1
|
Cost-effectiveness of enoxaparin versus aspirin in the prevention of venous thromboembolism after total hip or knee arthroplasty: an analysis from the CRISTAL cluster-randomized trial. Bone Joint J 2024; 106-B:589-595. [PMID: 38821513 DOI: 10.1302/0301-620x.106b6.bjj-2023-0783.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Aims The aim of this study was to evaluate the healthcare costs and benefits of enoxaparin compared to aspirin in the prevention of symptomatic venous thromboembolism (VTE) after total hip arthroplasty (THA) or total knee arthroplasty (TKA) using data from the CRISTAL trial. Methods This trial-based economic analysis reports value for money as incremental cost per quality-adjusted life-year (QALY) gained in 2022 Australian dollars, compared to a single threshold value of AUD$70,000 per QALY. Event costs were estimated based on occurrence of VTEs and bleeds, and on published guidelines for treatment. Unit costs were taken from Australian sources. QALYs were estimated using CRISTAL six-month follow-up data. Sensitivity analyses are presented that vary the cost of VTE treatment, and extend the analyses to two years. Results The CRISTAL trial found that enoxaparin was more effective than aspirin in preventing symptomatic VTE within 90 days of THA or TKA (risk difference 1.97% (95% confidence interval (CI) 0.54% to 3.41%; p = 0.007)). The additional cost after a THA or TKA was AUD$83 (95% CI 68 to 97) for enoxaparin, and enoxaparin resulted in an additional 0.002 QALYs (95% CI -0.002 to 0.005). Incremental cost per QALY gained was AUD$50,567 (95% CI 15,513, dominated) for enoxaparin. We can be 60% confident that the incremental cost per QALY does not exceed the willingness-to-pay threshold of AUD$70,000. Increasing the cost of VTE treatment and extension of costs and consequences to two years suggested greater confidence that enoxaparin is good value for money (70% and 63% confidence, respectively). Conclusion This analysis provides strong evidence that enoxaparin thromboprophylaxis following THA or TKA reduced VTEs, but weak evidence of net economic benefits over aspirin. If the value of avoiding VTEs is high, and there is a strong likelihood of VTE-related health impairments, we can be more confident that enoxaparin is cost-effective compared to aspirin.
Collapse
|
2
|
Mitchell RJ, Wijekulasuriya S, Mayor A, Borges FK, Tonelli AC, Ahn J, Seymour H. Principles for management of hip fracture for older adults taking direct oral anticoagulants: an international consensus statement. Anaesthesia 2024; 79:627-637. [PMID: 38319797 DOI: 10.1111/anae.16226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 02/08/2024]
Abstract
Hip fracture is a common serious injury among older adults, yet the management of hip fractures for patients taking direct oral anticoagulants remains inconsistent worldwide. Drawing from a synthesis of available evidence and expert opinion, best practice approaches for managing patients with a hip fracture and who are taking direct oral anticoagulants pre-operatively were considered by a working group of the Fragility Fracture Network Hip Fracture Audit Special Interest Group. The literature and related clinical guidelines were reviewed and a two-round modified Delphi study was conducted with a panel of experts from 16 countries and involved seven clinical specialities. Four consensus statements were achieved: peripheral nerve blocks can reasonably be performed on presentation for patients with hip fracture who are receiving direct oral anticoagulants; hip fracture surgery can reasonably be performed for patients taking direct oral anticoagulants < 36 h from last dose; general anaesthesia could reasonably be administered for patients with hip fracture and who are taking direct oral anticoagulants < 36 h from last dose (assuming eGFR > 60 ml.min-1.1.73 m-2); and it is generally reasonable to consider recommencing direct oral anticoagulants (considering blood loss and haemoglobin) < 48 h after hip fracture surgery. No consensus was achieved regarding timing of spinal anaesthesia. The consensus statements were developed to aid clinicians in their decision-making and to reduce practice variations in the management of patients with hip fracture and who are taking direct oral anticoagulants. Each statement will need to be considered specific to each individual patient's treatment.
Collapse
Affiliation(s)
- R J Mitchell
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - S Wijekulasuriya
- Department of Anaesthesia, Huddersfield Royal Infirmary, Huddersfield, UK
| | - A Mayor
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - F K Borges
- Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - A C Tonelli
- Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Michigan, Ann Arbour, MI, USA
| | - J Ahn
- Department of Geriatric Medicine, Fiona Stanley Fremantle Hospitals Group, Perth, WA, Australia
| | - H Seymour
- Department of Geriatric Medicine, Fiona Stanley Fremantle Hospitals Group, Perth, WA, Australia
| |
Collapse
|
3
|
Patel P, Patel SH, Siddegowda A, Potini BR, Miriyala V, Patel D, Singh N. Effectiveness of Novel Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e61374. [PMID: 38947715 PMCID: PMC11214541 DOI: 10.7759/cureus.61374] [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] [Accepted: 05/29/2024] [Indexed: 07/02/2024] Open
Abstract
Atrial fibrillation (AF) is a common cardiac arrhythmia associated with an increased risk of stroke and systemic embolism (SE). Anticoagulation therapy, particularly with vitamin K antagonists (VKA) or novel oral anticoagulants (NOACs), is essential for stroke prevention in patients with AF. However, the comparative effectiveness of NOACs and warfarin remains debatable. Of the 34 studies included, 14 studies involving 166,845 patients were included in the meta-analysis and 20 studies were included in the systematic review. Our findings indicate that NOACs were associated with a significantly lesser risk of stroke/SE with a relative risk (RR) of 0.84 and p=0.0005, and all-cause mortality RR=0.88 and p=0.006. There were no significant differences between major bleeding events with an RR of 0.87 and p=0.22, and serious adverse events (SAE) with RR=1.01 and p=0.35, compared to warfarin in patients with AF. Our meta-analysis demonstrates strong evidence for the superiority in reducing stroke/SE and all-cause mortality of NOACs compared to warfarin. However, no significant differences were identified in the bleeding outcomes or SAEs between the two groups.
Collapse
Affiliation(s)
- Priyansh Patel
- Department of Cardiovascular Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Saloni H Patel
- Department of Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad, IND
| | - Akshaya Siddegowda
- Department of Internal Medicine, Jagadguru Sri Shivarathreeshwara Medical College, Mysore, IND
| | | | - Varsha Miriyala
- Department of Internal Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, IND
| | - Diya Patel
- Department of Internal Medicine, Gujarat Medical Education and Research Society, Sola, Ahmedabad, IND
| | - Navpreet Singh
- Department of Internal Medicine, Gian Sagar Medical College and Hospital, Patiala, IND
| |
Collapse
|
4
|
Pozzi A, Lucà F, Gelsomino S, Abrignani MG, Giubilato S, Di Fusco SA, Rao CM, Cornara S, Caretta G, Ceravolo R, Parrini I, Geraci G, Riccio C, Grimaldi M, Colivicchi F, Oliva F, Gulizia MM. Coagulation Tests and Reversal Agents in Patients Treated with Oral Anticoagulants: The Challenging Scenarios of Life-Threatening Bleeding and Unplanned Invasive Procedures. J Clin Med 2024; 13:2451. [PMID: 38730979 PMCID: PMC11084691 DOI: 10.3390/jcm13092451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/22/2024] [Accepted: 04/07/2024] [Indexed: 05/13/2024] Open
Abstract
In clinical practice, the number of patients treated with direct oral anticoagulants (DOACs) has consistently increased over the years. Since anticoagulant therapy has been associated with an annual incidence of major bleeding (MB) events of approximately 2% to 3.5%, it is of paramount importance to understand how to manage anticoagulated patients with major or life-threatening bleeding. A considerable number of these patients' conditions necessitate hospitalization, and the administration of reversal agents may be imperative to manage and control bleeding episodes effectively. Importantly, effective strategies for reversing the anticoagulant effects of DOACs have been well recognized. Specifically, idarucizumab has obtained regulatory approval for the reversal of dabigatran, and andexanet alfa has recently been approved for reversing the effects of apixaban or rivaroxaban in patients experiencing life-threatening or uncontrolled bleeding events. Moreover, continuous endeavors are being made to develop supplementary reversal agents. In emergency scenarios where specific reversal agents might not be accessible, non-specific hemostatic agents such as prothrombin complex concentrate can be utilized to neutralize the anticoagulant effects of DOACs. However, it is paramount to emphasize that specific reversal agents, characterized by their efficacy and safety, should be the preferred choice when suitable. Moreover, it is worth noting that adherence to the guidelines for the reversal agents is poor, and there is a notable gap between international recommendations and actual clinical practices in this regard. This narrative review aims to provide physicians with a practical approach to managing specific reversal agents.
