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Grymonprez M, Steurbaut S, Capiau A, Vauterin D, Van Vaerenbergh F, Mehuys E, Boussery K, De Backer TL, Lahousse L. Minimal Adherence Threshold to Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation to Reduce the Risk of Thromboembolism and Death: A Nationwide Cohort Study. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07507-3. [PMID: 37707648 DOI: 10.1007/s10557-023-07507-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/15/2023]
Abstract
PURPOSE Poor adherence to non-vitamin K antagonist oral anticoagulants (NOACs) may raise thromboembolic risks in patients with atrial fibrillation (AF). However, the minimal adherence to maintain the protective effect of NOACs is currently unknown. Therefore, we investigated thresholds of NOAC adherence in association with thromboembolic and mortality risks. METHODS Patients with AF initiating NOACs between 2013 and 2019 were identified in Belgian nationwide data. Adherence was measured using the proportion of days covered (PDC) after one year of treatment. Inverse probability of treatment weighted Cox regression was used to investigate outcomes. RESULTS 92,111 persons were included (250,750 person-years). Compared to NOAC users with a one-year PDC of 100%, significantly higher risks of stroke or systemic embolism were observed among NOAC users with PDCs of 85-89% (adjusted hazard ratio (aHR) 1.35, 95% confidence interval (CI) (1.19-1.54)), 80-84% (aHR 1.31, 95%CI (1.08-1.58)) and < 80% (aHR 1.64, 95%CI (1.34-2.01)), while no significant differences were observed among NOAC users with one-year PDCs of 95-99% (aHR 1.02, 95%CI (0.94-1.12)) or 90-94% (aHR 1.06, 95%CI (0.95-1.18)). Significantly higher risks of all-cause mortality were observed with decreasing levels of NOAC adherence, which were already higher among NOAC users with a one-year PDC of 90-94% versus 100% (aHR 1.09, 95%CI (1.01-1.17)). Findings were similar with once-daily and twice-daily dosed NOACs. CONCLUSION Poor adherence to NOACs is associated with increased risks of thromboembolism and all-cause mortality. The minimal adherence threshold should be ≥ 90%, preferably even ≥ 95%.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090, Belgium
- Department of Hospital Pharmacy, UZ Brussel, Laarbeeklaan 101, Jette, 1090, Belgium
| | - Andreas Capiau
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium
| | - Delphine Vauterin
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium
| | - Frauke Van Vaerenbergh
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium
| | - Els Mehuys
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium
| | - Koen Boussery
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, Ghent, 9000, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, Ghent, 9000, Belgium.
- Department of Epidemiology, Erasmus Medical Center, Doctor Molewaterplein 40, Rotterdam, 3015, The Netherlands.
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Zhang W, McDermott S, Salzberg DC, Hollis ND, Hardin J. A Randomized Controlled Trial using Brief Educational Messages Directed to Adults with Intellectual Disability and Hypertension or their Helpers Reduces Hospital Stays. Am J Health Promot 2023; 37:894-904. [PMID: 36880149 PMCID: PMC10467014 DOI: 10.1177/08901171231161470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
PURPOSE We assessed an educational intervention to reduce the number of emergency department (ED) and inpatient stays for cardiovascular diagnoses, among South Carolina adult Medicaid Members with intellectual and developmental disability and hypertension (Members). DESIGN This Randomized Controlled Trial (RCT) included Members or the person who helped them with their medications (Helpers). Participants, who included Members and/or their Helpers, were randomly assigned to an Intervention or Control group. SETTING South Carolina Department of Health and Human Services, which administers Medicaid, identified eligible Members. SAMPLE 412 Medicaid Members - 214 Intervention (54 Members participating directly; 160 Helpers participating in lieu of Members) who received the messages about hypertension and surveys about knowledge and behavior and 198 Controls (62 Members; 136 Helpers) who only received surveys of knowledge and behavior. INTERVENTION Educational intervention about hypertension included a flyer and monthly text or phone messages for one year. MEASURES Input measures - characteristics of the Members; Outcome measures - hospital emergency department (ED) and inpatient visits for cardiovascular conditions. ANALYSIS Quantile regression tested the association of Intervention/Control group status with ED and inpatient visits. We also estimated models using Zero-inflated Poisson (ZIP) models for sensitivity analysis. RESULTS Participants in the Intervention group with highest baseline hospital use (top 20% ED; top 15% Inpatient) had significant reductions in Year 1 (.57 fewer ED and 2 fewer inpatient days) compared to the Control group. For ED visits, improvement continued in year two. CONCLUSION The intervention reduced the frequency of cardiovascular disease-related ED visits and Inpatient days for participants in the Intervention group in the highest quantiles of hospital use, and the improvement was better for those who had a Helper.
