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Lloyd KE, Hall LH, Ziegler L, Foy R, Green SMC, MacKenzie M, Taylor DG, Smith SG. Acceptability of aspirin for cancer preventive therapy: a survey and qualitative study exploring the views of the UK general population. BMJ Open 2023; 13:e078703. [PMID: 38110374 DOI: 10.1136/bmjopen-2023-078703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVES Aspirin could be offered for colorectal cancer prevention for the UK general population. To ensure the views of the general population are considered in future guidance, we explored public perceptions of aspirin for preventive therapy. DESIGN We conducted an online survey to investigate aspirin use, and awareness of aspirin for cancer prevention among the UK general population. We conducted semistructured interviews with a subsample of survey respondents to explore participants' acceptability towards aspirin for cancer preventive therapy. We analysed the interview data using reflexive thematic analysis and mapped the themes onto the Theoretical Domains Framework, and the Necessity and Concerns Framework. SETTING Online survey and remote interviews. PARTICIPANTS We recruited 400 UK respondents aged 50-70 years through a market research company to the survey. We purposefully sampled, recruited and interviewed 20 survey respondents. RESULTS In the survey, 19.0% (76/400) of respondents were aware that aspirin can be used to prevent cancer. Among those who had previously taken aspirin, 1.9% (4/216) had taken it for cancer prevention. The interviews generated three themes: (1) perceived necessity of aspirin; (2) concerns about side effects; and (3) preferred information sources. Participants with a personal or family history of cancer were more likely to perceive aspirin as necessary for cancer prevention. Concerns about taking aspirin at higher doses and its side effects, such as gastrointestinal bleeding, were common. Many described wanting guidance and advice on aspirin to be communicated from sources perceived as trustworthy, such as healthcare professionals. CONCLUSIONS Among the general population, those with a personal or family history of cancer may be more receptive towards taking aspirin for preventive therapy. Future policies and campaigns recommending aspirin may be of particular interest to these groups. Multiple considerations about the benefits and risks of aspirin highlight the need to support informed decisions on the medication.
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Affiliation(s)
- Kelly E Lloyd
- Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Louise H Hall
- Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Lucy Ziegler
- Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Sophie M C Green
- Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | | | - David G Taylor
- School of Pharmacy, University College London, London, UK
| | - Samuel G Smith
- Leeds Institute of Health Sciences, University of Leeds Faculty of Medicine and Health, Leeds, UK
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Cao Y, Feng YY, Du W, Li J, Fei YL, Yang H, Wang M, Li SJ, Li XJ, Han B. Non‑persistence to Oral Anticoagulation Therapy in Elderly Patients with Non‑valvular Atrial Fibrillation. Patient Prefer Adherence 2023; 17:3185-3194. [PMID: 38084322 PMCID: PMC10710792 DOI: 10.2147/ppa.s435592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/25/2023] [Indexed: 03/22/2024] Open
Abstract
PURPOSE To investigate the reasons for elderly atrial fibrillation (AF) patients not continuing their oral anticoagulation (OAC) treatment and the factors that influence this behavior. METHODS Elderly AF patients (aged≥75 years) hospitalized from December 2019 to May 2022 were consecutively enrolled. Clinical, demographic, and concomitant medication data were collected. The endpoint was defined as OAC discontinuation for more than 30 days or a switch to an alternative therapy. Predictors of OAC non-persistence were investigated using a multivariable Cox regression model. RESULTS This study included 560 participants (51.1% men, mean age 80.9±0.2 years). During a median follow-up of 20 months, medication persistence was observed in 322 patients (57.5%). Non-persistence was found to be significantly higher with warfarin than with NOAC (48.8% vs 33.6%, p = 0.006). In the multivariate analysis, OAC non-persistence was independently predicted by a history of permanent pacemaker implantation, the use of antiplatelet drugs, employee Medicare, living with children, college degree or above, and persistent AF (HR = 1.580, 1.586, 0.604, 0.668, 0.028, 0.769, p < 0.05, respectively). Treatment discontinuation within 3 months of discharge was observed in a large number of patients (81.8%). Medication discontinuation due to bleeding was more frequently observed in patients who continued for longer than 3 months (p < 0.001), while discontinuation due to patient preference was more frequent in those with shorter durations (≤3 months) (p = 0.049). Patient preference was the second leading cause of non-persistence in patients, regardless of whether they were taking warfarin or NOAC. CONCLUSION OAC non-persistence remains high among elderly AF patients during long-term follow-up, with a significant proportion discontinuing shortly after discharge. This pattern of non-persistence is heavily influenced by demographic factors and patient preference. Further interventions should be developed based on the reasons and risk factors to improve persistence and initiated early in the treatment process.
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Affiliation(s)
- Yue Cao
- Division of Cardiology, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Yue-Yue Feng
- Division of Cardiology, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Wei Du
- Division of Cardiology, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Jing Li
- Division of Cardiology, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Ya-Lan Fei
- Division of Cardiology, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Hao Yang
- Division of Cardiology, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Meng Wang
- Division of Cardiology, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Shi-Jie Li
- Division of Cardiology, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Xian-Jin Li
- Division of Cardiology, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Bing Han
- Division of Cardiology, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
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Erlingsdottir HY, Ketilsdottir A, Hendriks JM, Ingadottir B. Disease-Related Knowledge and Need for Revision of Care for Patients with Atrial Fibrillation: A Cross Sectional Study. Patient Prefer Adherence 2023; 17:2621-2630. [PMID: 37900057 PMCID: PMC10612480 DOI: 10.2147/ppa.s428444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/29/2023] [Indexed: 10/31/2023] Open
Abstract
Purpose To evaluate the disease-related knowledge of outpatients with atrial fibrillation (AF), and the relationship with health literacy and other background variables. Patients and Methods In this cross-sectional survey study, conducted in Iceland, patients with AF scheduled for an electrical cardioversion or AF catheter ablation were recruited from a hospital outpatient clinic. They completed the validated Atrial Fibrillation Knowledge Scale (AFKS), a 11-item instrument (with possible score 0-10, 10 being the best knowledge) which evaluates knowledge pertaining to AF in general, AF symptom detection and AF treatment. Health literacy was assessed with the 16 item European Health Literacy Survey Questionnaire (HLS-EU-Q) and patients answered questions about their background. Data was analysed with parametric tests. Results In total, 185 participants completed the questionnaire (mean age 63 ±10), 77% were male, 74% with previous electrical cardioversion and 76% were on non-vitamin K antagonist oral anticoagulants (NOAC) medication. The mean score on the AFKS was 6.5 (±1.8). The best knowledge was concerning oral anticoagulation therapy (96% answered correctly) and the least knowledge was regarding responses to AF episodes (17% answered correctly). Patients with sufficient health literacy (52%) had better knowledge of AF (M 6.8 ±1.7 vs M 6.3 ±1.9, p = 0.05). Age, educational level, health literacy and AF pattern explained 22% of the variance in AF knowledge. Conclusion Patients with AF have inadequate knowledge of their condition, potentially as a result of insufficient health literacy. AF knowledge may be improved using integrated management where patients are actively involved in the care and health literacy is considered in the provided patient education.
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Affiliation(s)
- Helga Yr Erlingsdottir
- Faculty of Nursing and Midwifery, School of Health Sciences, University of Iceland, Reykjavik, Iceland
- Cardio-Vascular and Cancer Center, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Audur Ketilsdottir
- Faculty of Nursing and Midwifery, School of Health Sciences, University of Iceland, Reykjavik, Iceland
- Cardio-Vascular and Cancer Center, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Jeroen M Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Brynja Ingadottir
- Faculty of Nursing and Midwifery, School of Health Sciences, University of Iceland, Reykjavik, Iceland
- Office of Chief Nursing Officer, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
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Angeli F, Reboldi G, Agnelli G, Ambrosio G, Capucci A, Carreras G, Cavallini C, Murrone A, Vaudo G, Zingarini G, Verdecchia P. Use of Oral Anticoagulants in Patients with Atrial Fibrillation: Preliminary Data from the Italian Atrial Fibrillation (ITALY-AF) Registry. Clin Pract 2023; 13:1173-1181. [PMID: 37887081 PMCID: PMC10605134 DOI: 10.3390/clinpract13050105] [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: 06/30/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AFIB), the most frequent cardiac arrhythmia, is a major risk factor for stroke, heart failure, and death. Because of the recent advances in AFIB management and the availability of new oral anticoagulants (OACs), there is a need for a systematic and predefined collection of contemporary data regarding its management and treatment. METHODS The objective of the ongoing ITALY-AFIB registry is to evaluate the long-term morbidity and mortality in patients with AFIB and to verify the implementation of the current guidelines for stroke prevention in these patients. The registry includes consecutive in- and out-patients with first diagnosed, paroxysmal, persistent, or permanent AFIB. In patients in sinus rhythm at entry, the qualifying episode of AFIB, confirmed by ECG diagnosis, had to have occurred within 1 year before entry. The clinical record form is web-based and accessible by personal keyword. RESULTS Enrolment into the registry started in the year 2013. In a current cohort of 2470 patients (mean age 75 ± 11 years, males 56%), the mean CHA2DS2-VASc score was 3.7 ± 1.8, and the mean HAS-BLED was 1.6 ± 0.9. There were no significant sex differences in the AFIB subtypes. At the end of the inclusion visit and after receiving knowledge of the web-based electronic estimate of risk for stroke and bleeding, the proportion of patients discharged with OACs was 80%. After exclusion of patients with first diagnosed AFIB (n = 397), the proportion of patients with prescription of OACs rose from 66% before the visit to 82% on discharge (p < 0.0001). Prescription of aspirin or other antiplatelet drugs fell from 18% before the visit to 10% on discharge (p < 0.0001). CONCLUSIONS A web-based management of AFIB with automated estimation of risk profiles appears to favorably affect adherence to AFIB guidelines, based on a high proportion of patients treated with OACs and a substantial decline in the use of antiplatelet drugs.
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Affiliation(s)
- Fabio Angeli
- Department of Medicine and Technological Innovation (DiMIT), University of Insubria, 21100 Varese, Italy
- Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS Tradate, 21049 Varese, Italy
| | | | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine—Stroke Unit, University of Perugia, 06123 Perugia, Italy
- Maugeri Scientific Clinical Institutes—IRCCS, 27100 Pavia, Italy
| | - Giuseppe Ambrosio
- Division of Cardiology, School of Medicine, University of Perugia, 06123 Perugia, Italy
| | - Alessandro Capucci
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital Umberto I, Lancisi-Salesi, 60123 Ancona, Italy
| | - Giovanni Carreras
- Arrhythmology Unit, Cardiology Department, Terni University Hospital, 05100 Terni, Italy
| | - Claudio Cavallini
- Struttura Complessa di Cardiologia, Hospital S. Maria della Misericordia, 06129 Perugia, Italy; (C.C.)
| | - Adriano Murrone
- Struttura Complessa di Cardiologia, Hospital of Città di Castello, Città di Castello, 06012 Perugia, Italy
| | - Gaetano Vaudo
- Department of Medicine, University of Perugia, 06123 Perugia, Italy
- Unit of Internal Medicine, Terni University Hospital, 05100 Terni, Italy
| | - Gianluca Zingarini
- Struttura Complessa di Cardiologia, Hospital S. Maria della Misericordia, 06129 Perugia, Italy; (C.C.)
| | - Paolo Verdecchia
- Struttura Complessa di Cardiologia, Hospital S. Maria della Misericordia, 06129 Perugia, Italy; (C.C.)
- Fondazione Umbra Cuore e Ipertensione-ONLUS, 06124 Perugia, Italy
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Chang S, Xu W, Wu S, Desteghe L, Zhang F, Zhang J. An instrument to measure atrial fibrillation knowledge in Chinese patients: validation of the Jessa Atrial fibrillation Knowledge Questionnaire. Front Pharmacol 2023; 14:1148524. [PMID: 37416065 PMCID: PMC10321709 DOI: 10.3389/fphar.2023.1148524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/05/2023] [Indexed: 07/08/2023] Open
Abstract
Background: There is no validated tool to assess patients' knowledge of oral anticoagulant therapy in atrial fibrillation in China. Methods: Using a standard translation program, the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ) was translated into Chinese. The reliability of the JAKQ was assessed by internal consistency (Cronbach's α coefficient), repeatability (test-retest reliability), and sensitivity tests. Effectiveness was assessed by hypothesizing that a lower JAKQ score was a risk factor for bleeding. A total of 447 patients with atrial fibrillation (AF) who were hospitalized between July 2019 and December 2021 were studied and followed up. Participants were followed up 1, 3, 6, and 12 months after enrollment. Bleeding during follow-up was recorded. Data were obtained from hospital databases and telephone follow-up. Result: A total of 447 patients with AF completed JAKQ. The mean age of patients was 67.7 ± 10.2 years. The median JAKQ score was 31.3% (12.5-43.8). The Cronbach's α coefficient of JAKQ was 0.616-0.637, and the test-retest reliability value was 0.902 (p < 0.001). Multivariate logistic regression showed that the higher knowledge level of AF was associated with secondary education or above, an income of more than 2000 yuan, and a history of AF of more than 1 year. Bleeding was associated with a lower JAKQ score, hypertension, and a history of bleeding. Non-bleeding patients on VKA had a better understanding of how often INR should be monitored and what to do if an OAC dose was missed. Conclusion: The Chinese version of JAKQ shows good reliability and validity, indicating that it is a valuable tool for AF and oral anticoagulation (OAC) knowledge assessment. It can be used in clinical practice to guide educational activities and improve the effectiveness and safety of treatment. It was shown that Chinese patients with AF have insufficient knowledge about AF and OAC. Lower JAKQ scores are associated with bleeding, so targeted education is necessary. Targeted educational efforts should focus on patients recently diagnosed with AF and those with lower formal education and income.