Collapse
Affiliation(s)
- Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy;
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, 6229 HX Maastricht, The Netherlands
| | | | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy;
| | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy;
| | - Giorgio Caretta
- Sant’Andrea Hospital, ASL 5 Regione Liguria, 19124 La Spezia, Italy;
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 97100 Lamezia, Italy;
| | - Iris Parrini
- Cardiology Department, Mauriziano Hospital, 10128 Torino, Italy;
| | - Giovanna Geraci
- Cardiology Unit, S. Antonio Abate Hospital, ASP Trapani, 91016 Erice, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy;
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Fabrizio Oliva
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy;
| | | |
Collapse
|
5
|
Davis TME, Davis WA. An assessment of factors contributing to the decline in risk of stroke complicating type 2 diabetes: The Fremantle Diabetes Study. Diabetes Obes Metab 2024; 26:1125-1128. [PMID: 38073429 DOI: 10.1111/dom.15391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/17/2023] [Accepted: 11/18/2023] [Indexed: 02/06/2024]
Affiliation(s)
- Timothy M E Davis
- Medical School, University of Western Australia, Fremantle, Western Australia, Australia
- Department of Endocrinology and Diabetes, Fiona Stanley and Fremantle Hospitals, Murdoch, Western Australia, Australia
| | - Wendy A Davis
- Medical School, University of Western Australia, Fremantle, Western Australia, Australia
| |
Collapse
|
6
|
Aarnio E, Huupponen R, Martikainen J, Korhonen MJ. Reimbursement and use of oral anticoagulants during 2014-2022 - A register-based study. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 11:100284. [PMID: 37538990 PMCID: PMC10393798 DOI: 10.1016/j.rcsop.2023.100284] [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: 03/03/2023] [Revised: 05/05/2023] [Accepted: 05/28/2023] [Indexed: 08/05/2023] Open
Abstract
Background Vitamin K antagonists, warfarin in particular, have been the mainstay of anticoagulation therapy, but their use has declined in many countries since direct oral anticoagulants (DOACs) have entered the market. Objective To examine utilization trends of oral anticoagulants (OACs) in Finland considering the reimbursement of DOACs and changes to national treatment guidelines for the treatment of atrial fibrillation (AF). Methods Both public, aggregated data on reimbursed OAC dispensations and individual-level data on electronic dispensations during 2014-2022 were applied. Data on electronic dispensations during 2015-2016 were used to study OAC initiations. Data on entitlements to reimbursement for DOACs came from public data. Results In 2014, there were almost 20,000 DOAC users, rising to 214,000 in 2022. The number of warfarin users declined since 2015 from over 181,000 to around 59,000 users in 2022, DOACs exceeding warfarin in the number of users in 2019. The total DOAC costs were higher than warfarin costs each year. Rivaroxaban was the most widely used DOAC during 2014-2018, and apixaban during 2019-2022. In 2015, there were more warfarin (56.7%) than DOAC (43.3%) initiators, but the result was opposite for 2016 (warfarin 39.4%, DOACs 60.6%). The number of individuals entitled to reimbursement for DOACs has increased steadily, and in 2022, there were over 196,000 individuals entitled to this reimbursement due to AF. Conclusions The uptake of DOACs in Finland appears to have been gradual and slower than in many other countries. During the 2010s, the treatment guidelines for AF were more cautious in recommending DOACs than the European guidelines. The use of DOACs increased as their reimbursement became less restrictive.
Collapse
Affiliation(s)
- Emma Aarnio
- School of Pharmacy, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland
- Institute of Biomedicine, University of Turku, FI-20014 University of Turku, Finland
| | - Risto Huupponen
- Institute of Biomedicine, University of Turku, FI-20014 University of Turku, Finland
| | - Janne Martikainen
- School of Pharmacy, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland
| | - Maarit J. Korhonen
- Institute of Biomedicine, University of Turku, FI-20014 University of Turku, Finland
| |
Collapse
|
7
|
Romero JM, Rojas-Serrano LF. Current Evaluation of Intracerebral Hemorrhage. Radiol Clin North Am 2023; 61:479-490. [PMID: 36931764 DOI: 10.1016/j.rcl.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Advanced imaging is currently critical in diagnosing, predicting, and managing intracerebral hemorrhage. MD CT angiography has occupied the first line of evaluating patients with a clinical diagnosis of a stroke, given its rapid acquisition time, high resolution of vascular structures, and sensitivity for secondary causes of ICH.
Collapse
Affiliation(s)
- Javier M Romero
- Radiology Department, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Gray Building, 241G, MA 02114, USA.
| | | |
Collapse
|
8
|
Computed Tomography Angiography for Detection of Pulmonary Embolism in Western Australia Shows Increasing Use with Decreasing Diagnostic Yield. J Clin Med 2023; 12:jcm12030980. [PMID: 36769627 PMCID: PMC9917579 DOI: 10.3390/jcm12030980] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
(1) Background: Pulmonary embolism (PE) can be fatal. Computed tomography pulmonary angiography (CTPA) can accurately diagnose PE, but it should be used only when reasonable pre-test probability exists. Overtesting with CTPA exposes patients to excess ionizing radiation and contrast media, while PE overdiagnosis leads to the treatment of small emboli unlikely to cause harm. This study assessed trends in CTPA use and diagnostic yield. We also assessed trends in PE hospitalizations and mortality to indicate PE severity. (2) Methods: Analysis of Western Australian linked administrative data for 2003-2015 including hospitalizations, emergency department (ED) attendances, and CTPA performed at hospitals. Age-sex standardized trends were calculated for CTPA use, PE hospitalizations, and mortality (as a proxy for severity). Logistic regression assessed diagnostic yield of CTPA following unplanned ED presentations. (3) Results: CTPA use increased from 3.3 per 10,000 person-years in 2003 (95% CI 3.0-3.6) to 17.1 per 10,000 person-years (16.5-17.7) in 2015. Diagnostic yield of CTPA increased from 12.7% in 2003 to 17.4% in 2005, declining to 12.2% in 2015 (p = 0.049). PE hospitalizations increased from 3.8 per 10,000 (3.5-4.1) in 2003 to 5.2 per 10,000 (4.8-5.5) in 2015. Mortality remained constant at 0.50 per 10,000 (0.39-0.62) in 2003 and 0.42 per 10,000 (0.32-0.51) in 2015. (4) Conclusions: CTPA increased from 2003 to 2015, while diagnostic yield decreased, potentially indicating overtesting. PE mortality remained constant despite increasing hospitalizations, likely indicating a higher proportion of less severe cases. As treatment can be harmful, this could represent overdiagnosis.