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Affiliation(s)
- Wanfang Zhang
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
| | - Suzanne McDermott
- Department of Environmental, Occupational, and Geospatial Health Sciences, CUNY Graduate School of Public Health, New York, NY, USA
| | - Deborah C. Salzberg
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
| | - NaTasha D. Hollis
- National Center on Birth Defects and Developmental Disability, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - James Hardin
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
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Zhao X, Tong Z, Sun L, Zhang Q, Du X, Xu S, Shen C, Wei Y, Liu W, Miao L, Zeng Y. Clinical Characteristics, Treatment Patterns, and Effectiveness in Chinese Patients with Angina Pectoris Using Electronic Patient-Reported Outcomes: Protocol for a Multicenter, Prospective, Cohort Study (GREAT). Adv Ther 2023; 40:1899-1912. [PMID: 36737594 DOI: 10.1007/s12325-023-02425-0] [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] [Received: 10/14/2022] [Accepted: 01/03/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Angina pectoris (AP) is the initial and the most common manifestation of coronary artery disease (CAD). Therefore, management and control of AP can help prevent further complications associated with CAD. However, there is under-reporting of angina symptoms in clinical practice, resulting in under-treatment and reduced quality of life (QoL). Prospective and standardized monitoring is needed to support timely and appropriate treatment. OBJECTIVES To establish a large cohort of Chinese patients with AP and compare the effectiveness of different anti-angina regimens with the help of electronic patient-reported outcomes (e-PROs), using the Seattle Angina Questionnaire (SAQ) to assess health status. METHODS The registry study (GREAT) is a multicenter, prospective, observational, cohort study. Patients diagnosed with AP will be enrolled from 10 hospitals and assessed based on the different anti-anginal regimens. Patients will be followed up every 3 months from baseline to 12 months to observe the difference in the therapeutic effectiveness of the drugs. Data will be collected in the form of e-PROs combined with on-site visit records. PLANNED OUTCOMES The change in SAQ summary score (SAQ SS) at Month 12 from baseline will be the primary outcome. The secondary measures will include changes in SAQ SS at Months 3, 6, and 9 from baseline, changes in retest results of vascular stenosis imaging at Month 12 from baseline, and medication adherence based on the proportion of days covered. Safety data will be evaluated based on the incidence of adverse events (AEs). CONCLUSION This study will evaluate the effectiveness of anti-anginal regimens using ePROs in real-world settings in China. The results from this study may provide a new perspective on treatment patterns and the effectiveness of different anti-anginal regimens for patients with AP. STUDY REGISTRATION NUMBER NCT05050773.
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Affiliation(s)
- Xiliang Zhao
- Center for Cardiology, Beijing Anzhen Hospital, Beijing, 100029, China
| | - Zichuan Tong
- Department of Cardiology, Beijing Daxing District People's Hospital, Beijing, China
| | - Liling Sun
- Department of Cardiology, Beijing Changping District Hospital, Beijing, China
| | - Qihua Zhang
- Department of Cardiology, Beijing Miyun District Hospital, Beijing, China
| | - Xin Du
- Center for Cardiology, Beijing Anzhen Hospital, Beijing, 100029, China
| | - Su'e Xu
- Department of Cardiology, Huai'an Hospital of Traditional Chinese Medicine, Beijing, China
| | - Chengning Shen
- Department of Cardiology, Ruyang People's Hospital, Ruyang, China
| | - Ying Wei
- Department of Cardiology, Dezhou People's Hospital, Dezhou, China
| | - Wei Liu
- Department of Cardiology, Beijing Jishuitan Hospital, Beijing, China
| | - Lifu Miao
- Department of Cardiology, Beijing Huaxin Hospital, Beijing, China
| | - Yong Zeng
- Center for Cardiology, Beijing Anzhen Hospital, Beijing, 100029, China.
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Kwan JY, Tang SH, Davies H, Sood M, Sucharitkul PP, Wallace T, Scott DJA, Coughlin PA, Bailey MA. Analyzing Sex Differences in Intensity of Cardiovascular Disease Prevention Medications in Patients With Abdominal Aortic Aneurysms-A Single-Center Cross-Sectional Study. Ann Vasc Surg 2023; 90:67-76. [PMID: 36460174 DOI: 10.1016/j.avsg.2022.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/08/2022] [Accepted: 10/22/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Patients with abdominal aortic aneurysm (AAA) are at a significant risk of cardiovascular events, similar to that of patients who have already experienced a major cardiac event. The European Society for Vascular Society AAA guidelines suggest that antiplatelet therapy and lipid-lowering therapy (LLT) should be considered in all patients with AAA. This study explores the overall prevalence and intensity of antithrombotic therapy and LLT, and lipid profile monitoring in a single center AAA surveillance cohort alongside any sex differences. METHODS This was a retrospective, single center, cross-sectional study of 614 patients enrolled in the AAA surveillance program of a tertiary vascular surgery unit. All patients undergoing at least 1 surveillance scan from January 1, 2018, to December 31, 2020, were assessed. Electronic hospital records linked to real-time primary care records were interrogated for data on demographics, comorbidities, antiplatelet and LLT prescriptions, and serum cholesterol laboratory results. An analysis of covariance test was used to account for the effects of confounding comorbidities. RESULTS Twenty-one percent of patients were not on antithrombotic therapy, and 20% of patients were not on LLT which reflects a group of patients receiving sub-optimal clinical care. In total, 47% of the cohort were on low/moderate intensity statin therapy which reflects a group of patients where care can be improved upon. Female sex was independently associated with a reduced likelihood of being prescribed LLT (P = 0.008, eta squared (ηp2) = 0.012, small effect size) but not antithrombotic therapy (P = 0.202). Fewer women underwent low-density lipoprotein cholesterol (LDL-C) monitoring (mean difference 9%, P = 0.040) and achieved the European Society of Cardiology-European Atherosclerosis Society- LDL-C target of <1.4 mmol/L (mean difference 9%, P = 0.040). CONCLUSIONS Overall, there is room for improvement in these aspects of cardiovascular risk prevention for both sexes. Sex differences in the prescription of LLT, the prevalence of lipid profile monitoring, and likelihood of achieving LDL-C targets exist among patients with AAA, with a lower prevalence in women.