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Affiliation(s)
- Sijie Chang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Wenlin Xu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Shuyi Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Lien Desteghe
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Feilong Zhang
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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Calvert P, Tamirisa K, Al-Ahmad A, Lip GYH, Gupta D. Racial and Ethnic Disparities in Stroke Prevention for Atrial Fibrillation. Am J Med 2023; 136:225-233. [PMID: 36495932 DOI: 10.1016/j.amjmed.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/01/2022] [Accepted: 11/06/2022] [Indexed: 12/13/2022]
Abstract
Racial and ethnic disparities in health care are well documented, although often underappreciated. In the setting of atrial fibrillation, stroke risk and severity may be higher in underrepresented ethnic populations. Additionally, the risk of bleeding is not uniform, and pharmacogenetics play an important role in anticoagulant therapy. In this narrative review, we discuss the complex issues surrounding stroke prevention in underrepresented ethnic groups with atrial fibrillation.
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Affiliation(s)
- Peter Calvert
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom
| | | | | | - Gregory Y H Lip
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom.
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Bhat A, Karthikeyan S, Chen HHL, Gan GCH, Denniss AR, Tan TC. BARRIERS TO GUIDELINE-DIRECTED ANTICOAGULATION IN PATIENTS WITH ATRIAL FIBRILLATION NEW APPROACHES TO AN OLD PROBLEM. Can J Cardiol 2023; 39:625-636. [PMID: 36716858 DOI: 10.1016/j.cjca.2023.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 01/22/2023] [Accepted: 01/22/2023] [Indexed: 01/29/2023] Open
Abstract
Optimising guideline-directed anticoagulation in atrial fibrillation remains a perennial problem despite strong evidence for improved health outcomes with use of guideline-directed anticoagulation. Efforts to improve uptake have been hampered by barriers found at the level of the physician, patient, disease and choices of therapy. Clinician judgement is often clouded by factors such as therapeutic inertia, aversion to bleeding risk and implicit bias. For patients, negative pre-conceptions of therapy, impact of therapy on day-to-day life and the nocebo effect pose significant barriers. Both groups are impacted by poor education. Utility of a single pronged approach directed towards clinicians or patients have demonstrated variable success, with the highest impact appreciated in studies employing shared decision models. Further, there is emerging evidence for use of integrated models of care, which have shown improved efficacy in improving patient outcomes, as well as use of digital platforms such as mobile app-based interventions, which can be of aid to the clinician in improving patient adherence to anticoagulation with translated improved outcomes in clinical trials. Our narrative review article aims to investigate the physician and health system, patient, as well as drug therapy and disease barriers to uptake of guideline-directed anticoagulation in treatment of non-valvular atrial fibrillation.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia.
| | - Sowmiya Karthikeyan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia
| | - A Robert Denniss
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW 2145, Australia
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW 2145, Australia
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Tarn DM, Shih K, Tseng CH, Thomas A, Schwartz JB. Reasons for Nonadherence to the Direct Oral Anticoagulant Apixaban: A Cross-Sectional Survey of Atrial Fibrillation Patients. JACC. ADVANCES 2023; 2:100175. [PMID: 38939023 PMCID: PMC11198726 DOI: 10.1016/j.jacadv.2022.100175] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/22/2022] [Indexed: 06/29/2024]
Abstract
Background Nonadherence to direct oral anticoagulants to prevent stroke occurs in up to 40% of atrial fibrillation patients. Underlying reasons are poorly understood. Objectives This study quantified patient-reported reasons for nonadherence and identified strategies to improve adherence. Methods This is a cross-sectional survey of atrial fibrillation patients in 2 academic health systems who reported apixaban nonadherence. We examined patient-reported reasons for nonadherence and level of nonadherence (assessed by a validated 3-item adherence measure) using a multivariable logistic regression model. Results Of 419 study patients, 41.5% were women. The mean age was 71.1 ± 10 years and mean CHA2DS2VASc score was 3.2 ± 1.6. About two-thirds had adherence scores ≥80 (mild nonadherence) and one-third scores <80 (poor adherence). In all groups, forgetfulness contributed to nonadherence. Attitudes/beliefs associated with adherence score <80 included: not believing apixaban was needed (odds ratio [OR]: 12.24 [95% CI: 2.25-66.47]); medication cost (OR: 3.97 [95% CI: 1.67-9.42]); and fear of severe bleeding (OR: 3.28 [95% CI: 1.20-8.96]). Strategies that patients with adherence scores <80 selected as helping "a great deal/a lot" to increase adherence included bloodwork to evaluate efficacy (56%), physician counseling about adherence (55%), and having a reversal agent (39%). Almost one-half of all patients did not disclose nonadherence to their providers. Conclusions Patients may not disclose their nonadherence to prescribers, and attitudes related to apixaban nonadherence differ among patients with mild nonadherence versus poor adherence. While all patients may benefit from strategies to address forgetfulness, concerns related to the purpose of apixaban, cost, and bleeding risk may require special attention in those with poor adherence.
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Affiliation(s)
- Derjung M. Tarn
- Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, California, USA
| | - Kevin Shih
- Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, California, USA
| | - Chi-hong Tseng
- Division of General Internal Medicine/Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, California, USA
| | - Alveena Thomas
- Division of Geriatrics, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Janice B. Schwartz
- Division of Geriatrics, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Division of Clinical Pharmacology, Departments of Medicine and Bioengineering and Therapeutic Sciences, University of California-San Francisco, San Francisco, California, USA
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Dhore-Patil A, Crawford M, Nedunchezhian S, El Hajjar AH, Mekhael M, O'Keefe E, Daghar L, Noujaim C, Bhatnagar A, Pottle C, Sidhu G, Marrouche N. The association of disparities in neighborhood median household income and mortality in patients admitted to the hospital with atrial fibrillation. Prog Cardiovasc Dis 2023; 76:84-90. [PMID: 36462553 DOI: 10.1016/j.pcad.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 11/26/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Lower neighborhood median household income (nMHI) is associated with increased adverse outcomes in patients with atrial fibrillation (AF). However, its effect on mortality is yet unknown. METHODS Data from the regional United States (U.S.) electronic medical records database, Research Action for Health Network (REACHnet), was extracted for adult patients with AF at Tulane Medical Center over 10 years. Annual nMHI & neighborhood high school graduation (HSG) data was collected from the US Census bureau. Only African Americans (AA) and Caucasians (CC) who had socioeconomic data were included. Low nMHI and low HSG were defined as ≤$25,000 & <90% respectively. High nMHI and HSG were defined as >$50,000 & ≥90% respectively. Primary endpoints were all cause and cardiovascular (CV) mortality. Cox-proportional hazard ratios were used to evaluate the endpoints. RESULTS We included 4616 patients diagnosed with AF. During a median follow up of 4.6 years, 434 patients died of which 32.7% patients had CV mortality. There was a stepwise decrease in incidence of both all-cause and CV mortality as nMHI increased. Patients with low nMHI had the greatest risk of all-cause mortality (HR 1.9, C.I. 1.2-3.2, P 0.004). The association between low nMHI and all-cause mortality persisted after adjusting for age, sex, race, HSG and stroke risk factors using CHA2DS2VASC, delta CHA2DS2VASC scores and oral anticoagulant use. CV mortality followed a similar trend as all-cause mortality, however, this association was not significant after adjusting for the above variables. Apart from low nMHI, CHA2DS2VASC delta CHA2DS2VASC were statistically significant independent predictors of both all-cause and CV mortality. CONCLUSION Low nMHI is an independent risk factor for all cause and CV mortality in AF. Higher burden of co-morbidities is the driving force behind this disparity. Future studies should evaluate the role of educational and therapeutic intervention in these populations to reduce mortality.
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Affiliation(s)
- Aneesh Dhore-Patil
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine; Tulane University Heart and Vascular Institute, New Orleans, LA, USA; Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA
| | - Michael Crawford
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine; Tulane University Heart and Vascular Institute, New Orleans, LA, USA; Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA
| | - Saihaiharan Nedunchezhian
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Abdel Hadi El Hajjar
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Mario Mekhael
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Evan O'Keefe
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine; Tulane University Heart and Vascular Institute, New Orleans, LA, USA; Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA
| | - Lilas Daghar
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Department of General Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Charbel Noujaim
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Arezu Bhatnagar
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Christopher Pottle
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Gursukhmandeep Sidhu
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine; Tulane University Heart and Vascular Institute, New Orleans, LA, USA; Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA
| | - Nassir Marrouche
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine; Tulane University Heart and Vascular Institute, New Orleans, LA, USA; Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA.
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10
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Higher OAK (Oral Anticoagulation Knowledge) score at baseline associated with better TTR (Time in Therapeutic Range) in patients taking warfarin. J Thromb Thrombolysis 2023; 55:141-148. [PMID: 36326967 DOI: 10.1007/s11239-022-02718-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
A lack in patient knowledge of warfarin therapy is associated with poor adherence. This knowledge gap may result in a lower INR Time in Therapeutic Range (TTR). To investigate association between patient anticoagulation knowledge and warfarin control. Michigan Anticoagulation Quality Improvement Initiative (MAQI2) is a Blue Cross Blue Shield of Michigan sponsored consortium of six anticoagulation management services. Patients prescribed warfarin at two MAQI2 sites completed a voluntary Oral Anticoagulation Knowledge (OAK) questionnaire at warfarin initiation and 6-month follow-up. The results of 20 OAK questions and TTRs (excluding 1st month post-initiation) were compared using chi-square tests, t-tests and multivariate analysis adjusting for SAMe-TT2R2 and days on warfarin. Of 1836 surveys distributed at warfarin initiation, 481 (26.2%) patients completed the baseline questionnaire (within 1 month post-initiation): mean OAK score: 14.6 ± 3.4. Of those, 147 (30.6%) completed 6-month follow-up surveys (OAK: 12.7 ± 5.8). Patients with TTR ≥ 70% at baseline scored higher on OAK tests than patients with TTR < 70% in unadjusted analyses (15.1 ± 3.2 v. 14.2 ± 3.5, p = 0.003) and adjusted analysis (p = 0.020). There was no unadjusted or adjusted difference in OAK scores at 6-month follow-up between patients with TTR ≥ 70% and TTR < 70%. For patients who completed baseline and follow-up surveys, there was a decrease of 2.4 points in OAK score between baseline and 6-month follow up (p < 0.001). Higher baseline, but not follow-up, OAK score is associated with better warfarin control and average OAK scores decreased between baseline and follow-up. Further studies are needed to determine what type of patient education may improve patient knowledge retention and warfarin control.
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Paschoal E, Gooden TE, Olmos RD, Lotufo PA, Benseñor IM, Manaseki-Holland S, Lip GYH, Thomas GN, Jolly K, Lancashire E, Lane DA, Greenfield S, Goulart AC. Health care professionals' perceptions about atrial fibrillation care in the Brazilian public primary care system: a mixed-methods study. BMC Cardiovasc Disord 2022; 22:559. [PMID: 36550397 PMCID: PMC9772592 DOI: 10.1186/s12872-022-02927-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/29/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) negatively impacts health systems worldwide. We aimed to capture perceptions of and barriers and facilitators for AF care in Brazilian primary care units (PCUs) from the perspective of healthcare professionals (HCPs). METHODS This mixed-methods, cross-sectional study utilised an exploratory sequential design, beginning with the quantitative data collection (up to 18 closed questions) immediately followed by a semi-structured interview. HCPs were recruited from 11 PCUs in the Sao Paulo region and included managers, physicians, pharmacists, nurses and community health agents. Descriptive statistics were used to present findings from the quantitative questionnaire and inductive analysis was used to identify themes from the qualitative data. RESULTS One hundred seven HCPs were interviewed between September 2019 and May 2020. Three main themes were identified that encapsulated barriers and facilitators to AF care: access to care (appointments, equipment/tests and medication), HCP and patient roles (HCP/patient relationship and patient adherence) and the role of the organisation/system (infrastructure, training and protocols/guidelines). Findings from the qualitative analysis reinforced the quantitative findings, including a lack of AF-specific training for HCPs, protocols/guidelines on AF management, INR tests in the PCUs, patient knowledge of AF management and novel oral anticoagulants (NOACs) as key barriers to optimal AF care. CONCLUSIONS Development and implementation of AF-specific training for PCU HCPs are needed in Brazil, along with evidence-based protocols and guidelines, educational programmes for patients, better access to INR tests for patients taking warfarin and availability of NOACs.