Collapse
|
9
|
Impact of Paxlovid on international normalized ratio among patients on chronic warfarin therapy. Blood 2022; 140:2757-2759. [PMID: 36240439 PMCID: PMC9906278 DOI: 10.1182/blood.2022017433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/23/2022] [Accepted: 09/06/2022] [Indexed: 12/30/2022] Open
|
10
|
Ahn HJ, Lee SR, Choi EK, Rhee TM, Kwon S, Oh S, Lip GYH. Protective effect of proton pump inhibitor against gastrointestinal bleeding in patients receiving oral anticoagulants: A systematic review and meta-analysis. Br J Clin Pharmacol 2022; 88:4676-4687. [PMID: 35921204 DOI: 10.1111/bcp.15478] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/22/2022] [Accepted: 07/27/2022] [Indexed: 11/28/2022] Open
Abstract
AIM The evidence of a protective effect of proton pump inhibitor (PPI) in oral anticoagulant (OAC) treated patients against gastrointestinal bleeding (GIB) is still lacking. We conducted a meta-analysis to estimate the risk of GIB in patients with OAC and PPI co-therapy. METHODS A systematic search of PubMed, EMBASE, Cochrane, and Scopus databases was performed for studies reporting GIB risk in OAC and PPI co-therapy. Primary outcomes were total GIB and major GIB events. Pooled estimates of GIB risk were calculated by a random-effect meta-analysis and reported as odds ratios (OR) and 95% confidence interval (CI). RESULTS A total of 10 studies and 1,970,931 patients were included. OAC and PPI co-therapy were associated with a lower odds of total and major GIB; OR (95% CI) was 0.67 (0.62-0.74) for total and 0.68 (0.63-0.75) for major GIB, respectively. No differences in the GIB of PPI co-therapy were observed between Asians and non-Asians (p-for-difference, total GIB=0.70, major GIB=0.75, respectively). For all kinds of OAC except for edoxaban, PPI cotreatment was related to a lower odds of GIB by 24-44%. The protective effect of PPI on total GIB was more significant in concurrent antiplatelets or non-steroidal anti-inflammatory drug users and those with high bleeding risks: patients with previous GIB history, HAS-BLED ≥3, or underlying gastrointestinal diseases. CONCLUSION In patients who receive OAC, PPI co-therapy is associated with a lower total and major GIB irrespective of ethnic group and OAC type, except for edoxaban. PPI co-therapy can be considered particularly in high GIB risk patients.
Collapse
Affiliation(s)
- Hyo-Jeong Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae-Min Rhee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y H Lip
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
11
|
Zhou Y, Rastegar V, Read TE, Al-Mansour MR. Safety of Laparoscopic Appendectomy in the Setting of Coagulopathy: An ACS-NSQIP Study. J Surg Res 2022; 275:103-108. [DOI: 10.1016/j.jss.2022.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 12/31/2021] [Accepted: 01/29/2022] [Indexed: 10/18/2022]
|
12
|
Khiralla S, Meadows CA. The Effect of Switching From Warfarin to Novel Oral Anticoagulants on Patients’ Satisfaction and the Travel Burden in a Rural Setting. Cureus 2022; 14:e24608. [PMID: 35664412 PMCID: PMC9148718 DOI: 10.7759/cureus.24608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 12/30/2022] Open
Abstract
Introduction: New oral anticoagulants (NOACs) have shown comparable efficacy to warfarin in the treatment of patients with venous thromboembolism (VTE), stroke and atrial fibrillation (AF). Various studies on quality-of-life improvement in rural patients following the switch from vitamin K antagonists (VKAs) to NOACs have produced inconclusive results. The aim of the study is to assess the impact of switching from warfarin to NOACs on remotely living patients’ quality of life and the burden of travel. Methods: A questionnaire was provided to the patient by their pharmacists. The questionnaire assessed their travel burden and their level of satisfaction with their treatment. Results: The switch from warfarin to NOACs reduced the burden of travel in 75% of patients. A total of 66% of patients were hesitant about the efficacy of their warfarin treatment. The inconvenience caused due to international normalized ratio (INR) monitoring was reduced in 83% of patients; 70% and 72% of patients strongly agreed that NOACs improved their adherence and treatment satisfaction, respectively. The average number of patients’ travels for INR testing for warfarin monitoring was 7.27 trips/year. The average number of trips made by the patient to obtain their NOACs and warfarin scripts was 2.1 and 4.81 trips/year, respectively. Conclusion: The switch from warfarin, a VKA, to NOACs in patients who live in remote areas without medical services improved their quality of life, decreased their travel burden, and increased their treatment satisfaction and adherence. Switching to NOACs reduced the number of trips travelled by patients to obtain their anticoagulation scripts and/or to adjust their doses.
Collapse
|
13
|
Pyykönen M, Linna M, Tykkyläinen M, Delmelle E, Laatikainen T. Patient-specific and healthcare real-world costs of atrial fibrillation in individuals treated with direct oral anticoagulant agents or warfarin. BMC Health Serv Res 2021; 21:1299. [PMID: 34856979 PMCID: PMC8641166 DOI: 10.1186/s12913-021-07125-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 10/01/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Anticoagulant therapies are used to prevent atrial fibrillation-related strokes, with warfarin and direct oral anticoagulant (DOAC) the most common. In this study, we incorporate direct health care costs, drug costs, travel costs, and lost working and leisure time costs to estimate the total costs of the two therapies. METHODS This retrospective study used individual-level patient data from 4000 atrial fibrillation (AF) patients from North Karelia, Finland. Real-world data on healthcare use was obtained from the regional patient information system and data on reimbursed travel costs from the database of the Social Insurance Institution of Finland. The costs of the therapies were estimated between June 2017 and May 2018. Using a Geographical Information System (GIS), we estimated travel time and costs for each journey related to anticoagulant therapies. We ultimately applied therapy and travel costs to a cost model to reflect real-world expenditures. RESULTS The costs of anticoagulant therapies were calculated from the standpoint of patient and the healthcare service when considering all costs from AF-related healthcare visits, including major complications arising from atrial fibrillation. On average, the annual cost per patient for healthcare in the form of public expenditure was higher when using DOAC therapy than warfarin therapy (average cost = € 927 vs. € 805). Additionally, the average annual cost for patients was also higher with DOAC therapy (average cost = € 406.5 vs. € 296.7). In warfarin therapy, patients had considerable more travel and time costs due the different implementation practices of therapies. CONCLUSION The results indicated that DOAC therapy had higher costs over warfarin from the perspectives of the patient and healthcare service in the study area on average. Currently, the cost of the DOAC drug is the largest determinator of total therapy costs from both perspectives. Despite slightly higher costs, the patients on DOAC therapy experienced less AF-related complications during the study period.
Collapse
Affiliation(s)
- Mikko Pyykönen
- Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101 Joensuu, Finland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, P.O Box 11000, 00076 Aalto, Finland
| | - Markku Tykkyläinen
- Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101 Joensuu, Finland
| | - Eric Delmelle
- Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101 Joensuu, Finland
| | - Tiina Laatikainen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland
- Joint Municipal Authority for North Karelia Social and Health Services, Tikkamäentie 16, 80210 Joensuu, Finland
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki, Finland
| |
Collapse
|
14
|
Shiyovich A, Shalev V, Chodick G, Tirosh M, Katz A, Klar MM, Shuvy M, Pereg D, Minha S. Shifting from vitamin K antagonists to non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: predictors, patterns and temporal trends. BMC Cardiovasc Disord 2021; 21:493. [PMID: 34645389 PMCID: PMC8513259 DOI: 10.1186/s12872-021-02295-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background Non-Vitamin K antagonist oral anticoagulants (NOACs) emerged as an alternative with comparable or superior efficacy and safety to vitamin K antagonists (VKAs) for stroke prevention in patients with non-valvular atrial fibrillation (AF). Objectives The aim of the current study was to investigate the patterns, predictors, timelines and temporal trends of shifting from VKAs to NOACs. Methods In this retrospective observational study, the computerized database of a large healthcare provider in Israel, Maccabi Healthcare Services, was searched to identify patients with AF for whom either a VKA or NOAC was prescribed between 2012 and 2015. Time from diagnosis to therapy initiation and to shifting between therapies was evaluated. Results Out of 6987 eligible AF incident patients, 2338 (33.4%) initiated treatment with a VKA and 2221 (31.7%) with a NOAC. In addition, 5259 prevalent patients were analyzed. During the study period, NOAC prescriptions proportion among the newly diagnosed cases increased from 32 to 68.4% (p for trend < 0.001). The median time from diagnosis to first dispensing was greater in NOAC than VKA and decreased among patients treated with NOAC during the study period (2012: 1.9 and 0.3 months, 2015: 0.7 and 0.2 months, respectively). During follow-up, 3737 (49%) patients (54.3% and 47.1% of the incident and prevalent cases, respectively), shifted from a VKA to a NOAC, after a median of 22 months and 39 months in the incident and prevalent cases, respectively, decreasing throughout the study period. Female gender, younger age, southern district, higher CHADS2 and CHA2DS2-VASC score, non-smoking, and treatment with antiplatelets were associated with a greater likelihood for therapy shift. Shifting from a NOAC to a VKA decreased over time from 8 to 4.5% in 2012 to 0.5% and 0.7% in 2015 in the incident and prevalent groups, p < 0.001 respectively. Conclusions Shifting from VKA to NOAC occurred in 50% of the cases, more frequently among incident cases, and younger patients with greater stroke risk. Shifting from a NOAC to a VKA was much less frequent, yet it occurred more often in incident cases and decreased over time. A socially and economically sensitive program to optimize the initiation of OAC therapy upon diagnosis is warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02295-w.