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Affiliation(s)
- Jing Yi Kwan
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK; The Leeds Institute of Cardiovascular & Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - Steve Hm Tang
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Henry Davies
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK; The Leeds Institute of Cardiovascular & Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - Mehak Sood
- The Leeds Institute for Medical Education, School of Medicine, University of Leeds, Leeds, UK
| | - Penelope Pj Sucharitkul
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK; The Leeds Institute for Medical Education, School of Medicine, University of Leeds, Leeds, UK
| | - Tom Wallace
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Julian A Scott
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Patrick A Coughlin
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Marc A Bailey
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK; The Leeds Institute of Cardiovascular & Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK.
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Impacts of medication non-adherence to major modifiable stroke-related diseases on stroke prevention and mortality: a meta-analysis. J Neurol 2023; 270:2504-2516. [PMID: 36843040 PMCID: PMC9968645 DOI: 10.1007/s00415-023-11601-9] [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: 12/30/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Medication adherence is one of the crucial attempts in primary stroke prevention. The available evidence lacks comprehensive reviews exploring the association of medication adherence with stroke prevention. OBJECTIVES To investigate the effects of non-adherence to medications used to treat the modifiable risk of diseases on stroke-associated outcomes in primary stroke prevention. METHODS Study records were searched from PubMed, Embase, and CINAHL. Those studies reported risks relevant to stroke-associated outcomes and medication non-adherence for patients diagnosed with four modifiable stroke-related diseases (atrial fibrillation [AF], hyperlipidemia, hypertension, and type 2 diabetes mellitus) but without stroke history were included for meta-analysis and further subgroup, sensitivity, and publication bias analyses. A random effect model was performed to analyse the pooled risk estimates of relative risk (RR) and 95% confidence intervals (CIs). RESULTS Thirty-nine studies (with 2,117,789 participants in total) designed as cohort or case-control studies were included. Those patients presenting with four stroke-related diseases and categorised as medication non-adherent tended to result in stroke and/or associated death (all pooled RR ≥ 1 and 95% CI did not include 1). The findings of stratification and sensitivity analysis for each stroke-related disease showed a similar trend. Non-adherent patients with AF were prone to stroke occurrence (RR 1.852; 95% CI 1.583-2.166) but inclined to reduced bleeding (RR 0.894; 95% CI 0.803-0.996). The existence of publication bias warrants further interpretation. CONCLUSIONS Non-adherence to medications for the four stroke-related diseases contributes to the development of stroke and/or mortality in primary stroke prevention. More efforts are needed to improve patients' medication adherence.
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Giner-Soriano M, Prat-Vallverdú O, Ouchi D, Vilaplana-Carnerero C, Morros R. Sex and gender differences in the use of oral anticoagulants for non-valvular atrial fibrillation: A population-based cohort study in primary health care in catalonia. Front Pharmacol 2023; 14:1110036. [PMID: 36825151 PMCID: PMC9941166 DOI: 10.3389/fphar.2023.1110036] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/18/2023] [Indexed: 02/10/2023] Open
Abstract
Objectives: To describe the sex and gender differences in the treatment initiation and in the socio-demographic and clinical characteristics of all patients initiating an oral anticoagulant (OAC), and the sex and gender differences in prescribed doses and adherence and persistence to the treatment of those receiving direct oral anticoagulants (DOAC). Material and methods: Cohort study including patients with non-valvular atrial fibrillation (NVAF) who initiated OAC in 2011-2020. Data proceed from SIDIAP, Information System for Research in Primary Care, in Catalonia, Spain. Results: 123,250 people initiated OAC, 46.9% women and 53.1% men. Women were older and the clinical characteristics differed between genders. Women had higher risk of stroke than men at baseline, were more frequently underdosed with DOAC and discontinued the DOAC less frequently than men. Conclusion: We described the dose adequacy of patients receiving DOAC, finding a high frequency of underdosing, and significantly higher in women in comparison with men. Adherence was generally high, only with higher levels in women for rivaroxaban. Persistence during the first year of treatment was also high in general, being significantly more persistent women than men in the case of dabigatran and edoxaban. Dose inadequacy, lack of adherence and of persistence can result in less effective and safe treatments. It is necessary to conduct studies analysing sex and gender differences in health and disease.
