (1 = poor, 5 = excellent) by the patient. The internal consistency of the questionnaire (Cronbach's alpha reliability coefficient) was more than 0.9 in all domains. Qualitative analysis was done for open-ended questions. One hundred respondents completed the questionnaire, two were void due to significant amounts of incomplete data. The gender split was 54 females, 43 males, and one did not answer the question. The average age was 43 (range 18-72). Sixty seven respondents were first-time attenders, 22 were follow-up patients and nine did not complete this section. The overall average score was 4.26 (range 1-5), with 90% of the patients recommending the service. The overall patient satisfaction for a VTE prophylaxis service is high although there is room for improvement as demonstrated by the range of the scores.

Atrial fibrillation and quality of life related to disease and treatment: focus on anticoagulation

ABSTRACT: 

Anticoagulation therapy is essential to reduce the risk of stroke in patients with atrial fibrillation. Traditionally, clinical trials have focused only on determining the efficacy and safety of anticoagulation but not on quality of life. In the last few years there has been a growing interest in determining the quality of life of patients treated with oral anticoagulation. In fact, specific tools that can evaluate quality of life related to atrial fibrillation and anticoagulation have been developed. Vitamin K antagonists have been shown to be effective in the prevention of thromboembolic complications. However, the use of vitamin K antagonists implies changes in behavior and lifestyle modifications that may have a negative impact on the quality of life. It has been suggested that self-monitoring of international normalized ratio could improve this impact. On the other hand, as new oral anticoagulants overcome these limitations, they may improve quality of life related with anticoagulant therapy. Unfortunately, although encouraging, the clinical experience with them is still quite limited.

Health related quality of life of patients undergoing oral anticoagulation therapy

This is a descriptive cross-sectional study, which aimed to analyze the health related quality of life (HRQoL) and its relationship with gender, age, duration and indication for the use of oral anticoagulants. A total of 178 patients were interviewed and the HRQoL was assessed through eight domains of the SF-36. The descriptive statistics used were, the Student's t, ANOVA and Tukey's tests for the comparison of the means between the groups. The indication for use was predominantly the metallic prosthetic heart valve (50%) with warfarin the most widely prescribed anticoagulant (83.3%). The means of the domains of the SF-36 ranged from 82 (Social aspects) to 54.8 (Physical aspects). Women, elderly, patients diagnosed with atrial fibrillation and with less than one year of medication use, presented a worse HRQoL evaluation. The results obtained can guide nursing actions, in that they indicate possible associations between the HRQoL and the sociodemographic and clinical variables of the patients.

Current issues in patient adherence and persistence: focus on anticoagulants for the treatment and prevention of thromboembolism

Warfarin therapy reduces morbidity and mortality related to thromboembolism. Yet adherence to long-term warfarin therapy remains challenging due to the risks of anticoagulant-associated complications and the burden of monitoring. The aim of this paper is to review determinants of adherence and persistence on long-term anticoagulant therapy for atrial fibrillation and venous thromboembolism. We evaluate what the current literature reveals about the impact of warfarin on quality of life, examine warfarin trial data for patterns of adherence, and summarize known risk factors for warfarin discontinuation. Studies suggest only modest adverse effects of warfarin on quality of life, but highlight the variability of individual lifestyle experiences of patients on warfarin. Interestingly, clinical trials comparing anticoagulant adherence to alternatives (such as aspirin) show that discontinuation rates on warfarin are not consistently higher than in control arms. Observational studies link a number of risk factors to warfarin non-adherence including younger age, male sex, lower stroke risk, poor cognitive function, poverty, and higher educational attainment. In addition to differentiating the relative impact of warfarin-associated complications (such as bleeding) versus the lifestyle burdens of warfarin monitoring on adherence, future investigation should focus on optimizing patient education and enhancing models of physician-patient shared-decision making around anticoagulation.

Scoring and psychometric validation of the Perception of Anticoagulant Treatment Questionnaire (PACT-Q)

Background

The 'Perception of Anti-Coagulant Treatment Questionnaire' (PACT-Q) was developed to assess patients' expectations of, and satisfaction with their anticoagulant treatment. This questionnaire needs to be finalised and psychometrically validated.

Methods

The PACT-Q was included in the United States, the Netherlands and France into three phase III multinational clinical trials conducted to evaluate efficacy and safety of a new long-acting anticoagulant drug (idraparinux) compared to vitamin K antagonist (VKA). PACT-Q was administered to patients with deep venous thrombosis (DVT), atrial fibrillation (AF) or pulmonary embolism (PE) at Day 1, to assess patients' expectations, and at 3 and 6 months to assess patients' satisfaction and treatment convenience and burden. The final structure of the PACT-Q (Principal Component Analysis – PCA – with Varimax Rotation) was first determined and its psychometric properties were then measured with validity of the structure (Multitrait analysis), internal consistency reliability (Cronbach's alpha coefficients) and known-group validity.

Results

PCA and multitrait analyses showed the multidimensionality of the "Treatment Expectations" dimension, comprising 7 items that had to be scored independently. The "Convenience" and "Burden of Disease and Treatment" dimensions of the hypothesised original structure of the questionnaire were combined, thus resulting in 13 items grouped into the single dimension "Convenience". The "Anticoagulant Treatment Satisfaction" dimension remained unchanged and included 7 items. All items of the "Convenience" and "Anticoagulant Treatment Satisfaction" dimensions displayed good convergent and discriminant validity. The internal consistency reliability was good, with a Cronbach's alpha of 0.84 for the "Convenience" dimension, and 0.76 for the "Anticoagulant Treatment Satisfaction" dimension. Known-group validity was good, especially with regard to occurrence of thromboembolic events within 3 months from randomisation.

Conclusion

The PACT-Q is a valid and reliable instrument that allows the assessment of patients' expectations and satisfaction regarding anticoagulant treatment, as well as their opinion about treatment convenience of use. Its two-part structure – assessment of expectations at baseline in the first part, and of convenience, burden and treatment satisfaction in the second – was validated and displays good and stable psychometric properties. These results are not sufficient to recommend the use of satisfaction as primary endpoint in clinical trials; further validation work is needed to support the interpretation of PACT-Q dimension scores. However, this first validation makes the PACT-Q an appropriate measure for use in clinical and pharmacoepidemiological research, as well as in real-life studies.

Trial Registration

(ClinicalTrials.gov numbers, NCT00067093, NCT00062803 and NCT00070655).