Collapse
Affiliation(s)
- Arthur Shiyovich
- Department of Cardiology, Rabin Medical Center, 39 Jabotinsky St., 49100, Petah Tikva, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Varda Shalev
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Maccabi Healthcare Services, Kahn-Sagol-Maccabi Research and Innovation Institute, Tel Aviv, Israel
| | - Gabriel Chodick
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Maccabi Healthcare Services, Kahn-Sagol-Maccabi Research and Innovation Institute, Tel Aviv, Israel
| | | | - Amos Katz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Miriam M Klar
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA.,Department of Cardiology, Shamir Medical Center, Zerifin, Israel
| | - Mony Shuvy
- Heart Institute, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - David Pereg
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Meir Medical Center, Kfar-Saba, Israel
| | - Sa'ar Minha
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Shamir Medical Center, Zerifin, Israel
| |
Collapse
|
15
|
Sato N, Cameron P, Mclellan S, Beck B, Gabbe B. Association between anticoagulants and mortality and functional outcomes in older patients with major trauma. Emerg Med J 2021; 39:emermed-2019-209368. [PMID: 34610958 DOI: 10.1136/emermed-2019-209368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 09/26/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The number of trauma patients taking anticoagulants and antiplatelet agents is increasing as society ages. However, there have been limited and inconsistent reports of the association between anticoagulants and mortality and functional outcomes. This study aimed to quantify the association between anticoagulant/antiplatelet medication at the time of injury and both short-term and longer-term outcomes in older major trauma patients. METHODS This was a population-based registry study using data from the Victorian State Trauma Registry from July 2017 to June 2018. We included patients with major trauma aged 65 years and older. The outcomes of interest were in-hospital mortality, hospital length of stay, intensive care unit length of stay and the Extended Glasgow Outcome Scale (GOS-E) at 6 months after injury. We examined the association between the outcomes and anticoagulants/antiplatelet agents at the time of injury and used multivariable logistic regression models to account for known confounders. RESULTS There were 1323 older adults eligible for inclusion in the study, of which 249 (18.8%) were taking anticoagulants (n=8 were taking both anticoagulants and antiplatelet agents), 380 (28.7%) were taking antiplatelet agents and 694 (52.5%) were not using either. Any anticoagulant use was associated with higher odds of in-hospital mortality (adjusted OR (AOR), 2.38; 95% CI 1.58 to 3.59) compared with not using anticoagulants. No differences were observed in the GOS-E at 6 months after injury between any anticoagulants use, antiplatelet use and no anticoagulant use (anticoagulant AOR, 0.71; 95% CI 0.48 to 1.05, antiplatelet AOR, 1.02; 95% CI 0.73 to 1.42). CONCLUSION Anticoagulant use at the time of injury was associated with higher odds of in-hospital mortality but did not adversely impact functional outcomes at 6 months after injury. These findings demonstrate the importance of seeking an accurate history of anticoagulant use and its indication, as well as the immediate initiation of reversal therapies.
Collapse
Affiliation(s)
- Nobuhiro Sato
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Susan Mclellan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Faculty of Medicine, Laval University, Quebec, Québec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Health Data Research UK, Swansea University, Swansea, West Glamorgan, UK
| |
Collapse
|
16
|
Nielsen PB, Søgaard M, Jensen M, Ording AG, Lip GY. Comparative effectiveness and safety of edoxaban versus warfarin in patients with atrial fibrillation: A nationwide cohort study. Int J Stroke 2021; 17:536-544. [PMID: 34142600 DOI: 10.1177/17474930211029441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE The effectiveness and safety of edoxaban 60 mg and 30 mg for stroke prevention compared with warfarin in patients with atrial fibrillation have not been well-described in a nationwide cohort of Caucasian patients treated in standard clinical practice. METHODS We used Danish nationwide registries to identify patients with atrial fibrillation during June 2016 and November 2018 who were treated with edoxaban or warfarin and computed rates per 100 person-years of thromboembolic, all-cause mortality, and bleeding events using an inverse probability of treatment weighting approach to account for baseline confounding. We used weighted pooled logistic regression to compute hazard ratios with 95% confidence intervals comparing events between edoxaban 60 mg and warfarin users; edoxaban 30 mg was not included in formal comparisons. RESULTS We identified 6451 atrial fibrillation patients, mean age was 72 years and 40% were females. A total of 1772 patients were treated with edoxaban 60 mg, 537 with edoxaban 30 mg, and 4142 with warfarin. The median CHA2DS2-VASc score was similar between warfarin and edoxaban 60 mg with a score of 3 (interquartile range (IQR) 2-4). In the inverse probability of treatment-weighted pseudo-population, the thromboembolic event rate for edoxaban 60 mg was 0.95 and 1.0 for warfarin, corresponding weighted hazard ratio of 1.00 (95% confidence intervals (CI) 0.59, 1.71). Edoxaban 60 mg users were associated with lower rates of all-cause mortality (3.93) compared to warfarin (6.04), with a hazard ratio of 0.64 (95% CI 0.47 to 0.88). The event rates for bleeding were 3.36 and 3.14, respectively; hazard ratio 1.09 (95% CI 0.77, 1.57). CONCLUSION Edoxaban 60 mg is a safe and effective treatment compared with warfarin for stroke prevention in routine clinical care for Danish (mainly Caucasian) patients with AF, with non-significantly different risks for stroke and clinically relevant bleeding, but lower all-cause mortality.