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Affiliation(s)
- Maria Giner-Soriano
- Fundació Institut Universitari Per a la Recerca a l’Atenció Primària De Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain,Universitat Autònoma De Barcelona (Cerdanyola del Vallès), Bellaterra, Spain,*Correspondence: Maria Giner-Soriano,
| | | | - Dan Ouchi
- Fundació Institut Universitari Per a la Recerca a l’Atenció Primària De Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain,Universitat Autònoma De Barcelona (Cerdanyola del Vallès), Bellaterra, Spain
| | - Carles Vilaplana-Carnerero
- Fundació Institut Universitari Per a la Recerca a l’Atenció Primària De Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain,Universitat Autònoma De Barcelona (Cerdanyola del Vallès), Bellaterra, Spain,Plataforma SCReN, UIC IDIAPJGol, Barcelona, Spain
| | - Rosa Morros
- Fundació Institut Universitari Per a la Recerca a l’Atenció Primària De Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain,Plataforma SCReN, UIC IDIAPJGol, Barcelona, Spain,Departament De Farmacologia, Terapèutica i Toxicologia, Universitat Autònoma De Barcelona (Cerdanyola del Vallès), Bellaterra, Spain,Institut Català De la Salut, Barcelona, Spain
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7
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Bonilla Guijarro A, Bailén M, Hernando A. [Analysis of medication adherence using electronic prescriptions in a community pharmacy: 'REACT' study]. FARMACEUTICOS COMUNITARIOS 2023; 15:41-55. [PMID: 39156185 PMCID: PMC11326682 DOI: 10.33620/fc.2173-9218.(2023).05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/18/2022] [Indexed: 01/28/2023]
Abstract
Background Patients` lack of adherence to pharmacological treatments has a major impact, both clinical and economical. While different methods are used to measure adherence, retrospective studies are being used more frequently as they are more objective, less prone to bias by patient perception and interfere less with patients' lives. The electronic prescription system provides the community pharmacy with a useful tool to conduct this research. Objective To measure the adherence of patients to their chronic medication considering different therapeutic drug groups and their mental health using electronic prescription information available in a database. Methods An observational, ambispective and logitudinal study was developed for 300 patients. Adherence was assessed using Proportion of Days Covered (PDC) per patient and per treatment and the Morisky Green Levine test. Data on patients' dispensed medication for the last 12 months was obtained through the electronic prescription system. Data on patient mental health was gathered using the PHQ-2 screen for depression. Results A total of 300 patients were recruited, but only 290 were included in the analysis. 25.5%; [95%CI: 20.6:30.9] were classified as polymedicated. The median PDC per patient was 0.90 (IQR: 0.73 - 1). According to the Morisky Green Levine questionnaire, 57.9% of the patients [95%CI 52.0:63.6] adhered to their treatments. Concurrence between the Morisky Green Levine test and the PDC had a kappa k=0.086. Conclusion The electronic prescription turned out to be a useful tool to gain insight into adherence to long-term treatments measured in terms of the PDC.
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Affiliation(s)
- Amparo Bonilla Guijarro
- Doctora en Biomedicina y Ciencias de la Salud. Farmacia Comunitaria Amparo Bonilla, Madrid.España
| | - Maria Bailén
- Doctora en Farmacia. Universidad Autónoma de MadridUniversidad Autónoma de MadridEspaña
| | - Asunción Hernando
- Doctora en Medicina. Instituto de Investigación Hospital Universitario 12 de Octubre (I+12), CIBERINFEC.Instituto de Investigación Hospital Universitario 12 de OctubreEspaña
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Oni-Orisan A, Haldar T, Cayabyab MA, Ranatunga DK, Hoffmann TJ, Iribarren C, Krauss RM, Risch N. Polygenic Risk Score and Statin Relative Risk Reduction for Primary Prevention of Myocardial Infarction in a Real-World Population. Clin Pharmacol Ther 2022; 112:1070-1078. [PMID: 35862449 PMCID: PMC10112337 DOI: 10.1002/cpt.2715] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/12/2022] [Indexed: 11/10/2022]
Abstract
Genetic substudies of randomized controlled trials demonstrate that high coronary heart disease (CHD) polygenic risk score modifies statin CHD relative risk reduction; it is unknown if the association extends to statin users undergoing routine care. We sought to determine how statin effectiveness is modified by CHD polygenic risk score in a real-world cohort of participants without previous myocardial infarction. We determined CHD polygenic risk scores in participants of the Genetic Epidemiology Research on Adult Health and Aging (GERA) cohort. Covariate-adjusted Cox regression models were used to compare the risk of cardiovascular outcomes between statin users and matched nonusers. Statin effectiveness on incident myocardial infarction showed no gradient with increasing 10-year Pooled Cohort Equations atherosclerotic cardiovascular disease (ASCVD) risk across low, borderline, intermediate, and high ASCVD risk score groups. In contrast, statin effectiveness by polygenic risk was largest in the high polygenic risk score group (hazard ratio (HR) 0.41, 95% confidence interval (CI), 0.31-0.53; P = 1.5E-11), intermediate in the intermediate polygenic risk score group (HR 0.56, 95% CI, 0.47-0.66; P = 8.4E-12), and smallest in the low polygenic risk score group (HR 0.67, 95% CI, 0.47-0.97; P = 0.03; P for high vs. low = 0.01). ASCVD risk and statin low-density lipoprotein cholesterol (LDL-C) lowering did not differ across polygenic risk score groups. In patients undergoing routine care, CHD polygenic risk modified statin relative risk reduction of incident myocardial infarction independent of LDL-C lowering. Our findings extend prior work by identifying a subset (i.e., self-identified White individuals with low CHD polygenic risk scores) with attenuated clinical benefit from statins.