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Affiliation(s)
- Elisabete Paschoal
- grid.488478.f0000 0004 0578 1483Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Tiffany E. Gooden
- grid.6572.60000 0004 1936 7486Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Rodrigo D. Olmos
- grid.488478.f0000 0004 0578 1483Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de Sao Paulo, Sao Paulo, Brazil ,grid.11899.380000 0004 1937 0722School of Medicine, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Paulo A. Lotufo
- grid.488478.f0000 0004 0578 1483Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de Sao Paulo, Sao Paulo, Brazil ,grid.11899.380000 0004 1937 0722School of Medicine, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Isabela M. Benseñor
- grid.488478.f0000 0004 0578 1483Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de Sao Paulo, Sao Paulo, Brazil ,grid.11899.380000 0004 1937 0722School of Medicine, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Semira Manaseki-Holland
- grid.6572.60000 0004 1936 7486Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gregory Y. H. Lip
- grid.6572.60000 0004 1936 7486Institute for Applied Health Research, University of Birmingham, Birmingham, UK ,grid.415992.20000 0004 0398 7066Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK ,grid.5117.20000 0001 0742 471XDepartment of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - G. Neil Thomas
- grid.6572.60000 0004 1936 7486Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kate Jolly
- grid.6572.60000 0004 1936 7486Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Emma Lancashire
- grid.6572.60000 0004 1936 7486Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Deirdre A. Lane
- grid.6572.60000 0004 1936 7486Institute for Applied Health Research, University of Birmingham, Birmingham, UK ,grid.415992.20000 0004 0398 7066Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Sheila Greenfield
- grid.6572.60000 0004 1936 7486Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alessandra C. Goulart
- grid.488478.f0000 0004 0578 1483Center for Clinical and Epidemiological Research, Hospital Universitário, Universidade de Sao Paulo, Sao Paulo, Brazil
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12
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Souza-Silva MVR, Domingues MLDP, Chagas VS, Pereira DN, de Sá LC, Almeida MSS, Sales TLS, Raposo MC, Guimarães NS, Oliveira JADQ, Ribeiro ALP, Cardoso CS, Martins MAP, Enes TB, Soares TBDC, Baldoni AO, Marcolino MS. Implementation of a text messaging intervention to patients on warfarin therapy in Brazilian primary care units: a quasi-experimental study. BMC PRIMARY CARE 2022; 23:54. [PMID: 35321654 PMCID: PMC8942053 DOI: 10.1186/s12875-022-01647-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/23/2022] [Indexed: 11/10/2022]
Abstract
Background Warfarin remains the most affordable oral anticoagulant in many countries. However, it may have serious side effects, and the success of the therapy depends on the patient’s understanding of the medication and their adherence to treatment. The use of short messages services (SMS) is a strategy that can be used to educate patients, but there are no studies evaluating this intervention in patients taking warfarin. Therefore, we aimed to develop, implement, and assess the feasibility of an intervention using SMS to primary care patients taking warfarin in a medium-sized Brazilian city. Methods A bank of 79 SMS was drafted and validated by an expert panel. During 6 months, three times a week, patients received messages about anticoagulation with warfarin. At baseline and after 3 months, we assessed their knowledge and adherence with validated instruments. At the end of the follow-up, participants answered a satisfaction questionnaire. Subsequently, a scale-up phase was conducted, with another round of the intervention including 82 participants (29 from the first phase and 53 newly recruited). Seven months after the end of the scale-up, we asked the patients for their insights about the long-term effects of this program. All patients signed informed consent. The study was approved by the Research and Ethics committee of the Universidade Federal de Minas Gerais. Results In the pilot, 33 (89.2%) patients completed the follow-up. Among the participants who answered the satisfaction questionnaire (n = 29), 86.2% considered that the intervention motivated a healthy lifestyle and improved their understanding of warfarin therapy. All patients were willing to continue receiving the messages. Adherence measured by the Measure of Adherence to Treatment (MAT) test was high in the pre-intervention assessment and remained high (96.7% vs. 93.3%; p = 1.0000). The proportion of patients who achieved > 75% correct answers on the Oral Anticoagulation Knowledge (OAK) test increased from 6.5% to 25.6, p = 0.0703. In the scale-up, 23 patients answered the long-term assessment questionnaire. The main long-term knowledge reported was dietary information. Nine patients received the messages but did not remember their content. Conclusion The intervention was well-accepted and had a positive impact on patient’s knowledge about oral anticoagulation therapy. The scale-up assessment reinforced the need to constantly monitor digital interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01647-5.
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13
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Wang M, Swinton M, Troyan S, Ho J, M Siegal D, Mbuagbaw L, Thabane L, M Holbrook A. Perceptions of patients and healthcare providers on patient education to improve oral anticoagulant management. J Eval Clin Pract 2022; 28:1027-1036. [PMID: 35142014 DOI: 10.1111/jep.13665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 12/31/2022]
Abstract
RATIONALE AND OBJECTIVES Education of patients is thought to be key to high-quality oral anticoagulant (OAC) medication management. Theoretically, improving patients' knowledge should improve their self-management skills and adherence. The study's objective was to explore the opinions of healthcare providers and patients on the desired content and format of patient education on OACs, in addition to perceived barriers to high-quality patient education. METHODS We applied qualitative descriptive methods in a focus group study on OAC management. Five focus group discussions were conducted in two health regions in Southwestern Ontario from 2017 to 2018 with 19 patients, 7 caregivers and 16 healthcare providers (physicians, nurses and pharmacists). During the focus groups, participants discussed their experiences with OAC education and made suggestions about the content and format for patient education on OACs. Transcripts were analysed using conventional content analysis. RESULTS We identified the five themes of patient education on OAC management: content of OAC education (rationale, risk and appropriate drug administration methods), the best times for providing OAC education (time of OACs initiation along with continuing education), preferred education delivery strategies (case management targeted patient information summaries from authoritative sources such as Thrombosis Canada and video education), patient and community pharmacist engagement in OAC education, and perceived barriers to optimal patient education (patients depending too much on their healthcare providers for advice, the limited time patients spend with healthcare providers, gaps in clear communication between providers and the lack of a nationally or provincially coordinated OAC management programme). CONCLUSION Our findings suggest that patients, caregivers and healthcare providers support the need for education on OACs, including for patients taking DOACs. Specific important content and proper education format are needed. The optimal combination of content, format, duration, timing and sources for OAC education requires further research.
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Affiliation(s)
- Mei Wang
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada.,Clinical Pharmacology & Toxicology Research, The Research Institute of St. Joseph's Hamilton, Hamilton, Ontario, Canada
| | - Marilyn Swinton
- School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sue Troyan
- Clinical Pharmacology & Toxicology Research, The Research Institute of St. Joseph's Hamilton, Hamilton, Ontario, Canada
| | - Joanne Ho
- Division of Clinical Pharmacology & Toxicology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Schlegel Research Institute for Aging, Waterloo, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada.,Biostatistics Unit, St Joseph's Healthcare-Hamilton, Hamilton, Ontario, Canada.,School of Public Health, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Anne M Holbrook
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada.,Clinical Pharmacology & Toxicology Research, The Research Institute of St. Joseph's Hamilton, Hamilton, Ontario, Canada.,Division of Clinical Pharmacology & Toxicology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Evidence-Based Recommendations: Management of Left Ventricular Thrombus Post-Acute Myocardial Infarction. Dimens Crit Care Nurs 2022; 41:313-320. [PMID: 36179309 DOI: 10.1097/dcc.0000000000000553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
One of the potential complications of acute myocardial infarction is left ventricular thrombus (LVT). The incidence of LVT following acute myocardial infarction has decreased dramatically with early invasive reperfusion techniques or fibrinolysis. However, the risk of LVT formation remains significant and is associated with an increased risk of systemic embolism, stroke, cardiovascular events, and even death. Current guidelines indicate that dual antiplatelet therapy and anticoagulation therapy for at least 3 months can reduce the risk of these events. While vitamin K antagonist is the preferred oral anticoagulant, there is growing evidence to support the use of direct-acting oral anticoagulants in LVT management. Cardiac magnetic resonance has shown the highest diagnostic accuracy for LVT assessment, followed by echocardiography with contrast agents. This article serves as a general review of the pathophysiology, diagnosis, and management of LVT.
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Efficacy of a Health Belief Model-Based Intervention for Anticoagulant Adherence in Patients With Atrial Fibrillation: A Randomized Controlled Trial. Res Theory Nurs Pract 2022. [DOI: 10.1891/rtnp-2021-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: Evidence supports anticoagulants' efficacy in reducing the risk of stroke in patients with atrial fibrillation. However, poor anticoagulant adherence increases the risks of stroke and bleeding.Aim: The study aims to test the efficacy of a health belief model-based intervention for improving the primary outcome, adherence to anticoagulant therapy, and the secondary outcomes, knowledge, beliefs, and self-efficacy of anticoagulant therapy.Methods: The study is a parallel randomized trial with a 1:1 allocation ratio. A convenience sample of 72 patients treated with anticoagulants for atrial fibrillation was recruited from cardiology clinics in Taiwan. They were randomly assigned to either the control or intervention groups. The health belief model-based intervention comprises a 60-minute individual face-to-face instruction and six follow-up telephone calls. A blinded outcome assessor collected self-report data from both groups at baseline (T1), 12th week (T2), and 24th week (T3).Results: A generalized estimating equation showed significant group-by-time interaction effects on both adherence to and knowledge of anticoagulant therapy. The intervention group showed significantly greater improvements in adherence (ß = -1.25, 95% CI: -2.46 to -0.04) and knowledge (ß = 17.93, 95% CI: 4.63–31.23) across the three time points than the control group did. However, there was no significant between-group difference in self-efficacy, perceived benefit, or perceived barriers to adherence.Conclusion: The study results support the intervention's efficacy on improving adherence to and knowledge of anticoagulant therapy among patients with atrial fibrillation, but no effect on other essential concepts health belief model.
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Batran RA, Sabri NA, Ali I, Fahmy SF. Cost-Effectiveness of the Pharmacist-Managed Warfarin Therapy vs. Standard Care for Patients With Mechanical Mitral Valve Prostheses: An Egyptian Healthcare Perspective. Front Cardiovasc Med 2022; 9:889197. [PMID: 35911528 PMCID: PMC9327740 DOI: 10.3389/fcvm.2022.889197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022] Open
Abstract
Background Despite warfarin therapy had been used for decades for patients with mechanical mitral valve prostheses (MMVPs), serious and life-threatening complications are still reported worldwide with a significant economic burden. This study is aimed at assessing the clinical and the cost-effectiveness of adopting pharmacist-managed warfarin therapy (PMWT) services for optimizing warfarin treatment in Egypt. Methods A prospective randomized trial in which 59 patients with MMVPs were randomly assigned to receive the PMWT services or the standard care and followed up for 1 year. The primary outcome was percentage time in the therapeutic range (TTR). For the cost-effectiveness analysis, a Markov cohort process model with nine mutually exclusive health states was developed from a medical provider’s perspective. A lifetime horizon was applied. All costs and outcomes were discounted at 3.5% annually. Results The study results revealed a significantly higher median TTR in the intervention group as compared to the control group; 96.8% [interquartile range (IQR) 77.9–100%] vs. 73.1% (52.7–95.1%), respectively, p = 0.008. A significant association between standard care and poor anticoagulation control (p = 0.021) was demonstrated by the multivariate regression analysis. For the cost-effectiveness analysis, the total cumulative quality-adjusted life-years (QALYs) and total costs per patient were 21.53 and 10.43; 436.38 and 1,242.25 United States dollar (USD) in the intervention and the control groups, respectively, with an incremental cost-effectiveness ratio (ICER) of −72.5796 for the intervention group. Conclusion The PMWT strategy was proven to provide a significantly better anticoagulation control and to be a cost-saving approach in Egyptian patients with MMVPs. Nevertheless, the dominance of this strategy is sustained by maintaining the therapeutic International Normalized Ratio (INR) control within the recommended range. Our findings will benefit Egyptian policy-makers who may seek novel health strategies for better resource allocation. Clinical Trial Registration [ClinicalTrials.gov], identifier [NCT04409613].
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Affiliation(s)
- Radwa Ahmed Batran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | - Nagwa Ali Sabri
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
- *Correspondence: Nagwa Ali Sabri, , orcid.org/0000-0002-2611-4853
| | - Ihab Ali
- Department of Cardiothoracic Surgery, Cardiothoracic Surgery Academy, Ain Shams University, Cairo, Egypt
| | - Sarah Farid Fahmy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
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Esteve-Pastor MA, Ruiz-Ortiz M, Muñiz J, Roldán-Rabadán I, Otero D, Cequier Á, Bertomeu-Martínez V, Badimón L, Anguita M, Lip GYH, Marín F. Impact of Integrated Care Management on Clinical Outcomes in Atrial Fibrillation Patients: A Report From the FANTASIIA Registry. Front Cardiovasc Med 2022; 9:856222. [PMID: 35586656 PMCID: PMC9108173 DOI: 10.3389/fcvm.2022.856222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 04/05/2022] [Indexed: 11/28/2022] Open
Abstract
Background An integrated and holistic approach is increasingly advocated in patients with atrial fibrillation (AF), based on the “Atrial fibrillation Better Care (ABC) pathway: A, Avoid stroke with anticoagulation; B, better symptom management; C, cardiovascular and comorbidity risk management.” The aim of this study was to examine the prevalence of adherence to each component of the ABC pathway and to analyze its impact on long-term prognosis in the “real-world” cohort of AF patients from the FANTASIIA registry. Methods This prospective study included consecutive AF outpatients anticoagulated with direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA) from June 2013 to October 2014. From the ABC pathway, adherence to the “A criterion” was defined by a time in the therapeutic range (TTR) ≥ 70% or correct dose with DOAC; “B criterion” adherence was defined by a European Heart Rhythm Association (EHRA) Symptom Scale I-II; and “C criterion” adherence was defined as optimized risk factors and comorbidity management. Baseline features and embolic events, severe bleeding, and all-cause and cardiovascular mortality rates up to 3 years of follow-up were analyzed, and a Cox multivariate analysis was performed to investigate the role of each component of the ABC pathway in predicting major events. Results A total of 1,955 AF patients (age: 74.4 ± 9.4 years; 43.2% female patients) were included in this study: adherence to A criterion was observed in 920 (47.1%) patients; adherence to B criterion was observed in 1,791 (91.6%) patients; and adherence to C criterion was observed in 682 (34.8%) patients. Only 394 (20.2%) of the whole population had good control of AF according to the ABC pathway. After a median follow-up of 1,078 days (IQR: 766–1,113), adherence to A criterion was independently associated with reduced cardiovascular mortality [HR: 0.67, 95%CI (0.45–0.99); p = 0.048] compared with non-adherence. Adherence to the B criterion was independently associated with reduced stroke [HR: 0.28, 95%CI (0.14–0.59); p < 0.001], all-cause mortality [HR: 0.49, 95%CI (0.35–0.69); p < 0.001], cardiovascular mortality [HR: 0.39, 95%CI (0.25–0.62); p < 0.001], and major adverse cardiovascular events (MACE) [HR: 0.41, 95%CI (0.28–0.62); p < 0.001] compared with non-adherence. AF patients with C criterion adherence had a significantly lower risk of myocardial infarction [HR: 0.31, 95%CI (0.15–0.66); p < 0.001]. Fully adherent ABC patients had a significant reduction in MACE [HR: 0.64, 95%CI (0.42–0.99); p = 0.042]. Conclusion In real-world anticoagulated AF patients from FANTASIIA registry, we observed a lack of adherence to integrated care management of AF following the ABC pathway. AF managed according to the ABC pathway was associated with a significant reduction in adverse outcomes during long follow-up, suggesting the benefit of a holistic and integrated approach to AF management.