Collapse
Affiliation(s)
- Peter B Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Mette Søgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Martin Jensen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Anne G Ording
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gregory Yh Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| |
Collapse
|
17
|
Meta-Analysis of Reversal Agents for Severe Bleeding Associated With Direct Oral Anticoagulants. J Am Coll Cardiol 2021; 77:2987-3001. [PMID: 34140101 DOI: 10.1016/j.jacc.2021.04.061] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/30/2021] [Accepted: 04/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have shown a positive benefit-risk balance in both clinical trials and real-world data, but approximately 2% to 3.5% of patients experience major bleeding annually. Many of these patients require hospitalization, and the administration of reversal agents may be required to control bleeding. OBJECTIVES The aim of this study was to investigate clinical outcomes associated with the use of 4-factor prothrombin complex concentrates, idarucizumab, or andexanet for reversal of severe DOAC-associated bleeding. METHODS The investigators systematically searched for studies of reversal agents for the treatment of severe bleeding associated with DOAC. Mortality rates, thromboembolic events, and hemostatic efficacy were meta-analyzed using a random effects model. RESULTS The investigators evaluated 60 studies in 4,735 patients with severe DOAC-related bleeding who were treated with 4-factor prothrombin complex concentrates (n = 2,688), idarucizumab (n = 1,111), or andexanet (n = 936). The mortality rate was 17.7% (95% confidence interval [CI]: 15.1% to 20.4%), and it was higher in patients with intracranial bleedings (20.2%) than in patients with extracranial hemorrhages (15.4%). The thromboembolism rate was 4.6% (95% CI: 3.3% to 6.0%), being particularly high with andexanet (10.7%; 95% CI: 6.5% to 15.7%). The effective hemostasis rate was 78.5% (95% CI: 75.1% to 81.8%) and was similar regardless of the reversal agent considered. The rebleeding rate was 13.2% (95% CI: 5.5% to 23.1%) and 78% of rebleeds occurred after resumption of anticoagulation. The risk of death was markedly and significantly associated with failure to achieve effective hemostasis (relative risk: 3.63; 95% CI: 2.56 to 5.16). The results were robust regardless of the type of study or the hemostatic scale used. CONCLUSIONS The risk of death after severe DOAC-related bleeding remains significant despite a high rate of effective hemostasis with reversal agents. Failure to achieve effective hemostasis strongly correlated with a fatal outcome. Thromboembolism rates are particularly high with andexanet. Comparative clinical trials are needed.
Collapse
|
18
|
Renda G, Pecen L, Patti G, Ricci F, Kotecha D, Siller-Matula JM, Schnabel RB, Wachter R, Sellal JM, Rohla M, Lucerna M, Huber K, Verheugt FWA, Zamorano JL, Brüggenjürgen B, Darius H, Duytschaever M, Le Heuzey JY, Schilling RJ, Kirchhof P, De Caterina R. Antithrombotic management and outcomes of patients with atrial fibrillation treated with NOACs early at the time of market introduction: Main results from the PREFER in AF Prolongation Registry. Intern Emerg Med 2021; 16:591-599. [PMID: 32955677 PMCID: PMC8049932 DOI: 10.1007/s11739-020-02442-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/08/2020] [Indexed: 02/01/2023]
Abstract
The management of patients with atrial fibrillation (AF) has rapidly changed with increasing use of non-vitamin K antagonist oral anticoagulants (NOACs) and changes in the use of rhythm control therapy. The prevention of thromboembolic events European Registry in Atrial Fibrillation Prolongation Registry (PREFER Prolongation) enrolled consecutive patients with AF on NOACs between 2014 and 2016 in a multicentre, prospective, observational study with one-year follow-up, focusing on the time of introduction of NOACs. Overall, 3783 patients were enrolled, with follow-up information available in 3223 (85%). Mean age was 72.2 ± 9.4 years, 40% were women, mean CHA2DS2VASc score was 3.4 ± 1.6, and 2587 (88.6%) had a CHA2DS2VASc score ≥ 2. Rivaroxaban was used in half of patients, and dabigatran and apixaban were used in about a quarter of patients each; edoxaban was not available for use in Europe at the time. Major cardiovascular event rate was low: serious events occurred in 74 patients (84 events, 2%), including 24 strokes (1%), 62 major bleeds (2%), of which 30 were life-threatening (1%) and 3 intracranial (0.1%), and 28 acute coronary syndromes (1%). Mortality was 2%. Antiarrhythmic drugs were used in about 50% of patients, catheter ablation in 5%. Adverse events were low in this contemporary European cohort of unselected AF patients treated with NOACs already at the time of their first introduction, despite high thromboembolic risk.
Collapse
Affiliation(s)
- Giulia Renda
- Department of Neuroscience, Imaging, and Clinical Science, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Ladislav Pecen
- Institute of Computer Science, Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont and Maggiore Della Carità Hospital, Novara, Italy
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging, and Clinical Science, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Dipak Kotecha
- University of Birmingham Institute of Cardiovascular Sciences, and UHB and SWBH NHS Trusts, Birmingham, UK
| | - Jolanta M Siller-Matula
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
- First Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Renate B Schnabel
- Department for General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK) Partner Site Hamburg / Kiel/ Lübeck, Hamburg, Germany
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
- DZHK (German Centre for Cardiovascular Research), Partner site, Göttingen, Germany
| | - Jean-Marc Sellal
- Department of Cardiology, University Hospital of Nancy, Nancy, France
| | - Miklos Rohla
- Third Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
| | | | - Kurt Huber
- Third Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University, Medical School, Vienna, Austria
| | | | - Jose Luis Zamorano
- Department of Cardiology, University Hospital Ramo´N Y Cajal, Madrid, Spain
| | | | | | | | | | | | - Paulus Kirchhof
- University of Birmingham Institute of Cardiovascular Sciences, and UHB and SWBH NHS Trusts, Birmingham, UK
| | - Raffaele De Caterina
- Chair of Cardiology, University Cardiology Division, University of Pisa, Pisa University Hospital, Pisa, and Fondazione VillaSerena Per La Ricerca, Città Sant'Angelo, Pescara, Italy.
| |
Collapse
|
19
|
Alqahtani S, Nehme Z, Williams B, Bernard S, Smith K. Changes in the incidence of out-of-hospital cardiac arrest: Differences between cardiac and non-cardiac aetiologies. Resuscitation 2020; 155:125-133. [DOI: 10.1016/j.resuscitation.2020.07.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/09/2020] [Accepted: 07/07/2020] [Indexed: 10/23/2022]
|
20
|
Atterman A, Asplund K, Friberg L, Engdahl J. Use of oral anticoagulants after ischaemic stroke in patients with atrial fibrillation and cancer. J Intern Med 2020; 288:457-468. [PMID: 32386073 DOI: 10.1111/joim.13092] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/14/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES The use of oral anticoagulants (OACs) amongst patients with atrial fibrillation (AF) has increased in the last decade. We aimed to describe temporal trends in the utilization of OACs for secondary prevention after ischaemic stroke amongst patients with AF and active cancer. METHODS This is a cross-sectional and cohort study of patients with active cancer (n = 1518) and without cancer (n = 50 953) in the Swedish national register Riksstroke, including all patients with ischaemic stroke between 1 July 2005 and 30 December 2017, discharged with AF. Prescription and dispensation before and after the introduction of nonvitamin K OACs (NOACs) in late 2011 were compared. We used logistic and Cox regression to analyse associations with OAC use, adjusting for hospital clustering and the competing risk of death. RESULTS The proportion of cancer patients with AF prescribed OACs at discharge after ischaemic stroke increased by 40.2% after 2011, compared with 69.3% in noncancer patients during the same period. Stroke and bleeding risk scores remained similar between patients with and without cancer. OAC dispensation during the following year did not increase as much in cancer patients (43.8% to 64.5%) as that in noncancer patients (46.0% to 74.9%), and the median time to OAC dispensation or censoring was significantly longer in cancer patients (94 vs. 30 days). CONCLUSION OAC treatment in poststroke patients with AF and active cancer has increased after the introduction of NOACs. However, the growing treatment gap in these patients compared to that in noncancer patients raises the possibility of underutilization.