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Affiliation(s)
- Akinyemi Oni-Orisan
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
- Institute for Human Genetics, University of California San Francisco, San Francisco, California, USA
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Tanushree Haldar
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Mari A.S. Cayabyab
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | | | - Thomas J. Hoffmann
- Institute for Human Genetics, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Carlos Iribarren
- Kaiser Permanente Division of Research, Oakland, California, USA
| | - Ronald M. Krauss
- Department of Pediatrics, University of California San Francisco, Oakland, California, USA
- Department of Medicine, University of California San Francisco, Oakland, California, USA
| | - Neil Risch
- Institute for Human Genetics, University of California San Francisco, San Francisco, California, USA
- Kaiser Permanente Division of Research, Oakland, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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9
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Teppo K, Jaakkola J, Biancari F, Halminen O, Linna M, Haukka J, Putaala J, Tiili P, Lehtonen O, Niemi M, Mustonen P, Kinnunen J, Hartikainen J, Airaksinen KEJ, Lehto M. Association of income and educational levels with adherence to direct oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study. Pharmacol Res Perspect 2022; 10:e00961. [PMID: 35599338 PMCID: PMC9124817 DOI: 10.1002/prp2.961] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/17/2022] [Indexed: 11/09/2022] Open
Abstract
Low socioeconomic status has been associated with poor outcomes in patients with atrial fibrillation (AF). However, little is known about socioeconomic disparities in adherence to stroke prevention with direct oral anticoagulants (DOACs). We assessed the hypothesis that AF patients with higher income or educational levels have better adherence to DOACs in terms of treatment implementation and persistence. The used nationwide registry‐based FinACAF cohort covers all patients with incident AF starting DOACs in Finland during 2011–2018. The implementation analyses included 74 222 (mean age 72.7 ± 10.5 years, 50.8% female) patients, and persistence analyses included 67 503 (mean age 75.3 ± 8.9 years, 53.6% female) patients with indication for permanent anticoagulation (CHA2DS2‐VASc score >1 in men and >2 in women). Patients were divided into income quartiles and into three categories based on their educational attainment. Therapy implementation was measured using the medication possession ratio (MPR), and patients with MPR ≥0.90 were defined adherent. Persistence was measured as the incidence of therapy discontinuation, defined as the first 135‐day period without DOAC purchases after drug initiation. Patients with higher income or education were consistently more likely adherent to DOACs in the implementation phase (comparing the highest income or educational category to the lowest: adjusted odds ratios 1.18 (1.12–1.25) and 1.21 (1.15–1.27), respectively). No association with income or educational levels was observed on the incidence of therapy discontinuation. In conclusion, we observed that income and educational levels both have independent positive association on the implementation of DOAC therapy but no association on therapy persistence in patients with AF.
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Affiliation(s)
| | - Jussi Jaakkola
- University of Turku, Turku, Finland.,Heart Unit, Satakunta Central Hospital, Pori, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland.,University of Eastern Finland, Kuopio, Finland
| | | | - Jukka Putaala
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | | | | | | | | | - Janne Kinnunen
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland.,Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - K E Juhani Airaksinen
- University of Turku, Turku, Finland.,Heart Center, Turku University Hospital, Turku, Finland
| | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,University of Helsinki, Helsinki, Finland.,Department of Internal Medicine, Lohja Hospital, Lohja, Finland
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Toma MM, Bungau SG, Tit DM, Moisi MI, Bustea C, Vesa CM, Behl T, Stoicescu M, Brisc CM, Purza LA, Gitea D, Diaconu CC. Use of anticoagulant drugs in patients with atrial fibrillation. Does adherence to therapy have a prognostic impact? Biomed Pharmacother 2022; 150:113002. [PMID: 35462339 DOI: 10.1016/j.biopha.2022.113002] [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: 02/23/2022] [Revised: 04/10/2022] [Accepted: 04/17/2022] [Indexed: 11/30/2022] Open
Abstract
Anticoagulant therapy represents a pivotal element that strongly influences the thromboembolic risk of non-valvular atrial fibrillation (NVAF) subjects. The main purpose of this review was to identify issues and suggest strategies to improve the oral anticoagulants (OACs) treatment adherence, which is the most important predictor of NVAF outcome. Advantages, efficacy, and impact of these drugs on patients' prognosis were revealed in important clinical trials on large cohorts of patients and are often prescribed nowadays. A real-life data registry, the Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD-AF) analyzed the profile and outcome of patients diagnosed with NVAF receiving oral antithrombotic treatment. The observations gathered in the registry were crucial for identifying relevant elements that clinicians must improve, such as adherence strategies and predisposing factors that correlated with stroke. Adherence to OACs in AF patients is essential from the viewpoint of clinical efficacy and safety. Major adverse events and negative outcome are correlated with a weak anticoagulation control caused by an ineffective treatment adherence strategy. Solving the issue of oral anticoagulation adherence is possible using new technologies, but future directions should be explored. Mobile phone applications centered on patients' needs, telemedicine programs that evaluate patients' evolution and detect adverse reactions or events, encouraging an adequate management of the event without interruption of OACs, represent perspectives with a major impact on treatment adherence.