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Affiliation(s)
- María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, CIBERCV, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Martín Ruiz-Ortiz
- Department of Cardiology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Javier Muñiz
- Grupo de Investigación Cardiovascular, Departamento de Ciencias de la Salud e Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, Universidade da Coruña, A Coruña, Spain
| | | | | | - Ángel Cequier
- Department of Cardiology, Hospital de Bellvitge, CIBERCV, Barcelona, Spain
| | | | - Lina Badimón
- Cardiovascular Research Center (CSIC-ICCC), Hospital de la Santa Creu i Sant Pau, CIBERCV, IIB-Sant Pau, Barcelona, Spain
| | - Manuel Anguita
- Department of Cardiology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, CIBERCV, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
- *Correspondence: Francisco Marín,
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Roldán V, Martínez-Montesinos L, López-Gálvez R, García-Tomás L, Lip GYH, Rivera-Caravaca JM, Marín F. Relation of the 'Atrial Fibrillation Better Care (ABC) Pathway' to the Quality of Anticoagulation in Atrial Fibrillation Patients Taking Vitamin K Antagonists. J Pers Med 2022; 12:jpm12030487. [PMID: 35330486 PMCID: PMC8954236 DOI: 10.3390/jpm12030487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/11/2022] [Accepted: 03/16/2022] [Indexed: 01/17/2023] Open
Abstract
The Atrial Fibrillation Better Care (ABC) pathway was proposed for a more integrated atrial fibrillation (AF) care. We investigated if adherence to the ABC pathway was associated to the quality of anticoagulation control in a cohort of AF outpatients starting vitamin K antagonists (VKAs) between July 2016 and June 2018. Patients were considered adherent to the ABC pathway if they met all of its components. The time in therapeutic range (TTR) was estimated at one year. In total, 1045 patients (51.6% female; median age 77 years; 63% ABC pathway adherent) were included. At one year, 474 (51.6%) of 919 patients with international normalized ratio (INR) data for TTR estimation had a TTR < 65%. Among ABC pathway non-adherent patients, a greater proportion had TRT < 65% (56.4% vs. 43.6%, p = 0.025), and TTR < 70% (64.9% vs. 35.1%, p = 0.033), with lower mean TTR in non-adherent patients (59.4 ± 22.3% vs. 63.9 ± 21.1%; p = 0.004). Logistic regression models demonstrated that the ABC pathway adherence in its continuous (aOR: 0.75, 95% CI 0.59−0.96) and categorical (aOR: 0.75, 95% CI 0.57−0.98) forms was independently associated with TTR ≥ 65%. In this ‘real-world’ cohort of AF patients starting VKAs, the ABC pathway adherent patients had better TTR, and more ABC criteria fulfilled increased the probability of achieving good TTR.
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Affiliation(s)
- Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), 30008 Murcia, Spain; (V.R.); (L.M.-M.); (L.G.-T.)
| | - Lorena Martínez-Montesinos
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), 30008 Murcia, Spain; (V.R.); (L.M.-M.); (L.G.-T.)
| | - Raquel López-Gálvez
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (R.L.-G.); (F.M.)
| | - Lucía García-Tomás
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), 30008 Murcia, Spain; (V.R.); (L.M.-M.); (L.G.-T.)
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK;
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (R.L.-G.); (F.M.)
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK;
- Correspondence:
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (R.L.-G.); (F.M.)
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Farinha JM, Jones ID, Lip GYH. Optimizing adherence and persistence to non-vitamin K antagonist oral anticoagulant therapy in atrial fibrillation. Eur Heart J Suppl 2022; 24:A42-A55. [PMID: 35185408 PMCID: PMC8850710 DOI: 10.1093/eurheartj/suab152] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke, which can be prevented by the use of oral anticoagulation. Although non-vitamin K antagonist oral anticoagulants (NOACs) have become the first choice for stroke prevention in the majority of patients with non-valvular AF, adherence and persistence to these medications remain suboptimal, which may translate into poor health outcomes and increased healthcare costs. Factors influencing adherence and persistence have been suggested to be patient-related, physician-related, and healthcare system-related. In this review, we discuss factors influencing patient adherence and persistence to NOACs and possible problem solving strategies, especially involving an integrated care management, aiming for the improvement in patient outcomes and treatment satisfaction.
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Affiliation(s)
- José Maria Farinha
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Ian D Jones
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- School of Nursing and Allied Health, Liverpool John Moores University, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Jiang S, Lv M, Wu T, Chen W, Zhang J. A smartphone application for remote adjustment of warfarin dose: Development and usability study. Appl Nurs Res 2022; 63:151521. [PMID: 35034699 DOI: 10.1016/j.apnr.2021.151521] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/17/2021] [Accepted: 10/30/2021] [Indexed: 10/19/2022]
Abstract
AIM The aim of this article is (a) to design and develop a smartphone app called Alfalfa that can provide remote dose adjustment (b) to evaluate its usability. BACKGROUND Patients taking warfarin need to spend substantial time, money, and energy frequently visiting the hospital in order to adjust its dose. Internet technology may be able to provide convenient dose adjustment services for these patients. METHODS We thought and discussed repeatedly about how to ensure the safety and effectiveness of remote administration of warfarin, and finally designed and developed the Alfalfa app. In addition, patients and medical practitioners were invited to participate in a system usability scale (SUS) to assess the usability of Alfalfa. RESULTS As of July 5, 2021, the number of Alfalfa accounts was 1736, including 1624 patients and 112 medical staff, and it provided a total of 12,968 remote dose adjustments. A total of 26 people participated in the questionnaire, including 15 patients and 11 medical staff. The results of SUS show that the usability score of patient terminal and medical terminal is 61.8 and 82.7, respectively. And age does not affect the usability of patient terminal. The usability of the Alfalfa app was rated similarly by younger and older adults (63.5 vs. 58.5, P = .535). CONCLUSIONS This study proves that the Alfalfa app can be used for remote management of warfarin. The usability of medical terminal is acceptable to medical practitioners, while the usability of patient terminal needs further improvement. TRIAL REGISTRATION ChiCTR1900021920.
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Affiliation(s)
- Shaojun Jiang
- Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou 350001, Fujian, China
| | - Meina Lv
- Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou 350001, Fujian, China
| | - Tingting Wu
- Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou 350001, Fujian, China
| | - Wenjun Chen
- Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou 350001, Fujian, China
| | - Jinhua Zhang
- Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou 350001, Fujian, China.
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Senoo K, Miki T, Ohkura T, Iwakoshi H, Nishimura T, Shiraishi H, Teramukai S, Matoba S. A Smartphone App to Improve Oral Anticoagulation Adherence in Patients With Atrial Fibrillation: Prospective Observational Study. JMIR Mhealth Uhealth 2022; 10:e30807. [PMID: 34894626 PMCID: PMC8783280 DOI: 10.2196/30807] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 11/25/2021] [Accepted: 12/07/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Poor adherence to oral anticoagulation in elderly patients with atrial fibrillation (AF) has been shown to negatively impact health care costs, morbidity, and mortality. Although various methods such as automated reminders, counseling, telephone support, and patient education have been effective in improving medication adherence, the burden on health care providers has been considerable. Recently, an attempt has been made to improve medication adherence without burdening health care providers by using smartphone apps; however, the use of the app for elderly patients with AF is still limited. OBJECTIVE The purpose of this study was to determine whether the newly developed smartphone app for patients with AF (the Smart AF), which integrates education, automatic reminder, and patient engagement strategies with a simple user interface, can improve medication adherence in elderly patients with AF. METHODS Patient enrollment was carried out by obtaining informed consent from patients with AF attending Kyoto Prefectural University of Medicine hospital between May 2019 and September 2020. Follow-up was planned at 1, 3, and 6 months after enrollment, and questionnaire reminders were automatically sent to patient apps at designated follow-up time points. A questionnaire-based survey of medication adherence was performed electronically using the self-reported 8-item Morisky Medication Adherence Scale (MMAS-8) as the survey tool. RESULTS A total of 136 patients with AF were enrolled in this study. During the follow-up period, 112 (82%) patients underwent follow-up at 1 month, 107 (79%) at 3 months, and 96 (71%) at 6 months. The mean age of the enrolled patients was 64.3 years (SD 9.6), and male participants accounted for 79.4% (108/136) of the study population. The mean CHADS2 (congestive heart failure, hypertension, age, diabetes, previous stroke, or transient ischemic attack) score was 1.2, with hypertension being the most common comorbidity. At the time of enrollment, 126 (93%) and 10 (7%) patients were taking direct oral anticoagulants and warfarin, respectively. For medication adherence as measured according to the MMAS-8, MMAS scores at 1 month, 3 months, and 6 months were significantly improved compared with baseline MMAS scores (all P values less than .01). The overall improvement in medication adherence achieved by the 6-month intervention was as follows: 77.8% (14/18) of the patients in the high adherence group (score=8) at baseline remained in the same state, 45.3% (24/53) of the patients in the medium adherence group (score=6 to <8) at baseline moved to the high adherence group, and 72% (18/25) of the patients in the low adherence group (score <6) moved to either the medium or high adherence group. CONCLUSIONS The Smart AF app improved medication adherence among elderly patients with AF. In the realm of medication management, an approach using a mobile health technology that emphasizes education, automatic reminder, and patient engagement may be helpful.
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Affiliation(s)
- Keitaro Senoo
- Department of Cardiac Arrhythmia Research and Innovation, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomonori Miki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takashi Ohkura
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hibiki Iwakoshi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuro Nishimura
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hirokazu Shiraishi
- Department of Cardiac Arrhythmia Research and Innovation, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Teramukai
- Departments of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiac Arrhythmia Research and Innovation, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Dsouza JP, Chakrabarty J, Ramachandran P, Guddattu V, Nayak BS, George A. Effectiveness of a Nursing Intervention Module on Adherence, Knowledge, Quality of Life, and Complications Among Patients Receiving Anticoagulation therapy-a Randomized Controlled Trial Protocol. Patient Prefer Adherence 2022; 16:1723-1731. [PMID: 35903081 PMCID: PMC9314451 DOI: 10.2147/ppa.s365585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Cardiovascular diseases are one of the major causes of mortality at the global level. They account for approximately 17.9 million deaths per year. Warfarin and acenocoumarol are the commonly used oral anticoagulants to treat and prevent thromboembolic disorders in patients with cardiovascular diseases. In India, approximately 2-2.5 million patients with rheumatic heart disease are receiving oral anticoagulation therapy. Additionally, this therapy is provided for stroke prevention in the case of atrial fibrillation and the treatment of valvular heart disease, stroke, and deep vein thrombosis. As the therapeutic range of these drugs is narrow and is affected by many factors, their use is challenging. This study aims to evaluate the effectiveness of a nursing intervention module in terms of adherence to therapy, knowledge, quality of life, and complications among patients receiving oral anticoagulation therapy. Furthermore, this study will address factors that affect adherence and the risk for bleeding by using a randomized controlled trial design. METHODS This single-blind, single-center, randomized controlled trial will focus on adherence to oral anticoagulation therapy. A total of 320 patients who are on oral anticoagulation therapy will be randomized into blocks and allocated to either the intervention or standard care group. The intervention will comprise the use of a nursing intervention module that includes a booklet, log sheet, and decision aid on oral anticoagulation therapy adherence. Outcome measures, that is, knowledge regarding oral anticoagulation therapy, adherence, complications, and quality of life, will be assessed at the baseline and during follow-ups. DISCUSSION Patient safety can be best achieved through patients' adherence to medication dose and monitoring of blood test values. Thromboembolic and bleeding complications are likely to occur when either the patient does not adhere to the treatment or the therapeutic range of the international normalized ratio is not maintained. This study will assess the nonadherence behavior and the effectiveness of a nursing intervention module toward adherence behavior. TRIAL REGISTRATION This research project is registered under the Clinical Trial Registry of India (CTRI/2019/06/019610).
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Affiliation(s)
- Janet Prameela Dsouza
- Department of Medical-Surgical Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Jyothi Chakrabarty
- Department of Medical-Surgical Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India
- Correspondence: Jyothi Chakrabarty, Professor and Head, Department of Medical-Surgical Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India, Tel +91 9880078542, Email
| | - Padmakumar Ramachandran
- Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
- Padmakumar Ramachandran, Professor and Unit Head, Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India, Tel +91 9900921428, Email
| | - Vasudeva Guddattu
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Baby S Nayak
- Department of Child Health Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Anice George
- Department of Child Health Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Pharmacist-Facilitated Interactive E-Learning for Patients Newly Initiated on Warfarin: A Randomised Controlled Study. PHARMACY (BASEL, SWITZERLAND) 2021; 10:pharmacy10010003. [PMID: 35076593 PMCID: PMC8788505 DOI: 10.3390/pharmacy10010003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 01/31/2023]
Abstract
It is not known whether electronic-learning (e-learning) is effective for educating hospital inpatients about complex medications such as warfarin. This prospective randomised controlled study compared pharmacist-facilitated e-learning with standard pharmacist-delivered face-to-face education on patients’ or their unpaid carers’ knowledge of warfarin and satisfaction with warfarin education as well as the time that was spent by pharmacists in delivering warfarin education. Adult English-speaking patients (or their carers) who had been prescribed warfarin were randomised to receive standard pharmacist face-to-face education (control) or an e-learning module on a tablet device facilitated by a pharmacist (intervention). All of the participants received written warfarin information and were presented with the opportunity to ask any questions that they may have had to a pharmacist. Fifty-four participants completed the study (27 per group). The participants who received e-learning had median correct Oral Anticoagulation Knowledge (OAK) test scores of 85% compared to 80% for standard education (p = 0.14). The participants in both groups were satisfied with the information that they received. There was a trend towards pharmacists spending less time on warfarin education for the e-learning group than in the standard education group (25.5 vs. 33 min, respectively, p = 0.05). Education delivered via pharmacist-facilitated e-learning was non-inferior in terms of patient or carer warfarin knowledge compared to standard pharmacist-delivered education.