Collapse
Affiliation(s)
- A Atterman
- From the, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - K Asplund
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden, On behalf of Riksstroke
| | - L Friberg
- From the, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - J Engdahl
- From the, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| |
Collapse
|
21
|
Zhang W, Anderson CS, Kilkenny MF, Kim J, Dewey HM, Andrew NE, Lannin NA, Thrift AG, Grimley R, Sundararajan V, Cadilhac DA. Hospital admissions prior to primary intracerebral haemorrhage and relevant factors associated with survival. J Stroke Cerebrovasc Dis 2020; 29:105026. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/24/2020] [Accepted: 06/03/2020] [Indexed: 02/06/2023] Open
|
22
|
Tan SK, Looi WL, Yeo HY. Estimation of direct medical costs of warfarin, dabigatran and rivaroxaban treatments in non‐valvular atrial fibrillation patients in a tertiary public hospital, Malaysia. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2020. [DOI: 10.1002/jppr.1647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Swee Kee Tan
- Department of Pharmacy Hospital Pulau Pinang Ministry of Health Malaysia Pulau Pinang Malaysia
| | - Wan Lin Looi
- Department of Pharmacy Hospital Pulau Pinang Ministry of Health Malaysia Pulau Pinang Malaysia
| | - Hui Yee Yeo
- Clinical Research Centre Hospital Seberang Jaya Ministry of Health Malaysia Pulau Pinang Malaysia
| |
Collapse
|
23
|
Gattellari M, Hayen A, Leung DYC, Zwar NA, Worthington JM. Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial. BMC FAMILY PRACTICE 2020; 21:102. [PMID: 32513116 PMCID: PMC7281948 DOI: 10.1186/s12875-020-01175-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2020] [Indexed: 12/15/2022]
Abstract
Background Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. Methods We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. Results One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86–1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). Conclusions Specialist feed-back in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. Trial registration ANZCTRN12611000076976 Retrospectively registered.
Collapse
Affiliation(s)
- Melina Gattellari
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia. .,Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, New South Wales, 2170, Australia.
| | - Andrew Hayen
- Faculty of Health, University of Technology Sydney, 15 Broadway, Ultimo, New South Wales, 2007, Australia
| | - Dominic Y C Leung
- South Western Sydney Clinical School UNSW, Liverpool, Australia.,Department of Cardiology, Liverpool Health Service, Sydney South West Local Health District, Clinical Services Building, Elizabeth Street, Liverpool (Sydney), New South Wales, 2170, Australia
| | - Nicholas A Zwar
- Faculty of Health, Sciences and Medicine, Bond University, 14 University Drive, Robina, Queensland, 4226, Australia
| | - John M Worthington
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia.,South Western Sydney Clinical School UNSW, Liverpool, Australia
| |
Collapse
|
24
|
Mainka FF, Ferreira VL, Mendes AM, Marques GL, Fernandez-Llimos F, Tonin FS, Pontarolo R. Safety and Efficacy of Oral Anticoagulants Therapies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Network Meta-Analysis. J Cardiovasc Pharmacol Ther 2020; 25:399-408. [DOI: 10.1177/1074248420930136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: Different antithrombotic treatments, from vitamin K antagonists to direct oral anticoagulants (DOACs), are available to reduce ischemic risks in patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI). Objective: To synthetize evidence about the benefit–risk ratio of antithrombotic treatments and their combinations in patients with AF and PCI. Methods: A network meta-analysis and a stochastic multicriteria acceptability analysis (SMAA) were performed including randomized controlled trials (RCT) that evaluate antithrombotic treatments in adults with AF and PCI. Searches were conducted in PubMed and Scopus (updated November-2019). Outcomes compared included bleeding, stroke, and death (Prospero registration: CRD42019146813). Results: Five RCTs were included (11 532 patients). Vitamin K antagonists + dual antiplatelet therapy was associated with major bleeding (odds ratio: 0.52 [95% CI: 0.32-0.86]) compared to DOAC + P2Y12. No statistical differences were found among DOAC regimens for the main outcomes, including bleeding, stroke, and death. Surface under the cumulative ranking curve analysis (SUCRA) and SMAA demonstrated edoxaban 60 mg + P2Y12 inhibitor as the worst option (28%). Apixaban 5 mg + P2Y12 inhibitor was the safest alternative (63%) in all scenarios. Conclusions: Insufficient evidence on the clinical superiority among anticoagulant regimens exists, although apixaban slightly stands out. Edoxaban was associated with more adverse events. To strength this evidence, well-designed, low risk of bias clinical trials are needed. Cost-minimization analyses are required to provide further information for clinical decision-making.
Collapse
Affiliation(s)
- Felipe F. Mainka
- Pharmaceutical Sciences Postgraduate Programme, Federal University of Paraná, Curitiba, Brazil
| | - Vinicius L. Ferreira
- Pharmaceutical Sciences Postgraduate Programme, Federal University of Paraná, Curitiba, Brazil
| | - Antonio M. Mendes
- Pharmaceutical Sciences Postgraduate Programme, Federal University of Paraná, Curitiba, Brazil
| | | | - Fernando Fernandez-Llimos
- Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Fernanda S. Tonin
- Pharmaceutical Sciences Postgraduate Programme, Federal University of Paraná, Curitiba, Brazil
- Research Institute for Medicines (iMed.ULisboa), Universidade de Lisboa, Lisbon, Portugal
| | - Roberto Pontarolo
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
| |
Collapse
|
25
|
Gattellari M, Goumas C, Jalaludin B, Worthington JM. Population-based stroke surveillance using big data: state-wide epidemiological trends in admissions and mortality in New South Wales, Australia. Neurol Res 2020; 42:587-596. [PMID: 32449879 DOI: 10.1080/01616412.2020.1766860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Epidemiological trends for major causes of death and disability, such as stroke, may be monitored using administrative data to guide public health initiatives and service delivery. METHODS We calculated admissions rates for ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage between 1 January 2005 and December 31st, 2013 and rates of 30-day mortality and 365-day mortality in 30-day survivors to 31 December 2014 for patients aged 15 years or older from New South Wales, Australia. Annual Average Percentage Change in rates was estimated using negative binomial regression. RESULTS Of 81,703 eligible admissions, 64,047 (78.4%) were ischaemic strokes and 13,302 (16.3%) and 4,778 (5.8%) were intracerebral and subarachnoid haemorrhages, respectively. Intracerebral haemorrhage admissions significantly declined by an average of 2.2% annually (95% Confidence Interval = -3.5% to -0.9%) (p < 0.001). Thirty-day mortality rates significantly declined for ischaemic stroke (Average Percentage Change -2.9%, 95% Confidence Interval = -5.2% to -1.0%) (p = 0.004) and subarachnoid haemorrhage (Average Percentage Change = -2.6%, 95% Confidence Interval = -4.8% to -0.2%) (p = 0.04). Mortality at 365-days amongst 30-day survivors of ischaemic stroke and intracerebral haemorrhage was stable over time and increased in subarachnoid haemorrhage (Annual Percentage Change 6.2%, 95% Confidence Interval = -0.1% to 12.8%), although not significantly (p = 0.05). DISCUSSION Improved prevention may have underpinned declining intracerebral haemorrhage rates while survival gains suggest that innovations in care are being successfully translated. Mortality in patients surviving the acute period is unchanged and may be increasing for subarachnoid haemorrhage warranting investment in post-discharge care and secondary prevention.