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Affiliation(s)
- Mirela Marioara Toma
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410087, Romania.
| | - Simona Gabriela Bungau
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410087, Romania; Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Delia Mirela Tit
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410087, Romania; Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Madalina Ioana Moisi
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania.
| | - Cristiana Bustea
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania.
| | - Cosmin Mihai Vesa
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania.
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, 140401 Punjab, India.
| | - Manuela Stoicescu
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania.
| | - Cristina Mihaela Brisc
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania.
| | - Lavinia Anamaria Purza
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Daniela Gitea
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Camelia Cristina Diaconu
- Department 5, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania; Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania.
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11
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Skirdenko YP, Nikolaev NA, Pereverzeva KG, Timakova AY, Galus AS, Yakushin SS. Modern Anticoagulant Therapy for Atrial Fibrillation: Patient Adherence in Clinical Practice. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-02-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aim. To assess the adherence of doctors and patients to anticoagulant therapy for atrial fibrillation (AF).Materials and methods. An observational prospective study included 99 patients with AF at high risk of thromboembolic complications in Ryazan and Omsk. To study adherence, a questionnaire for quantitative assessment of treatment adherence ("QAA-25") was used. The questionnaire allows you to assess adherence by three main parameters separately: adherence to drug therapy, lifestyle modification and medical support. For the purposes of the study, adherence rates of less than 75% were regarded as insufficient, 75%. % or more as sufficient. To assess food preferences and determine the risk of changes in the activity of warfarin, a questionnaire of food preferences was used. The questionnaire allows you to assess the risk of alimentary increase (≥30 points) and decrease (≥60 points) of warfarin activity, as well as the overall risk of alimentary change (≥90 points) of warfarin activity in each patient, taking into account the volume and frequency of consumption of products that affect the activity of warfarin.Results. After the first visit, 99% of respondents received anticoagulant treatment. Rivaroxaban was the leader in prescribability among anticoagulants (36.7%). About a third of respondents were prescribed apixaban by a doctor (30.6%) and dabigatran (17.3%) and warfarin (19.4%) were prescribed almost twice as rarely as rivaroxaban. Respondents with the highest rates of adherence to drug therapy, lifestyle modification and medical support are AF patients taking apixaban. The respondents who were prescribed rivaroxaban had the lowest level of adherence to drug therapy and lifestyle modification. And the lowest level of commitment to medical support is among respondents who have been prescribed warfarin. The number of people with a sufficient level of commitment did not reach half. Only 43.9% were ready to take prescribed medications and slightly more than a third (34.7%) agreed to come to appointments for a long time. But, despite the importance of lifestyle modification in patients with AF, only 16.3% of respondents said they were ready to give up bad habits, lose weight and lead a more active lifestyle. The proportion of people with sufficient adherence to drug therapy was the smallest in the group taking rivaroxaban (25.7%). The least number of respondents with sufficient commitment to medical support in the group taking dabigatran (25%). Only one in ten patients (11.1%) taking warfarin had a sufficient level of commitment to lifestyle modification. 15% of the study participants had an increased risk of alimentary changes in the activity of warfarin.Conclusion. Assessment of adherence to anticoagulant therapy by doctors in two regional centers (Omsk and Ryazan) showed high prescribability of preventive antithrombotic therapy, which corresponds to modern therapeutic approaches. At the same time, patients demonstrated rather low levels of adherence to drug therapy, lifestyle modification, and medical support.