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Osasu YM, Cooper R, Mitchell C. Patients' and clinicians' perceptions of oral anticoagulants in atrial fibrillation: a systematic narrative review and meta-analysis. BMC FAMILY PRACTICE 2021; 22:254. [PMID: 34937557 PMCID: PMC8697449 DOI: 10.1186/s12875-021-01590-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 11/22/2021] [Indexed: 11/10/2022]
Abstract
Background Atrial fibrillation (AF) increases the risk of developing a stroke by 20%. AF related strokes are associated with greater morbidity. Historically, warfarin was the anticoagulant of choice for stroke prevention in patients with AF but lately patients are being switched or started on direct oral anticoagulants (DOACs). DOACs are promoted as safer alternatives to warfarin and it is expected that they will be associated with fewer challenges both for patients and healthcare professionals. This systematic narrative review aimed to explore perspectives of patients and professionals on medicines optimisation of oral anticoagulation with vitamin K antagonists and DOACs in atrial fibrillation. Methods Prospero registration CRD42018091591. Systematic searches undertaken of research studies (qualitative and quantitative), published February 2018 to November 2020 from several databases (Web of Science, Scopus, Medline Via Ovid, CINHAL via Ebsco, and PubMED via NCBI) following PRISMA methodology. Data were organised using Covidence software. Two reviewers independently assessed the quality of the included studies and synthesized the findings (thematic analysis approach). Results Thirty-four studies were included. Studies were critically appraised using established critical appraisal tools (Qualsyst) and a risk of bias was assigned. Clinicians considered old age and the associated complexities such as co-morbidities and the increased potential for bleeding as potential barriers to optimising anticoagulation. Whereas patients’ health and medication beliefs influenced adherence. Notably, structured patient support was important in enhancing safety and effective anticoagulation. For both patients and clinicians, confidence and experience of safe anticoagulation was influenced by the presence of co-morbidities, poor knowledge and understanding of AF and the purpose of anticoagulation. Conclusion Age, complex multimorbidity and polypharmacy influence prescribing, with DOACs being perceived to be safer than warfarin. This systematic narrative review suggests that interventions are needed to support patient self-management. There are residual anxieties associated with long term anticoagulation in the context of complexities. Trial registration Not applicable.
Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01590-x.
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Affiliation(s)
- Yeyenta Mina Osasu
- Academic Unit of Primary Medical Care, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, S5 7AU, UK.
| | | | - Caroline Mitchell
- Academic Unit of Primary Medical Care, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, S5 7AU, UK
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Phrommintikul A, Nathisuwan S, Gunaparn S, Krittayaphong R, Wongcharoen W, Sehmi S, Mehta S, Winkles N, Brocklehurst P, Mathers J, Jowett S, Jolly K, Lane D, Thomas GN, Lip GYH. Prospective randomised trial examining the impact of an educational intervention versus usual care on anticoagulation therapy control based on an SAMe-TT 2R 2 score-guided strategy in anticoagulant-naïve Thai patients with atrial fibrillation (TREATS-AF): a study protocol. BMJ Open 2021; 11:e051987. [PMID: 34635526 PMCID: PMC8506852 DOI: 10.1136/bmjopen-2021-051987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The burden of atrial fibrillation (AF) in Thailand is high and associated with increased morbidity, mortality and healthcare costs. Vitamin K antagonists (eg, warfarin), commonly used for stroke prevention in patients with AF in Thailand, are effective but are often suboptimally controlled. We aim to evaluate the impact of an SAMe-TT2R2 score-guided strategy and educational intervention compared to usual care on anticoagulation control expressed by the time in therapeutic range (TTR) at 12 months, in anticoagulant-naïve Thai patients with AF. METHODS AND ANALYSIS Multicentre, open-label, parallel-group, randomised controlled trial conducted in Thailand among adult patients (age: 18 years) with AF who are anticoagulant naïve. Patients will be randomised to one of two groups; an SAMe-TT2R2 score-guided strategy with educational intervention and usual care versus usual care alone. The planned follow-up period is 12 months. The primary outcome is TTR at 12 months. Secondary outcomes include: (1) TTR at 6 months; (2) thromboembolic and bleeding events at 12 months; (3) composite major adverse cardiovascular events at 12 months; (4) change in patients' knowledge of AF between baseline and 6 months and 12 months; (5) cost effectiveness; (6) quality of life at baseline, 6 months and 12 months using EQ-5D-5L (Thai version) and (7) patient satisfaction/perceptions of the TREAT intervention. An embedded qualitative study will assess patient perceptions of the TREAT intervention. ETHICS AND DISSEMINATION The study has been approved by the Ethical Review Committee, Ministry of Public Health of Thailand, and registered in the Thai Clinical Trials Registry. The results of this trial will be submitted for publication in a peer-reviewed journal. Participants will be informed via a link to a preview of the publication. A lay summary will also be provided to all participants prior to publication. TRIAL REGISTRATION NUMBER TCTR20180711003.
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Affiliation(s)
- Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center for Medical Excellence, Faculty of Medicine, Chiang Mai, Thailand
| | - Surakit Nathisuwan
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Siriluck Gunaparn
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sukhi Sehmi
- Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Samir Mehta
- Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Neil Winkles
- Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Jonathan Mathers
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sue Jowett
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Deirdre Lane
- Department of Cardiovascular Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - G Neil Thomas
- Department of Public Health and Epidemiology, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg Universitet, Aalborg, Denmark
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Rivera-Caravaca JM, Harrison SL, Buckley BJR, Fazio-Eynullayeva E, Underhill P, Marín F, Lip GYH. Efficacy and safety of direct-acting oral anticoagulants compared to vitamin K antagonists in COVID-19 outpatients with cardiometabolic diseases. Cardiovasc Diabetol 2021; 20:176. [PMID: 34481513 PMCID: PMC8417638 DOI: 10.1186/s12933-021-01368-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/23/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND It remains uncertain if prior use of oral anticoagulants (OACs) in COVID-19 outpatients with multimorbidity impacts prognosis, especially if cardiometabolic diseases are present. Clinical outcomes 30-days after COVID-19 diagnosis were compared between outpatients with cardiometabolic disease receiving vitamin K antagonist (VKA) or direct-acting OAC (DOAC) therapy at time of COVID-19 diagnosis. METHODS A study was conducted using TriNetX, a global federated health research network. Adult outpatients with cardiometabolic disease (i.e. diabetes mellitus and any disease of the circulatory system) treated with VKAs or DOACs at time of COVID-19 diagnosis between 20-Jan-2020 and 15-Feb-2021 were included. Propensity score matching (PSM) was used to balance cohorts receiving VKAs and DOACs. The primary outcomes were all-cause mortality, intensive care unit (ICU) admission/mechanical ventilation (MV) necessity, intracranial haemorrhage (ICH)/gastrointestinal bleeding, and the composite of any arterial or venous thrombotic event(s) at 30-days after COVID-19 diagnosis. RESULTS 2275 patients were included. After PSM, 1270 patients remained in the study (635 on VKAs; 635 on DOACs). VKA-treated patients had similar risks and 30-day event-free survival than patients on DOACs regarding all-cause mortality, ICU admission/MV necessity, and ICH/gastrointestinal bleeding. The risk of any arterial or venous thrombotic event was 43% higher in the VKA cohort (hazard ratio 1.43, 95% confidence interval 1.03-1.98; Log-Rank test p = 0.029). CONCLUSION In COVID-19 outpatients with cardiometabolic diseases, prior use of DOAC therapy compared to VKA therapy at the time of COVID-19 diagnosis demonstrated lower risk of arterial or venous thrombotic outcomes, without increasing the risk of bleeding.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Benjamin J R Buckley
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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[Improvement of knowledge of patients treated with an oral anticoagulant after a pharmaceutical interview at the hospital]. ANNALES PHARMACEUTIQUES FRANÇAISES 2021; 80:467-477. [PMID: 34481785 DOI: 10.1016/j.pharma.2021.08.007] [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: 09/17/2020] [Revised: 08/20/2021] [Accepted: 08/27/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Patients treated with oral anticoagulants need an adapted education in order to optimize the management of these treatments. The objective was to assess the knowledge of patients before and after a pharmaceutical interview carried out by pharmacy students on digital tablets at the hospital. METHODS A prospective study took place in the cardiology department, with a first phase from December 2016 to June 2018. Patient's knowledge were assessed during a pharmaceutical interview; additional informations were done for unacquired concepts. The second phase took place in October 2018, and patient's knowledge were assessed during a phone call for patients who had at least given one wrong answer on the four selected questions. RESULTS Sixty-eight and twenty-two patients were included respectively for phases 1 and 2 (mean age=70±3.4; treatments number=8.2±0.9). 36 patients were treated by Vitamin K antagonists and 32 by direct oral anticoagulants. 57% of patients with oral anticoagulants gave a good answer for principles of the treatment and the surveillance during phase 1, and 33% for signs of overdose. A significant improvement for the 22 patients with poor knowledge was observed in phase 2 (1.73 vs. 2.5; P=0.006). CONCLUSIONS The playful interview improves the patient's knowledge over time. Developing the relationship between the hospital and community pharmacists would allow us to optimize the patient follow-up.
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Examining Adherence to Medication in Patients With Atrial Fibrillation: The Role of Medication Beliefs, Attitudes, and Depression. J Cardiovasc Nurs 2021; 35:337-346. [PMID: 32084080 DOI: 10.1097/jcn.0000000000000650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND/OBJECTIVES This study examined whether beliefs about medicines, drug attitudes, and depression independently predicted anticoagulant and antiarrhythmic adherence (focusing on the implementation phase of nonadherence) in patients with atrial fibrillation (AF). METHODS This cross-sectional study was part of a larger longitudinal study. Patients with AF (N = 118) completed the Patient Health Questionnaire-8. The Beliefs about Medicines Questionnaire, Drug Attitude Inventory, and Morisky-Green-Levine Medication Adherence Scale (self-report adherence measure), related to anticoagulants and antiarrhythmics, were also completed. Correlation and multiple logistic regression analyses were conducted. RESULTS There were no significant differences in nonadherence to anticoagulants or antiarrhythmics. Greater concerns (r = 0.23, P = .01) were significantly, positively associated with anticoagulant nonadherence only. Depression and drug attitudes were not significantly associated with anticoagulant/antiarrhythmic adherence. Predictors reliably distinguished adherers and nonadherers to anticoagulant medication in the regression model, explaining 14% of the variance, but only concern beliefs (odds ratio, 1.20) made a significant independent contribution to prediction (χ = 11.40, P = .02, with df = 4). When entered independently into a regression model, concerns (odds ratio, 1.24) significantly explained 10.3% of the variance (χ = 7.97, P = .01, with df = 1). Regressions were not significant for antiarrhythmic medication (P = .30). CONCLUSIONS Specifying medication type is important when examining nonadherence in chronic conditions. Concerns about anticoagulants, rather than depression, were significantly associated with nonadherence to anticoagulants but not antiarrhythmics. Anticoagulant concerns should be targeted at AF clinics, with an aim to reduce nonadherence and potentially modifiable adverse outcomes such as stroke.
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Lin SY, Chen YW, Kang HC, Wu YJ, Chen PZ, Wu CW, Lin CS, Wu FLL, Shen LJ, Huang YM, Huang CF. Effects of a pharmacist-managed anticoagulation outpatient clinic in Taiwan: evaluation of patient knowledge, satisfaction, and clinical outcomes. Postgrad Med 2021; 133:964-973. [PMID: 34180349 DOI: 10.1080/00325481.2021.1949212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: The study aimed to evaluate the improvement of patient knowledge of warfarin use, satisfaction with pharmacists, and the quality of international normalized ratio (INR) control after the implementation of an anticoagulant clinic (ACC) service.Methods: This was a prospective single-group pre- and post-comparison study. Patients who were at least 20 years of age and participated in a pharmacist-managed ACC service were enrolled from February 2012 to September 2015. Each participant completed a self-administered questionnaire before and after the ACC service to evaluate changes in warfarin knowledge. Another questionnaire was distributed after the ACC to evaluate participants' satisfaction with the pharmacist service in the ACC. The INR levels before and after the ACC intervention were obtained to calculate the proportion of time spent in the therapeutic INR range (time in therapeutic range, TTR). Paired t-tests were used to compare changes in participants' knowledge related to warfarin use. Multiple linear regressions were performed to explore the predictors associated with the participants' knowledge scores and TTR after the ACC intervention.Results: One hundred and forty-eight participants were enrolled in this study. A significant improvement (31.5%,p<0.001) in the knowledge of warfarin use was observed at the end of the ACC intervention. The interaction between warfarin and food was the most confusing factor for participants in warfarin use. More than 95% of the participants perceived a positive value of the pharmacist-managed ACC service. However, the consultation fee was the least satisfactory of the ACC service. The average TTR increased from 51.0±34.3% to 78.6±24.5% (p<0.001) after the ACC service was implemented. Participants' education levels and baseline knowledge scores were significant determinants associated with the knowledge improvement in the appropriate warfarin use (p<0.001).Conclusions: A pharmacist-managed ACC improved patient knowledge of warfarin use and INR control, and led to high satisfaction with the pharmacist service in the ACC in Taiwan. Pharmacists should focus on patients with lower education levels to facilitate their understanding of the appropriate warfarin use for better health outcomes.