Collapse
Affiliation(s)
- Melina Gattellari
- Ingham Institute for Applied Medical Research , Liverpool (Sydney), Australia.,Department of Neurology, Royal Prince Alfred Hospital , Camperdown (Sydney), Australia
| | - Chris Goumas
- Ingham Institute for Applied Medical Research , Liverpool (Sydney), Australia.,School of Public Health, the University of Sydney , Sydney, Australia
| | - Bin Jalaludin
- Ingham Institute for Applied Medical Research , Liverpool (Sydney), Australia.,Population Health Intelligence, Healthy People and Places Unit, South Western Sydney Local Health District , Liverpool, Sydney, Australia.,School of Public Health and Community Medicine, The University of New South Wales , Sydney, Australia
| | - John M Worthington
- Ingham Institute for Applied Medical Research , Liverpool (Sydney), Australia.,Department of Neurology, Royal Prince Alfred Hospital , Camperdown (Sydney), Australia.,School of Public Health and Community Medicine, The University of New South Wales , Sydney, Australia.,South Western Sydney Clinical School, The University of New South Wales , Liverpool, Sydney, Australia
| |
Collapse
|
26
|
Tomari S, Magin P, Lasserson D, Quain D, Valderas JM, Dewey HM, Barber PA, Spratt NJ, Cadilhac DA, Feigin VL, Rothwell PM, Zareie H, Garcia-Esperon C, Davey A, Najib N, Sales M, Levi CR. The Characteristics of Patients With Possible Transient Ischemic Attack and Minor Stroke in the Hunter and Manning Valley Regions, Australia (the INSIST Study). Front Neurol 2020; 11:383. [PMID: 32670173 PMCID: PMC7326044 DOI: 10.3389/fneur.2020.00383] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/15/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Transient ischemic attack (TIA) and minor stroke (TIAMS) are risk factors for stroke recurrence. Some TIAMS may be preventable by appropriate primary prevention. We aimed to recruit "possible-TIAMS" patients in the INternational comparison of Systems of care and patient outcomes In minor Stroke and TIA (INSIST) study. Methods: A prospective inception cohort study performed across 16 Hunter-Manning region, Australia, general practices in the catchment of one secondary-care acute neurovascular clinic. Possible-TIAMS patients were recruited from August 2012 to August 2016. We describe the baseline demographics, risk factors and pre-event medications of participating patients. Results: There were 613 participants (mean age; 69 ± 12 years, 335 women), and 604 (99%) were Caucasian. Hypertension was the most common risk factor (69%) followed by hyperlipidemia (52%), diabetes mellitus (17%), atrial fibrillation (AF) (17%), prior TIA (13%) or stroke (10%). Eighty-nine (36%) of the 249 participants taking antiplatelet therapy had no known history of cardiovascular morbidity. Of 102 participants with known AF, 91 (89%) had a CHA2DS2-VASc score ≥ 2 but only 47 (46%) were taking anticoagulation therapy. Among 304 participants taking an antiplatelet or anticoagulant agent, 30 (10%) had stopped taking these in the month prior to the index event. Conclusion: This study provides the first contemporary data on TIAMS or TIAMS-mimics in Australia. Community and health provider education is required to address the under-use of anticoagulation therapy in patients with known AF, possibly inappropriate use of antiplatelet therapy and possibly inappropriate discontinuation of antiplatelet or anticoagulation therapy.
Collapse
Affiliation(s)
- Shinya Tomari
- Priority Research Centre for Stroke, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Parker Magin
- Discipline of General Practice, University of Newcastle, Newcastle, NSW, Australia
| | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Debbie Quain
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Jose M. Valderas
- Health Service & Policy Research Group, University of Exeter – Saint Lukes Campus, Exeter, United Kingdom
| | - Helen M. Dewey
- Faculty of Medicine, Nursing and Health Sciences, Box Hill Hospital, Monash University, Melbourne, VIC, Australia
| | - P. Alan Barber
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Neil J. Spratt
- Priority Research Centre for Stroke, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Dominique A. Cadilhac
- Stroke and Aging Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Valery L. Feigin
- AUT University, National Institute for Stroke & Applied Neurosciences, Auckland, New Zealand
| | - Peter M. Rothwell
- Nuffield Department of Clinical Neuroscience, Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Hossein Zareie
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | | | - Andrew Davey
- Discipline of General Practice, University of Newcastle, Newcastle, NSW, Australia
| | - Nashwa Najib
- Discipline of General Practice, University of Newcastle, Newcastle, NSW, Australia
| | - Milton Sales
- Discipline of General Practice, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher R. Levi
- Priority Research Centre for Stroke, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
- The Ingham Institute, SPHERE, Sydney, NSW, Australia
| |
Collapse
|
27
|
Khan Y, Zaidi SO, Razak BS, Zaki M, Malik BH. Use of New Oral Anticoagulants / Direct Oral Anticoagulants in Malignant Patients. Cureus 2020; 12:e7007. [PMID: 32206471 PMCID: PMC7077741 DOI: 10.7759/cureus.7007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 02/16/2020] [Indexed: 12/13/2022] Open
Abstract
Vitamin K antagonists are being used in the last five decades as an effective anticoagulant. However, for the past few years, new oral anticoagulants (NOACs) have been introduced as newer anticoagulant agents, which are gradually replacing the previously used vitamin K antagonist. Yet, these agents have not fully replaced the use of warfarin and heparin. NOACs have few advantages over the vitamin K antagonist as they act on a specific factor of coagulation cascade rather than inhibiting the whole vitamin K synthesis. In this article, all the data has been searched electronically on PubMed and PRISMA guidelines were not followed. Instead, we used MOOSE statements and the data searched on PubMed was from articles published in the last five years. A total of 12,269 patients were observed;,out of which 64.19% had active cancer and 35.80% was observed as a control group comprised of both male or female participants. Approximately 61.14% were using NOACs, 42.83% were on warfarin, and 2.72% were on low-molecular-weight heparin (LMWH). The NOACs used in different patients were in the following percentages; edoxaban (6.81%), apixaban (5.28%), dabigatran (10.09%), and rivaroxaban (10.02%). The use of NOACs has been increasing day by day but these agents have not completely replaced the warfarin or heparin, because of some demerits associated with the use of warfarin and some conditions where these drugs should be avoided. All NOACs have either hepatic or renal clearance so the hepatic activity and creatinine clearance rate must be monitored before the start of NOACs. The drug interaction between anticancer drugs and NOACs is still not fully reported. The effects of NOACs in AF and VTE are therapeutically effective, but in oncology patients several other co-factors are also involved with the use of NOACs due to which, it is either contraindicated or in some cases dose adjustment is required. However, very little information has been collected and more investigation must be done in this perspective.
Collapse
Affiliation(s)
- Yusra Khan
- Pharmacy, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Syed Owais Zaidi
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bibi S Razak
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Mariann Zaki
- Family Medicine, Nova Southeastern University School of Osteopathic Medicine, Sarasota, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| |
Collapse
|
28
|
Valente M, Leung S, Wu P, Oh DH, Tran H, Choi PMC. Ischaemic stroke and transient ischaemic attack on anticoagulants: outcomes in the era of direct oral anticoagulants. Intern Med J 2020; 50:110-113. [PMID: 31943619 DOI: 10.1111/imj.14652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 01/01/2023]
Abstract
Clinical and imaging characteristics of patients receiving direct oral anticoagulants presenting with transient ischaemic attack or stroke are lacking. A retrospective review of all patients who presented to a high-volume primary stroke centre with acute stroke symptoms while prescribed an oral anticoagulant between January 2012 and June 2017. Clinical, radiological characteristics and functional outcomes were examined. Anticoagulated patients diagnosed with stroke or transient ischaemic attack shared similar disease and outcome characteristics irrespective of anticoagulants used. One-third of warfarin patients with sub-therapeutic international normalised ratios were treated with thrombolytics but no direct oral anticoagulants level was performed in any of the patients, with only one treated by intravenous thrombolysis.