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Affiliation(s)
- Yu. P. Skirdenko
- Omsk State Medical University; National Medical Research Center for Therapy and Preventive Medicine
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12
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Navin SF, Nardolillo J, Stambaugh A, Young C, Nguyen P, Apodaca M. Pharmacist monitoring of direct oral anticoagulants for American Indians and Alaska Natives in the outpatient setting. J Am Pharm Assoc (2003) 2022; 62:598-603. [PMID: 34728162 DOI: 10.1016/j.japh.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) call into question the role of traditional pharmacist-run clinics, and few studies have described the incorporation of DOAC's into traditional anticoagulation management services (AMS) OBJECTIVE: To describe the incorporation of DOACs into a pharmacist-run AMS for American Indian and Alaska Native (AI/AN) patients and determine outcomes related to adherence, follow-up, and pharmacist interventions. PRACTICE DESCRIPTION Traditional AMS embedded in ambulatory clinic. Warfarin managed by pharmacists under a collaborative practice agreement with supervising physician. PRACTICE INNOVATION DOACs incorporated into AMS by transitioning warfarin patients to rivaroxaban and apixaban and managing new patients with DOAC. Follow-up occurred via phone call and at longer intervals. EVALUATION METHODS Single-center, retrospective, observational analysis of AI/AN patients who were followed up by pharmacy AMS. The outcomes measured include adherence to DOAC therapy, number of telephonic encounters versus face-to-face visits, frequency of follow-up, types of interventions made at each visit, and an estimate of face-to-face clinic time savings. RESULTS A total of 50 patients were included for analysis. The average medication possession ratio was 91%. The majority of visits occurred over the phone (59%), and most follow-up visits occurred every 3 months (62%). The top 3 most frequent interventions were adherence education, initial DOAC education, and education on use of nonsteroidal anti-inflammatory drugs. PRACTICE IMPLICATIONS Traditional AMS can evolve by incorporating DOACs and maintaining follow-up. CONCLUSION Pharmacist monitoring of DOACs may promote high levels of adherence and lead to time savings by reducing the amount of time spent in traditional AMS.
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13
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Teppo K, Jaakkola J, Airaksinen KEJ, Biancari F, Halminen O, Putaala J, Mustonen P, Haukka J, Hartikainen J, Luojus A, Niemi M, Linna M, Lehto M. Mental health conditions and adherence to direct oral anticoagulants in patients with incident atrial fibrillation: A nationwide cohort study. Gen Hosp Psychiatry 2022; 74:88-93. [PMID: 34999528 DOI: 10.1016/j.genhosppsych.2021.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/18/2021] [Accepted: 12/29/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Medication adherence is essential for effective stroke prevention in patients with atrial fibrillation (AF). We aimed to assess whether adherence to direct oral anticoagulants (DOACs) in AF patients is affected by the presence of mental health conditions (MHCs). METHODS The nationwide FinACAF cohort covered 74,222 AF patients from all levels of care receiving DOACs during 2011-2018 in Finland. Medication possession ratio (MPR) was used to quantify adherence. Patients with MPR ≥0.90 were defined adherent. MHCs of interest were depression, bipolar disorder, anxiety disorder and schizophrenia. RESULTS The patients' (mean age 75.4 ± 9.5 years, 50.8% female) mean MPR was 0.84 (SD 0.22), and 59.5% had MPR ≥0.90. Compared to patients without MHC, the adjusted ORs (95% CI) for adherent DOAC use emerged slightly lower in patients with depression (0.92 (0.84-0.99)) and bipolar disorder (0.77 (0.61-0.97)) and unsignificant in patients with anxiety disorder (1.08 (0.96-1.21)) and schizophrenia (1.13 (0.90-1.43)). However, when only persistent DOAC therapy was analyzed, no MHC was associated with poor adherence, and instead anxiety disorder was associated with adherent DOAC use (1.18 (1.04-1.34)). CONCLUSION Adherence to DOACs in AF patients in Finland was relatively high, and no meaningful differences between patients with and without MHCs were observed.
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Affiliation(s)
| | - Jussi Jaakkola
- University of Turku, Turku, Finland; Heart Center, Turku University Hospital, Turku, Finland; Heart Unit, Satakunta Central Hospital, Pori, Finland
| | - K E Juhani Airaksinen
- University of Turku, Turku, Finland; Heart Center, Turku University Hospital, Turku, Finland
| | - Fausto Biancari
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy; Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | | | - Jukka Putaala
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- University of Turku, Turku, Finland; Heart Center, Turku University Hospital, Turku, Finland
| | | | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland; Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Alex Luojus
- University of Helsinki, Helsinki, Finland; Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland; Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland; Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland; University of Eastern Finland, Kuopio, Finland
| | - Mika Lehto
- University of Helsinki, Helsinki, Finland; Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Lohja Hospital, Department of Internal Medicine, Lohja, Finland
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14
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Caliskan T, Akalan H, Yilmaz I, Karaarslan N, Sirin DY, Ozbek H. The effects of rivaroxaban, an oral anticoagulant, on human IVD primary cultures. Arch Med Sci 2022; 18:1062-1070. [PMID: 35832710 PMCID: PMC9266726 DOI: 10.5114/aoms/136323] [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: 11/05/2020] [Accepted: 05/02/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The present study aimed to investigate the potential effects of rivaroxaban, an oral anticoagulant that inhibits the effects of factor Xa, on intact intervertebral disc tissue cells and the extracellular matrix (ECM). MATERIAL AND METHODS Rivaroxaban was applied to primary human cell cultures prepared from tissues of the intervertebral disc. Comparative molecular analyses were performed on non-drug-treated control group samples. Descriptive statistics were presented as the mean ± standard deviation. An analysis of variance test was performed to determine whether there were significant differences in the mean across the groups. When differences across groups were observed, Tukey's honestly significant difference post-hoc test was used for multiple pairwise comparisons. The significance of the obtained data was determined statistically. The α significance value was < 0.05. RESULTS The cells in the control group and in the rivaroxaban-treated group were viable, healthy, and proliferated (p < 0.05). However, the expression levels of the chondroadherin gene (CHAD), cartilage oligo matrix protein (COMP), matrix metalloproteinase (MMP)-13, and MMP-19 genes were changed (p < 0.05). CONCLUSIONS Although rivaroxaban does not suppress cell proliferation due to morphological, biological, and biochemical changes in the intervertebral disc tissue, it may change the expression of genes that are related to ECM maintenance.