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Affiliation(s)
- Shin-Yi Lin
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Yi-Wen Chen
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Hao-Cheng Kang
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Yee-Jen Wu
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Pin-Zi Chen
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Chia-Wei Wu
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Chii-Shan Lin
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Fe-Lin Lin Wu
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei City, Taiwan.,Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei City, Taiwan.,National Taiwan University Cancer Center, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Li-Jiuan Shen
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei City, Taiwan.,Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Yen-Ming Huang
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Chih-Fen Huang
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei City, Taiwan
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Ivany E, Lane DA, Dan GA, Doehner W, Farkowski MM, Iliodromitis K, Lenarczyk R, Potpara TS. Antithrombotic therapy for stroke prevention in patients with atrial fibrillation who survive an intracerebral haemorrhage: results of an EHRA survey. Europace 2021; 23:806-814. [PMID: 34020460 DOI: 10.1093/europace/euaa423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/30/2020] [Indexed: 11/13/2022] Open
Abstract
The aim of this survey is to provide a snapshot of current practice regarding antithrombotic therapy (ATT) in patients with atrial fibrillation (AF) comorbid with intracerebral haemorrhage (ICH). An online survey was distributed to members of the European Heart Rhythm Association. A total of 163 clinicians responded, mostly cardiologists or electrophysiologists (87.7%), predominantly working in University hospitals (61.3%). Most respondents (47.2%) had seen one to five patients with AF comorbid with ICH in the last 12 months. Among patients sustaining an ICH on oral anticoagulation (OAC), 84.3% respondents would consider some form of ATT post-ICH, with 73.2% preferring to switch from a vitamin-K antagonist (VKA) to a non-VKA oral anticoagulant (NOAC) and 37.2% preferring to switch from one NOAC to another. Most (36.6%) would restart OAC >30 days post-ICH. Among patients considered unable to take OAC, left atrial appendage occlusion procedure was the therapy of choice in 73.3% respondents. When deciding on ATT, respondents considered patient's CHA2DS2-VASc score, ICH type, demographics, risk factors, and patient adherence. The main reason for not restarting or commencing ATT was concern about recurrent ICH (80.8%). National or international clinical guidelines would be advantageous to support decision-making (84.3%). Other helpful resources reported were multidisciplinary team involvement (46.9%) and patient education (82%). In summary, most survey respondents would prescribe OAC therapy for patients with AF who have sustained an ICH on OAC and would restart OAC >30 days post-ICH. The risk of recurrent ICH was the main reason for not prescribing any ATT post-ICH.
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Affiliation(s)
- Elena Ivany
- Liverpool Centre for Cardiovascular Science, University of Liverpool, 6 West Derby Street, Liverpool L7 8TX, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, 6 West Derby Street, Liverpool L7 8TX, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gheorghe-Andrei Dan
- 'Internal Medicine, Carol Davila' University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany.,Department of Cardiology (Virchow Klinikum), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michal M Farkowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | | | - Radoslaw Lenarczyk
- Department of Cardiology, Congenital Heart Defects and Electrotherapy, Medical University of Silesia, Silesian Center of Heart Disease, Zabrze, Poland
| | - Tatjana S Potpara
- Serbia School of Medicine, University of Belgrade, Belgrade, Serbia.,Department for Intensive Care in Cardiac Arrhythmias, Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
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31
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Kozieł M, Teutsch C, Bayer V, Lu S, Gurusamy VK, Halperin JL, Rothman KJ, Diener H, Ma C, Huisman MV, Lip GYH. Changes in anticoagulant prescription patterns over time for patients with atrial fibrillation around the world. J Arrhythm 2021; 37:990-1006. [PMID: 34386125 PMCID: PMC8339088 DOI: 10.1002/joa3.12588] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Prescribing patterns for stroke prevention in atrial fibrillation (AF) patients evolved with approval of non-Vitamin K antagonist oral anticoagulants (NOACs) over time. OBJECTIVES To assess changes in anticoagulant prescription patterns in various geographical regions upon first approval of a NOAC and to analyze the evolution of oral anticoagulants (OACs) use over time in relation to CHA2DS2-VASc and HAS-BLED risk profiles. METHODS Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) Phases II and III reported data on antithrombotic therapy for patients with newly diagnosed AF and ≥1 stroke risk factor. We focused on sites enrolling patients in both phases and reported treatment patterns for the first 4 years after initial NOAC approval. RESULTS From GLORIA-AF Phases II and III, 27 432 patients were eligible for this analysis. When contrasting the first year with the fourth year of enrolment, the proportion of NOAC prescriptions increased in Asia from 29.2% to 60.8%, in Europe from 53.4% to 75.8%, in North America from 49.0% to 73.9% and in Latin America from 55.7% to 71.1%. The proportion of Vitamin K antagonists (VKAs) use decreased across all regions over time, in Asia from 26.0% to 9.8%, in Europe from 35.5% to 16.8%, in North America from 28.9% to 12.1%, and in Latin America from 32.4% to 17.8%. In the multivariable analysis, factors associated with NOAC prescription were as follows: enrolment year, type of site, region, stroke and bleeding risk scores, and type and categorization of AF. CONCLUSIONS During 4 years after the approval of the first NOAC, NOAC use increased, while VKA use decreased, across all regions.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart and Chest HospitalLiverpoolUK
- Department of Cardiology and AngiologySilesian Centre for Heart DiseasesZabrzePoland
| | - Christine Teutsch
- Department of Clinical Development and Medical AffairsTherapeutic Area CardiometabolismBoehringer Ingelheim International GmbHIngelheimGermany
| | - Valentina Bayer
- Biostatistics and Data Sciences DepartmentBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
| | - Shihai Lu
- Biostatistics and Data Sciences DepartmentBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
| | | | | | | | | | - Chang‐Sheng Ma
- University of Duisburg‐EssenEssenGermany
- Cardiology DepartmentAtrial Fibrillation CenterBeijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Menno V. Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart and Chest HospitalLiverpoolUK
- Department of Cardiology and AngiologySilesian Centre for Heart DiseasesZabrzePoland
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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Rivera-Caravaca JM, Badimón L, Ferreira-Gonzalez I, Gómez-Doblas JJ, Roca-Luque I, Lekuona I, Jiménez-Candil J, Rodríguez-Padial L, González-Juanatey C, Calvo-Jambrina R, Fácila L, Ruiz-Ortiz M, Anguita M, Marín F. Variables affecting the quality of anticoagulation in atrial fibrillation patients newly initiating vitamin K antagonists: insights from the national and multicentre SULTAN registry. Europace 2021; 24:4-11. [PMID: 34115857 DOI: 10.1093/europace/euab131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/03/2021] [Indexed: 12/26/2022] Open
Abstract
AIMS Vitamin K antagonists (VKAs) are effective drugs reducing the risk for stroke in atrial fibrillation (AF), but the benefits derived from such therapy depend on the international normalized ratio (INR) maintenance in a narrow therapeutic range. Here, we aimed to determine independent variables driving poor anticoagulation control [defined as a time in therapeutic range (TTR) <65%] in a 'real world' national cohort of AF patients. METHODS AND RESULTS The SULTAN registry is a multicentre, prospective study, involving patients with non-valvular AF from 72 cardiology units expert in AF in Spain. At inclusion, all patients naïve for oral anticoagulation were started with VKAs for the first time. For the analysis, the first month of anticoagulation and those patients with <3 INR determinations were disregarded. Patients were followed up during 1 year. A total of 870 patients (53.9% male, the mean age of 73.6 ± 9.2 years, mean CHA2DS2-VASc and HAS-BLED of 3.3 ± 1.5 and 1.4 ± 0.9, respectively) were included in the full analysis set. In overall, 7889 INR determinations were available. At 1-year, the mean TTR was 63.1 ± 22.1% and 49.2% patients had a TTR < 65%. Multivariate Cox regression analysis showed that coronary artery disease [odds ratio (OR) 1.81, 95% confidence interval (CI) 1.14-2.87; P = 0.012] and amiodarone use (OR 1.54, 95% CI 1.01-2.34; P = 0.046) were independently associated with poor quality of anticoagulation (TTR <65%). CONCLUSION This study demonstrated that the quality of anticoagulation in AF patients newly starting VKAs is sub-optimal. Previous coronary artery disease and concomitant use of amiodarone were identified as independent variables affecting the poor quality of VKA therapy during the first year.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Ctra. Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Lina Badimón
- Cardiovascular Science Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, CIBERCV, Barcelona, Spain
| | - Ignacio Ferreira-Gonzalez
- Department of Cardiology, Vall d'Hebron University Hospital, Barcelona, and CIBER de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Juan José Gómez-Doblas
- Unidad de Gestión Clínica del Corazón, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), CIBERCV, Málaga, Spain
| | - Ivo Roca-Luque
- Department of Cardiology, Vall d'Hebron University Hospital, Barcelona, and CIBER de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Iñaki Lekuona
- Department of Cardiology, Hospital Galdakao, Bizkaia, Spain
| | | | | | | | - Román Calvo-Jambrina
- Coronary Unit, Department of Cardiology, Virgen Macarena University Hospital, Seville, Spain
| | - Lorenzo Fácila
- Department of Cardiology, Hospital General Universitario, University of Valencia, Valencia, Spain
| | - Martín Ruiz-Ortiz
- Department of Cardiology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Manuel Anguita
- Department of Cardiology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Ctra. Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
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Shiga T, Kimura T, Fukushima N, Yoshiyama Y, Iwade K, Mori F, Ajiro Y, Haruta S, Yamada Y, Sawada E, Hagiwara N. Electronic monitoring of adherence to once-daily and twice-daily direct oral anticoagulants in patients with atrial fibrillation: Baseline data from the SMAAP-AF trial. J Arrhythm 2021; 37:616-625. [PMID: 34141014 PMCID: PMC8207342 DOI: 10.1002/joa3.12532] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/06/2021] [Accepted: 03/11/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Nonadherence diminishes the efficacy of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF). This report presents the baseline survey results regarding medication adherence among NVAF patients who were treated with once-daily edoxaban or twice-daily apixaban from a randomized control trial of the effect of an educational intervention on DOAC adherence. METHODS We prospectively studied 301 NVAF patients who were treated with edoxaban (n = 175) or apixaban (n = 126) during the 12-week observation period. Adherence was measured with an electronic monitoring system and is expressed as the percentage of days with the correct doses in the measurement period (days). Adherence to DOAC therapy was defined based on the standard threshold (≥80%) or a strict threshold (≥90%). RESULTS Of the 301 patients, 33 had incomplete data or protocol deviations, leaving 268 patients (edoxaban 158 and apixaban 110) for the per-protocol baseline analysis. There was no difference in adherence (threshold ≥80%) between the groups (edoxaban 95% vs apixaban 91%, P = .2), but there was a lower proportion of patients with strict adherence (threshold ≥90%) among apixaban users than among edoxaban users (edoxaban 87% vs apixaban 76%, P = .02). Multivariate analysis showed a negative relationship between apixaban use and an adherence rate ≥90% (odds ratio 0.49, 95% confidence interval [CI]: 0.25-0.94). CONCLUSIONS Our study showed that the proportion of DOAC users with adherence (≥80%) did not differ between the groups, but the proportion of patients with strict adherence (≥90%) was lower among those using apixaban than among those using edoxaban.
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Affiliation(s)
- Tsuyoshi Shiga
- Department of CardiologyTokyo Women’s Medical UniversityTokyoJapan
- Department of Clinical Pharmacology and TherapeuticsThe Jikei University School of MedicineTokyoJapan
| | - Toshimi Kimura
- Department of PharmacyTokyo Women’s Medical University HospitalTokyoJapan
| | - Noritoshi Fukushima
- Department of Preventive Medicine and Public HealthTokyo Medical UniversityTokyoJapan
| | | | - Kazunori Iwade
- Department of CardiologyNational Hospital Organization Yokohama Medical CenterYokohamaJapan
| | - Fumiaki Mori
- Department of CardiologyNational Hospital Organization Yokohama Medical CenterYokohamaJapan
| | - Yoichi Ajiro
- Department of CardiologyNational Hospital Organization Yokohama Medical CenterYokohamaJapan
| | - Shoji Haruta
- Department of CardiologyTokyo Women’s Medical University Yachiyo Medical CenterYachiyoJapan
| | - Yuichiro Yamada
- Department of CardiologyTokyo Women’s Medical University Yachiyo Medical CenterYachiyoJapan
| | - Emi Sawada
- Department of CardiologyTokyo Women’s Medical UniversityTokyoJapan
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Jeddou KB, Abbassi A, M'barka FB, Bedoui Y, Boukhris I, Baccar H, Khalfallah N, Ouahchi Z. Evaluation of anticoagulant therapy management in a teaching hospital in Tunisia: information and education for vitamin k antagonist newly treated patients need to be improved. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2021; 29:389-393. [PMID: 34014322 DOI: 10.1093/ijpp/riab024] [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: 07/15/2020] [Accepted: 04/30/2021] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The objective of this study was to assess the level of Vitamin K antagonist (VKA) therapy knowledge among VKA newly treated patients. METHODS Questionnaire-based interviews were administered in a university hospital to VKA newly treated patients covering both cognitive (i.e. indication, route of administration, treatment monitoring and side effects) and know-how (i.e. safety precautions, what affects anticoagulant therapy and the management of overdose signs) aspects of therapy knowledge. KEY FINDINGS A total of 55 patients were included. The mean overall score of patients' knowledge was 5.78 (SD = 3.425) out of 20. The mean scores of cognitive and practical knowledge were 3.8 (2.26) and 1.98 (1.78) out of 10, respectively. Factors associated with an insufficient level of VKA therapy knowledge included low level of education, lack of access to therapy information and continuous access to this information. CONCLUSIONS Knowledge about VKA therapy among newly treated patients is insufficient. Patient's medication knowledge should be improved to ensure better adherence.