Collapse
Affiliation(s)
- Michael Valente
- Department of Neuroscience, Eastern Health, Melbourne, Victoria, Australia
| | - Shelton Leung
- Department of Neuroscience, Eastern Health, Melbourne, Victoria, Australia
| | - Philip Wu
- Department of Neuroscience, Eastern Health, Melbourne, Victoria, Australia
| | - Danielle H Oh
- Department of Haematology, Monash Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Hyuen Tran
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Haematology, Alfred Health, Melbourne, Victoria, Australia
| | - Philip M C Choi
- Department of Neuroscience, Eastern Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
29
|
Schaffer AL, Falster MO, Brieger D, Jorm LR, Wilson A, Hay M, Leeb K, Pearson S, Nasis A. Evidence-Practice Gaps in Postdischarge Initiation With Oral Anticoagulants in Patients With Atrial Fibrillation. J Am Heart Assoc 2019; 8:e014287. [PMID: 31795822 PMCID: PMC6951075 DOI: 10.1161/jaha.119.014287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Oral anticoagulant (OAC) therapy reduces the risk of stroke in people with atrial fibrillation (AF), and is considered best practice; however, there is little Australian evidence around the uptake of OACs in this population. Methods and Results We used linked hospital admissions, pharmaceutical dispensing claims, medical services, and mortality data for people in Australia's 2 most populous states (July 2010 to June 2015). Among OAC‐naïve people hospitalized with AF, we estimated initiation of OAC therapy within 30 days of discharge, and persistence with therapy in the first year. We analyzed both outcomes using multivariable Cox regression. In 71 184 people with AF (median age 78 years, 49% female), 22.7% initiated OAC therapy. Initiation was lowest in July to December 2011 (17.0%) and highest in July to December 2014 (30.1%) after subsidy of the direct OACs. In adjusted analyses, initiation was most likely in people with a CHA2DS2‐VA score ≥7 (versus 0) (hazard ratio=6.25, 95% CI 5.08–7.69), and a history of venous thromboembolism (hazard ratio=2.65, 95% CI 2.49–2.83). Of the people who initiated OAC therapy, 39.9% discontinued within 1 year; a lower risk of discontinuation was associated with a CHA2DS2‐VA score ≥7 (versus 0) (hazard ratio=0.22, 95% CI 0.14–0.35), or initiation on a direct OAC (versus warfarin) (hazard ratio=0.55, 95% CI 0.50–0.60). Conclusions We found that OAC therapy was severely underutilized in people hospitalized with AF, even among high‐risk individuals. Reasons for this underuse, whether patient, prescriber, or hospital related, should be identified and addressed to reduce stroke‐related morbidity and mortality in people with AF.
Collapse
Affiliation(s)
| | | | - David Brieger
- Cardiac Clinical Network Agency for Clinical Innovation Chatswood Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health UNSW Sydney Sydney Australia
| | | | - Melanie Hay
- Victorian Agency for Health Information Melbourne Australia
| | - Kira Leeb
- Victorian Agency for Health Information Melbourne Australia
| | - Sallie Pearson
- Centre for Big Data Research in Health UNSW Sydney Sydney Australia.,Menzies Centre for Health Policy Charles Perkins Centre The University of Sydney Australia
| | | |
Collapse
|
30
|
Eyding J, Bartig D, Weber R, Katsanos AH, Weimar C, Hacke W, Krogias C. Inpatient TIA and stroke care in adult patients in Germany - retrospective analysis of nationwide administrative data sets of 2011 to 2017. Neurol Res Pract 2019; 1:39. [PMID: 33324904 PMCID: PMC7650112 DOI: 10.1186/s42466-019-0044-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 10/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Comprehensive administrative data on TIA and stroke cases and treatment modalities are fundamental for improving structural conditions and adjusting future strategies of stroke care. METHODS The nationwide administrative database (German federal statistical office) was used to extract all adult inpatient TIA and stroke cases and corresponding procedural codes for the period 2011-2017. Numbers were specified according to age, sex, stroke unit (SU) and critical care treatment (ICU), early transfer, and in-hospital mortality. FINDINGS Inpatient adult TIA/stroke cases increased from annually 102,406 / 250,199 (2011) to 106,245 / 264,208 (2017). 84% of strokes were ischemic (AIS) also having the highest relative increase most likely due to more accurate coding within the time period, 68.2% of AIS were treated on SUs. 78% of hemorrhagic strokes were intracerebral hematomas (ICH; rather than subarachnoid hemorrhages [SAH]). Hemorrhagic strokes were increasingly treated on SUs (32.6% [2011], 37.8% [2017]). 68.8% of SAH were treated on ICUs (ICH:36.3%, AIS:10.3%). Early transfer in AIS increased (2.0 to 3.1%). Hemorrhagic strokes were associated with higher in-hospital mortality (SAH:19.6%, ICH:28.2%, AIS:7.3%). INTERPRETATION The absolute increase of strokes presumably reflects the aging society and more awareness for cerebrovascular disease. The relative increase of AIS may be attributable to an increased neurological expertise. The increasing amount of early transfers in AIS reflects new specialized treatment options. Our findings reflect the need for structural adjustments in inpatient stroke care.
Collapse
Affiliation(s)
- Jens Eyding
- Department of Neurology, Klinikum Dortmund gGmbH and Universityhospital Knappschaftskrankenhaus Bochum, Beurhausstr, 40, D-44137 Dortmund, Germany
- Northwest-German Stroke Circle e.V, Bochum, Germany
| | - Dirk Bartig
- Northwest-German Stroke Circle e.V, Bochum, Germany
- drg market, Osnabrück, Germany
| | - Ralph Weber
- Northwest-German Stroke Circle e.V, Bochum, Germany
- Department of Neurology, Alfried Krupp Hospital Essen, Ruhr University Bochum, Essen, Germany
| | - Aristeidis H. Katsanos
- Department of Neurology, University Hospital St. Josef-Hospital Bochum, Ruhr University Bochum, Bochum, Germany
- Second Department of Neurology, National and Kapodistrian University of Athens, Athens, Greece
| | - Christian Weimar
- Northwest-German Stroke Circle e.V, Bochum, Germany
- Department of Neurology, University of Essen-Duisburg, Duisburg, Germany
| | - Werner Hacke
- Senior Professor of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Christos Krogias
- Northwest-German Stroke Circle e.V, Bochum, Germany
- Department of Neurology, University Hospital St. Josef-Hospital Bochum, Ruhr University Bochum, Bochum, Germany
| |
Collapse
|
31
|
Behdarvand B, Karanges EA, Bero L. Pharmaceutical industry funding of events for healthcare professionals on non-vitamin K oral anticoagulants in Australia: an observational study. BMJ Open 2019; 9:e030253. [PMID: 31434780 PMCID: PMC6707659 DOI: 10.1136/bmjopen-2019-030253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To describe the nature, frequency and content of non-vitamin K oral anticoagulant (NOAC)-related events for healthcare professionals sponsored by the manufacturers of the NOACs in Australia. A secondary objective is to compare these data to the rate of dispensing of the NOACs in Australia. DESIGN AND SETTING This cross-sectional study examined consolidated data from publicly available Australian pharmaceutical industry transparency reports from October 2011 to September 2015 on NOAC-related educational events. Data from April 2011 to June 2016 on NOAC dispensing, subsidised under Australia's Pharmaceutical Benefits Scheme (PBS), were obtained from the Department of Health and the Department of Human Services. MAIN OUTCOME MEASURES Characteristics of NOAC-related educational events including costs (in Australian dollars, $A), numbers of events, information on healthcare professional attendees and content of events; and NOAC dispensing rates. RESULTS During the study period, there were 2797 NOAC-related events, costing manufacturers a total of $A10 578 745. Total expenditure for meals and beverages at all events was $A4 238 962. Events were predominantly attended by general practitioners (42%, 1174/2797), cardiologists (35%, 977/2797) and haematologists (23%, 635/2797). About 48% (1347/2797) of events were held in non-clinical settings, mainly restaurants, bars and cafes. Around 55% (1551/2797) of events consisted of either conferences, meetings or seminars. The analysis of the content presented at two events detected promotion of NOACs for unapproved indications, an emphasis on a favourable benefit/harm profile, and that all speakers had close ties with the manufacturers of the NOACs. Following PBS listings relevant to each NOAC, the numbers of events related to that NOAC and the prescribing of that NOAC increased. CONCLUSIONS Our findings suggest that the substantial investment in NOAC-related events made by four pharmaceutical companies had a promotional purpose. Healthcare professionals should seek independent information on newly subsidised medicines from, for example, government agencies or drug bulletins.
Collapse
Affiliation(s)
- Behrad Behdarvand
- Charles Perkins Centre and School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Emily A Karanges
- Charles Perkins Centre and School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Lisa Bero
- Charles Perkins Centre and School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|