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Affiliation(s)
| | - Aïmen Abbassi
- Department of Pharmacy, Charles Nicolle Hospital, Tunis, Tunisia
| | | | - Yosra Bedoui
- Department of Pharmacy, Charles Nicolle Hospital, Tunis, Tunisia
| | - Imene Boukhris
- Department of Internal Medicine, Charles Nicolle Hospital, Tunis, Tunisia
| | - Hédi Baccar
- Department of Cardiology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Narjess Khalfallah
- Department of Internal Medicine, Charles Nicolle Hospital, Tunis El Manar University, Tunis, Tunisia
| | - Zeineb Ouahchi
- Department of Pharmacy, Charles Nicolle Hospital, Tunis, Tunisia
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35
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Oh YH, Hwang SY. Individualized education focusing on self-management improved the knowledge and self-management behaviour of elderly people with atrial fibrillation: A randomized controlled trial. Int J Nurs Pract 2021; 27:e12902. [PMID: 33660379 DOI: 10.1111/ijn.12902] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 10/09/2020] [Accepted: 11/01/2020] [Indexed: 11/28/2022]
Abstract
AIM This study examined the effect of an individualized educational intervention on the knowledge, attitudes and self-management ability after 12 weeks for outpatients with atrial fibrillation. METHODS A randomized control-group pretest-post-test experimental design was used. Elderly outpatients with atrial fibrillation aged over 65 years were recruited from a university hospital in Korea. The experimental group received a 50-min individualized education on self-management, one telephone counselling after 8 weeks and maintenance of a self-management diary for 12 weeks. Data were collected from November 2017 to April 2018 and analysed using SPSS 22.0 for descriptive statistics and hypothesis testing. RESULTS The participants' mean age was 71.9 (4.6) years. Compared to the control group (n = 29), the experimental group (n = 31) showed a significantly greater improvement in knowledge regarding atrial fibrillation and stroke prevention (t = -2.27, p = .027) and self-management behaviours (t = -8.02, p < .001). There were no significant group differences in attitudes towards atrial fibrillation. CONCLUSION The findings suggest that education for elderly people with atrial fibrillation should be individualized, focusing on self-management in daily life to prevent cardiovascular complications. Future research is needed to confirm the long-term effects of such education programmes.
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Affiliation(s)
- Yun Hee Oh
- Department of Nursing, Cheju Halla University, Jeju, South Korea
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37
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Lo FMW, Wong EML, Hong FKW. The Effects of Educational Programs on Knowledge, International Normalized Ratio, Warfarin Adherence, and Warfarin-Related Complications in Patients Receiving Warfarin Therapy: An Integrative Review. J Cardiovasc Nurs 2021; 37:E32-E46. [PMID: 33657063 DOI: 10.1097/jcn.0000000000000790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Education is considered a crucial element in anticoagulation management for patients with atrial fibrillation, valvular disease, ischemic heart disease, and venous thromboembolism. However, the effects of education on the patients prescribed warfarin are seldom investigated. OBJECTIVES This integrative review was conducted to explore the effects of educational programs on patients prescribed warfarin for the aforementioned cardiovascular diseases and to identify the components of effective programs. METHODS A systematic search of clinical trials was performed in 8 databases from inception to August 2020. Two reviewers performed the eligibility assessment, methodological evaluation, and data extraction. A total of 9 studies were included and analyzed via narrative synthesis. RESULTS Nine studies involving a combined total of 1335 patients were included in the review. The findings suggest that educational programs have potential benefits related to international normalized ratio control and warfarin knowledge. However, their effects on major bleeding and thromboembolic events are unremarkable. Stronger evidence is recommended to confirm these findings, and the limited evidence examining the effects of education on warfarin adherence, minor bleeding, abnormal international normalized ratio, readmission rate, and warfarin-related mortality requires further exploration. Verbal education supported by written materials was the main educational delivery mode. A lecture length of approximately 45 minutes was likely appropriate. Notably, the integration of educational strategies, application of follow-up interventions and monitoring measures, adoption of psychological theories in program development, and inclusion of nurses or pharmacists in program conduction seemed to be effective program components. CONCLUSIONS The effects of educational programs on patients prescribed warfarin mainly for atrial fibrillation, valvular disease, ischemic heart disease, and venous thromboembolism remain inconclusive. Further research using randomized controlled trials is warranted.
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Affiliation(s)
- Flora M W Lo
- Flora M. W. Lo, MN Student, Doctor of Health Science, The Hong Kong Polytechnic University, Hong Kong. Eliza M. L. Wong, PhD Principal Research Fellow, School of Nursing, The Hong Kong Polytechnic University, Hong Kong. Felix K. W. Hong, MN Nurse, Nursing Department, Kiang Wu Hospital, Macao, China
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5238] [Impact Index Per Article: 1746.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Ng VWS, Siu CW, Chiu PKC, Kng CPL, Jamieson E, Wong ICK, Lam MPS. Understanding the barriers to using oral anticoagulants among long-term aspirin users with atrial fibrillation - a qualitative study. BMC Health Serv Res 2020; 20:1084. [PMID: 33238989 PMCID: PMC7691100 DOI: 10.1186/s12913-020-05947-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite international treatment guidelines currently advocating oral anticoagulants (OACs) as the only appropriate stroke prevention therapy for patients with atrial fibrillation (AF) and evidence that OACs can greatly reduce the risk of stroke with similar risk of bleeding compared with aspirin, the underuse of OACs in patients with AF is common globally, especially in Asia. This study aimed to identify the barriers to prescribing and using OACs among long-term aspirin users with AF. METHOD Face-to-face interviews were conducted with fourteen eligible patients with AF using a semi-structured interview guide. The interview recordings were transcribed verbatim and data was analyzed according to the principles of thematic analysis. RESULTS Five themes were developed: awareness of AF symptoms and diagnosis; knowledge and understanding of AF and stroke prevention therapy; role of decision-making in prescribing; willingness to switch from aspirin to OACs; and impact of OAC regimen on daily living. The majority of the patients were not aware of the symptoms and diagnosis of AF and only had a vague understanding of the illness and stroke prevention therapy, leading to their minimal involvement in decisions relating to their treatment. Some patients and their caregivers were particularly concerned about the bleeding complications from OACs and perceived aspirin to be a suitable alternative as they find the adverse effects from aspirin manageable and so preferred to remain on aspirin if switching to OACs was not compulsory. Lastly, the lifestyle modifications required when using warfarin, e.g. alternative dosing regimen, diet restriction, were seen as barriers to some patients and caregivers. CONCLUSION The findings revealed patients' knowledge gap in AF management which may be targeted using educational interventions to improve patients' understanding of AF and its management and hence encourage active participation in the decision-making of their treatment in the future.
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Affiliation(s)
- Vanessa W S Ng
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Patrick K C Chiu
- Division of Geriatrics, Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - Carolyn P L Kng
- Division of Geriatrics, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong SAR, China
| | - Elizabeth Jamieson
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - Ian C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China.,Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - May P S Lam
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China.
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Palm P, Qvist I, Rasmussen TB, Christensen SW, Håkonsen SJ, Risom SS. Educational interventions to improve outcomes in patients with atrial fibrillation-a systematic review. Int J Clin Pract 2020; 74:e13629. [PMID: 32726511 DOI: 10.1111/ijcp.13629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is an emerging epidemic associated with poor mental health and quality of life, as well as morbidity and mortality. Whilst other cardiovascular conditions have demonstrated positive outcomes from educational programmes, this approach is not well integrated in clinical practice in patients with AF. Though evidence in this area is mounting, a thorough overview seems to be lacking. AIM To assess benefits and harms of educational interventions compared with no intervention in adults with AF. METHOD A systematic review and meta-analysis were performed including the outcomes: Serious adverse events (mortality and readmission), mental health (anxiety and depression), physical capacity, quality of life and self-reported incidence of symptoms of AF. PubMed, Embase, CINAHL, Cochrane Library and PsycINFO were searched between June and august 2018. Data extraction and quality assessment were performed independently by two reviewers. The Cochrane Risk of Bias tool was applied for the randomised controlled trials and the Amstar Checklist for the systematic reviews. RESULTS Eight randomised controlled trials and one non-randomised interventional study were included, with a total of 2388 patients. Comparing with controls patient education was associated with a reduction in: Serious adverse events (Risk Ratio 0.78, CI 95% 0.63-0.97), anxiety with a mean difference of -0.62 (CI 95% -1.21, -0.04) and depression with a mean difference of -0.74 (CI 95% -1.34, -0.14). Health-related quality of life and physical capacity was found to increase after patient education, yet, only one study found statistically significant differences between groups. No differences were observed with regards to self-reported incidence of symptoms of AF. CONCLUSIONS Educational interventions significantly decrease the number of serious adverse events in patients with AF and seem to have a positive impact on mental health and self-reported quality of life. However, the evidence is limited, and more studies are warranted.
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Affiliation(s)
- Pernille Palm
- The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen O, Denmark
| | - Ina Qvist
- Department of Cardiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Trine Bernholdt Rasmussen
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen O, Denmark
| | | | - Sasja Jul Håkonsen
- Centre of Clinical Guidelines, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Signe Stelling Risom
- The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen O, Denmark
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen O, Denmark
- Institute of Nursing and Nutrision, University College Copenhagen, Copenhagen N, Denmark
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Sim V, Galbraith K. Effectiveness of multimedia interventions in the provision of patient education on anticoagulation therapy: A review. PATIENT EDUCATION AND COUNSELING 2020; 103:2009-2017. [PMID: 32532633 DOI: 10.1016/j.pec.2020.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE A literature review was conducted to identify available evidence on the use of multimedia patient educational interventions on anticoagulation therapy. METHODS A literature search was conducted on 9/4/2020 via six research databases. Publications that evaluated the effects of these interventions on anticoagulation therapy were included. RESULTS The review included ten original research studies (five randomized controlled trials, four observational studies and a pre- and post-interventional study), a systematic review and meta-analysis, three systematic reviews, a scoping review, and a literature review. Multimedia interventions significantly improved knowledge after education, but no significant differences found when compared to traditional methods. There was insufficient evidence to conclude whether knowledge retained over time. Patients were equally satisfied with both methods. Multimedia interventions significantly reduced healthcare professional's time required for education. Heterogeneity in intervention, methodology and results limited comparison and combination of findings across studies. CONCLUSION Multimedia patient educational interventions on anticoagulation therapy have similar outcomes to traditional methods in knowledge improvement and satisfaction, but they save health personnel time. PRACTICE IMPLICATIONS There is lack of evidence to support the effectiveness of multimedia interventions in educating patients on anticoagulation therapy. Larger randomized studies evaluating their benefits in health outcomes and clinical practice are warranted.
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Affiliation(s)
- Valerie Sim
- Royal Adelaide Hospital, Pharmacy Department, 1 Port Road, Adelaide, South Australia 5000, Australia.
| | - Kirsten Galbraith
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia.
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Rationale, considerations, and goals for atrial fibrillation centers of excellence: A Heart Rhythm Society perspective. Heart Rhythm 2020; 17:1804-1832. [DOI: 10.1016/j.hrthm.2020.04.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/19/2022]
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Fariborz Farsad B, Dastan F, Salamzadeh J, Moghadamnia Z, Eskandari R, Fahimi F. Assessment of Outpatients' Knowledge and Adherence on Warfarin: The Impact of a Simple Educational Pamphlet. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2020; 18:315-320. [PMID: 32802110 PMCID: PMC7393044 DOI: 10.22037/ijpr.2020.14766.12641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Warfarin is a critical medication that is broadly used for the treatment and prevention of thromboembolic disorders. Due to warfarin’s narrow therapeutic index, it is crucial that patients follow an appropriate dosage regimen. Patient knowledge is one of the most important factors to safe and effective use of warfarin. Due to the obvious risks of anticoagulants administration, evaluating patients’ awareness seems to be crucial. The purpose of this article was to evaluate the effects of intervention by an informative pamphlet on knowledge and adherence of patients who consumed warfarin. Two-hundred and fifty patients receiving warfarin were assigned to the study. They were asked to fill in the questionnaire. Then patients were provided with an educational pamphlet. In the second interview, patients filled the questionnaire again. Obtained data were assessed and analyzed by Excel software and SPSS version 18.0. Out of 250 patients who entered the study, 150 patients attended for the second interview. Data analysis revealed that out of 13 explanatory factors, only patients’ literacy level and income were the predictors which inversely correlated with the patients’ adherence (r = -0.44; p = 0.00040). Our educational intervention had a positive impact on patients’ knowledge regarding anticoagulation (p < 0.0001). Our findings revealed that a written informative pamphlet could effectively increase patients’ anticoagulation knowledge. Since, poorly literate patients had a lesser level of knowledge before and after educational intervention, it is recommended to develop appropriate educational programs especially designed for this group of patients.
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Affiliation(s)
- Bahram Fariborz Farsad
- Rajaei Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Farzaneh Dastan
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jamshid Salamzadeh
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Food Safety Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Moghadamnia
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Raha Eskandari
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fanak Fahimi
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Toscos T, Coupe A, Wagner S, Ahmed R, Roebuck A, Flanagan M, Drouin M, Mirro M. Engaging Patients in Atrial Fibrillation Management via Digital Health Technology: The Impact of Tailored Messaging. J Innov Card Rhythm Manag 2020; 11:4209-4217. [PMID: 32874747 PMCID: PMC7452738 DOI: 10.19102/icrm.2020.110802] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/17/2020] [Indexed: 01/08/2023] Open
Abstract
Patients with atrial fibrillation (AF) demonstrate persistent knowledge gaps regarding their condition and a substandard adherence to oral anticoagulant (OAC) medication, which contribute to thromboembolic stroke and other clot-related complications. Tailored patient education and medication reminders may help reduce these negative health outcomes. We sought to improve disease knowledge and medication adherence among a sample of AF patients using tailored education and nudges. The intervention leveraged three digital health technologies: a patient portal, an electronic-prescribing data feed, and a smart pill bottle. The content of the educational messaging, nudges, and cadence were tailored according to findings from our user-centered design studies and delivered via a patient portal (MyChart®; Epic Systems, Verona, WI, USA), with which participants were familiar. In a six-month randomized controlled trial with parallel groups, we used MyChart® to send educational messages and medication reminders according to a decision tree that emerged from our prior user-centered design studies. The intervention group demonstrated higher AF knowledge at study completion than the control group and more MyChart® logins throughout the trial, suggesting intervention uptake. Women were more adherent than men and patients diagnosed more than one year ago were more adherent than those with more recent diagnoses. The intervention and control group adherence rates were 93.1% and 89.5%, respectively; intervention effect was moderated by age, medication type, and prior MyChart® use. Within the intervention group, younger patients, those taking once-daily rivaroxaban, and those who were less active MyChart® users prior to the study benefited relative to their control group counterparts. Tailored educational and reminder messages contributed to increased adherence and disease knowledge among AF patients, though certain patient characteristics moderated the intervention's effectiveness. Technology-based health interventions can be useful for older adults with effective tailoring and training.
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Affiliation(s)
- Tammy Toscos
- Parkview Mirro Center for Research and Innovation, Health Services and Informatics Research Department, Parkview Health, Fort Wayne, IN 46845, USA
| | - Amanda Coupe
- Parkview Mirro Center for Research and Innovation, Health Services and Informatics Research Department, Parkview Health, Fort Wayne, IN 46845, USA
| | - Shauna Wagner
- Parkview Mirro Center for Research and Innovation, Health Services and Informatics Research Department, Parkview Health, Fort Wayne, IN 46845, USA
| | - Ryan Ahmed
- Parkview Mirro Center for Research and Innovation, Health Services and Informatics Research Department, Parkview Health, Fort Wayne, IN 46845, USA
| | - Amelia Roebuck
- Parkview Mirro Center for Research and Innovation, Health Services and Informatics Research Department, Parkview Health, Fort Wayne, IN 46845, USA
| | - Mindy Flanagan
- Parkview Mirro Center for Research and Innovation, Health Services and Informatics Research Department, Parkview Health, Fort Wayne, IN 46845, USA
| | - Michelle Drouin
- Parkview Mirro Center for Research and Innovation, Health Services and Informatics Research Department, Parkview Health, Fort Wayne, IN 46845, USA
| | - Michael Mirro
- Parkview Mirro Center for Research and Innovation, Health Services and Informatics Research Department, Parkview Health, Fort Wayne, IN 46845, USA
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A systematic review and meta-analysis of supplemental education in patients treated with oral anticoagulation. Blood Adv 2020; 3:1638-1646. [PMID: 31138592 DOI: 10.1182/bloodadvances.2019000067] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 04/14/2019] [Indexed: 12/30/2022] Open
Abstract
Oral anticoagulants (OACs) are indicated for treatment and prevention of thromboembolic diseases. Supplemental patient education (education) has been proposed to improve outcomes, and this systematic review assesses the effect of education on mortality, thromboembolic events (TEEs) including venous thromboembolism (VTE), and bleeding in patients taking OACs. Randomized controlled trials were included, and 2 authors independently screened articles and assessed risk of bias. In 9 trials (controls, n = 720; intervention group patients, n = 646), 4 assessed critical outcomes of mortality, TEEs (VTE, stroke, and systemic embolism), and bleeding to estimate absolute risk ratios. When comparing education with usual care, in 1000 patients, there may be 12 fewer deaths (95% confidence interval [CI], 19 fewer to 154 more) and 16 fewer bleeding events (95% CI, 34 fewer to 135 more), but this evidence is uncertain; the evidence also suggests 6 fewer VTEs (95% CI, 10 fewer to 16 more) and 8 fewer TEEs (95% CI, 16 fewer to 18 more). The mean difference in time in therapeutic range may be 2.4% higher in the education group compared with usual care (95% CI, 2.79% lower to 7.58% higher). We also found very low certainty of evidence for a large increase in knowledge scores (standardized mean difference, 0.84 standard deviation units higher; 95% CI, 0.51-1.16). Overall, the certainty of evidence was low to very low because of serious risk of bias and serious imprecision. Additional sufficiently powered trials or different approaches to education are required to better assess supplemental education effects on outcomes in patients taking OACs.
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Cross AJ, Elliott RA, Petrie K, Kuruvilla L, George J. Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications. Cochrane Database Syst Rev 2020; 5:CD012419. [PMID: 32383493 PMCID: PMC7207012 DOI: 10.1002/14651858.cd012419.pub2] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications. OBJECTIVES To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications. SEARCH METHODS We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality. MAIN RESULTS We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes. AUTHORS' CONCLUSIONS Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.
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Affiliation(s)
- Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Rohan A Elliott
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
- Pharmacy Department, Austin Health, Heidelberg, Australia
| | - Kate Petrie
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Lisha Kuruvilla
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
- Pharmacy Department, Barwon Health, North Geelong, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
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Zulkifly H, Cheli P, Lutchman I, Bai Y, Lip GYH, Lane DA. Anticoagulation control in different ethnic groups receiving vitamin K antagonist therapy for stroke prevention in atrial fibrillation. Thromb Res 2020; 192:12-20. [PMID: 32416364 DOI: 10.1016/j.thromres.2020.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/18/2020] [Accepted: 04/02/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Efficacy and safety of vitamin K antagonists (VKAs) is optimised in atrial fibrillation (AF) patients when the International Normalised Ratio (INR) is 2.0-3.0. Anticoagulation control comparing different ethnic groups is limited, although epidemiological studies suggest poorer INR control in non-white cohorts. METHODS VKA control was assessed retrospectively by time-in-the-therapeutic range (TTR) (Rosendaal method) and percentage INR-in-range (PINRR) in 991 White, Afro-Caribbean and South-Asian AF patients [overall mean (SD) age 71.6 (9.4) years; 55% male; mean (SD) CHA2DS2-VASc score 3.4 (1.6)] over a median (IQR) follow-up of 5.2 (3.2-7.0) years. RESULTS Compared to Whites, mean (SD) TTR and PINRR were significantly lower in South-Asians [TTR 67.9% vs. 60.5%; PINRR 58.8% vs. 51.6%, respectively] and Afro-Caribbeans [TTR 67.9% vs. 61.3%; PINRR 58.8% vs. 53.1%, respectively], despite similar INR monitoring intensity. Logistic regression revealed non-white ethnicity [OR 2.62; 95% Confidence Interval [CI] (1.67-4.10) and OR 3.47 (1.44-8.34)] and anaemia [OR 1.65 (1.00-2.70) and OR 6.27 (1.89-20.94)] as independent predictors of both TTR and PINRR < 70%, respectively. At follow-up, 329 (33.2%) patients experienced ≥1 major adverse clinical event. Cardiovascular hospitalisation was significantly higher among South-Asians (32.3%) compared to the Whites and Afro-Caribbeans (21.3% vs 25.6% respectively). CONCLUSIONS Ethnic disparities in quality of anticoagulation control are evident, with South-Asians and Afro-Caribbeans having poorer control compared to Whites, despite similar intensity INR monitoring. Non-white ethnicity remained the strongest independent predictor of poor TTR and PINRR. Interventions to improve anticoagulation control need to be implemented, particularly targeting ethnic minority patients.
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Affiliation(s)
- Hanis Zulkifly
- University of Birmingham Institute of Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom; Fakulti Farmasi, Universiti Teknologi MARA Kampus Puncak Alam, Selangor, Malaysia
| | - Paola Cheli
- University of Birmingham Institute of Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom
| | - Ivana Lutchman
- University of Birmingham Institute of Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom.
| | - Ying Bai
- University of Birmingham Institute of Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Tzikas A, Samaras A, Kartas A, Vasdeki D, Fotos G, Dividis G, Paschou E, Forozidou E, Tsoukra P, Kotsi E, Goulas I, Karvounis H, Giannakoulas G. Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with non-valvular Atrial Fibrillation (MISOAC-AF): a randomized clinical trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:f63-f71. [PMID: 32339234 DOI: 10.1093/ehjcvp/pvaa039] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/05/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022]
Abstract
AIMS We aimed to assess the impact of an educational, motivational intervention on the adherence to oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (AF). METHODS AND RESULTS Hospitalized patients with non-valvular AF who received OAC were randomly assigned to usual medical care or a proactive intervention, comprising motivational interviewing, and tailored counselling on medication adherence. The primary study outcome was adherence to OAC at 1 year, which was evaluated according to proportion of days covered (PDC) by OAC regimens and was assessed through nationwide registers of prescription claims. Secondary outcomes included the rate of persistence to OAC, gaps in treatment, and clinical events. A total of 1009 patients were randomized, 500 in the intervention group and 509 in the control group. At 1-year follow-up, 77.2% (386/500) of patients in the intervention group were adherent (PDC > 80%), compared with 55% (280/509) in the control group [adjusted odds ratio (aOR) 2.84, 95% confidence interval (CI) 2.14-3.75; P < 0.001]. Mean PDC ± standard deviation was 0.85 ± 0.26 and 0.75 ± 0.31, respectively (P < 0.001). Patients that received the intervention were more likely to persist in their OAC therapy at 1 year (aOR 2.42, 95% CI 1.71-3.41; P < 0.001). Usual medical care was associated with more major (≥3 months) treatment gaps (aOR 2.39, 95% CI 1.76-3.26; P < 0.001). Clinical events over a median follow-up period of 2 years did not differ among treatment groups. CONCLUSION In patients receiving OAC therapy for non-valvular AF, a multilevel motivational intervention significantly improved medication adherence and rate of therapy persistence, and reduced major gaps in treatment. No significant impact on clinical outcomes was observed. TRIAL REGISTRATION NUMBER NCT02941978.
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Affiliation(s)
- Apostolos Tzikas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece.,Department of Cardiology, Interbalkan European Medical Center, Asklipiou 10, Pylaia, Thessaloniki 55535, Greece
| | - Athanasios Samaras
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Anastasios Kartas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Dimitra Vasdeki
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - George Fotos
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - George Dividis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Eleni Paschou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Evropi Forozidou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Paraskevi Tsoukra
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Eleni Kotsi
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Ioannis Goulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Haralambos Karvounis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
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Samaras A, Kartas A, Vasdeki D, Dividis G, Forozidou E, Fotos G, Kotsi E, Paschou E, Tsoukra P, Goulas I, Karvounis H, Giannakoulas G, Tzikas A. Rationale and design of a randomized study comparing Motivational Interviewing to Support Oral Anticoagulation adherence versus usual care in patients with nonvalvular atrial fibrillation: The MISOAC-AF trial. Hellenic J Cardiol 2020; 61:453-454. [PMID: 32259588 DOI: 10.1016/j.hjc.2020.02.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 02/05/2023] Open
Affiliation(s)
- A Samaras
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - A Kartas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - D Vasdeki
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - G Dividis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - E Forozidou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - G Fotos
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - E Kotsi
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - E Paschou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - P Tsoukra
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - I Goulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - H Karvounis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - G Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - A Tzikas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece; Interbalkan European Medical Center, Asklipiou 10, Pylaia, Thessaloniki, Greece.
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Metaxas C, Albert V, Habegger S, Messerli M, Hersberger KE, Arnet I. Patient Knowledge about Oral Anticoagulation Therapy Assessed during an Intermediate Medication Review in Swiss Community Pharmacies. PHARMACY 2020; 8:pharmacy8020054. [PMID: 32231095 PMCID: PMC7355591 DOI: 10.3390/pharmacy8020054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/22/2020] [Accepted: 03/25/2020] [Indexed: 12/27/2022] Open
Abstract
Background: Therapy with oral anticoagulation (OAC) can be challenging, especially in high risk groups such as chronic patients. Gaps in patient knowledge about OAC are linked to reduced effectiveness and safety of treatment. The objectives of this study were i) to assess OAC knowledge gathered during an intermediate medication review (MR) in patients taking vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC); ii) to assess OAC knowledge two weeks after the MR, and iii) to evaluate patient satisfaction with the MR service in community pharmacies. Methods: Chronic OAC patients were invited for a regular MR service in Swiss community pharmacies, the so-called “Polymedication-Check” (PMC). OAC knowledge was assessed with seven newly generated items asked face-to-face during a PMC and by telephone two weeks later. Knowledge gaps, pharmacists’ spontaneous interventions, and patient satisfaction were documented by observing pharmacy students. Treatment groups were compared. Results: Of all patients (n = 81), the number of patients with one or more knowledge gaps decreased from 66% to 31.3% after PMC (p < 0.001). NOAC patients (n = 31) had more knowledge gaps than VKA patients (n = 50; p < 0.05). Most patients (98.6%) were satisfied with the counselling provided by the pharmacists. Conclusion: The majority of chronic OAC patients shows knowledge gaps. Although spontaneous, the provision of tailored education during a PMC increased patient OAC knowledge.
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