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Affiliation(s)
- Tezcan Caliskan
- Department of Neurosurgery, School of Medicine, Namik Kemal University, Tekirdag, Turkey
| | - Hande Akalan
- Department of Molecular Biology and Genetics, Faculty of Arts and Sciences, Namik Kemal University, Tekirdag, Turkey
| | - Ibrahim Yilmaz
- Department of Medical Pharmacology, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Numan Karaarslan
- Department of Neurosurgery, School of Medicine, Halic University, Istanbul, Turkey
| | - Duygu Yasar Sirin
- Department of Molecular Biology and Genetics, Faculty of Arts and Sciences, Namik Kemal University, Tekirdag, Turkey
| | - Hanefi Ozbek
- Department of Medical Pharmacology, Bakircay University School of Medicine, Izmir, Turkey
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15
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Rasu RS, Hunt SL, Dai J, Cui H, Phadnis MA, Jain N. Accurate Medication Adherence Measurement Using Administrative Data for Frequently Hospitalized Patients. Hosp Pharm 2021; 56:451-461. [PMID: 34720145 PMCID: PMC8554601 DOI: 10.1177/0018578720918550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Pharmacy administrative claims data remain an accessible and efficient source to measure medication adherence for frequently hospitalized patient populations that are systematically excluded from the landmark drug trials. Published pharmacotherapy studies use medication possession ratio (MPR) and proportion of days covered (PDC) to calculate medication adherence and usually fail to incorporate hospitalization and prescription overlap/gap from claims data. To make the cacophony of adherence measures clearer, this study created a refined hospital-adjusted algorithm to capture pharmacotherapy adherence among patients with end-stage renal disease (ESRD). Methods: The United States Renal Data System (USRDS) registry of ESRD was used to determine prescription-filling patterns of those receiving new prescriptions for oral P2Y12 inhibitors (P2Y12-I) between 2011 and 2015. P2Y12-I-naïve patients were followed until death, kidney transplantation, discontinuing medications, or loss to follow-up. After flagging/censoring key variables, the algorithm adjusted for hospital length of stay (LOS) and medication overlap. Hospital-adjusted medication adherence (HA-PDC) was calculated and compared with traditional MPR and PDC methods. Analyses were performed with SAS software. Results: Hospitalization occurred for 78% of the cohort (N = 46 514). The median LOS was 12 (interquartile range [IQR] = 2-34) days. MPR and PDC were 61% (IQR = 29%-94%) and 59% (IQR = 31%-93%), respectively. After applying adjustments for overlapping coverage days and hospital stays independently, HA-PDC adherence values changed in 41% and 52.7% of the cohort, respectively. When adjustments for overlap and hospital stay were made concurrently, HA-PDC adherence values changed in 68% of the cohort by 5.8% (HA-PDC median = 0.68, IQR = 0.31-0.93). HA-PDC declined over time (3M-6M-9M-12M). Nearly 48% of the cohort had a ≥30 days refill gap in the first 3 months, and this increased over time (P < .0001). Conclusions: Refill gaps should be investigated carefully to capture accurate pharmacotherapy adherence. HA-PDC measures increased adherence substantially when adjustments for hospital stay and medication refill overlaps are made. Furthermore, if hospitalizations were ignored for medications that are included in Medicare quality measures, such as Medicare STAR program, the apparent reduction in adherence might be associated with lower quality and health plan reimbursement.
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Affiliation(s)
- Rafia S. Rasu
- University of North Texas Health Science Center, Fort Worth, USA
| | | | - Junqiang Dai
- University of Kansas Medical Center, Kansas City, USA
| | - Huizhong Cui
- University of Kansas Medical Center, Kansas City, USA
| | | | - Nishank Jain
- University of Arkansas for Medical Sciences, Little Rock, USA
- Central Arkansas Veterans Healthcare System, Little Rock, USA
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16
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Charlton A, Vidal X, Sabaté M, Bailarín E, Martínez LML, Ibáñez L. Factors associated with primary nonadherence to newly initiated direct oral anticoagulants in patients with nonvalvular atrial fibrillation. J Manag Care Spec Pharm 2021; 27:1210-1220. [PMID: 34464214 PMCID: PMC10391044 DOI: 10.18553/jmcp.2021.27.9.1210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Direct oral anticoagulants (DOACs) are widely used for the prevention of stroke in nonvalvular atrial fibrillation (NVAF); however, real-world primary nonadherence (failing to collect the first prescription) has been measured in very few studies. OBJECTIVE: To report primary nonadherence in NVAF patients who are newly prescribed DOACs and identify associated factors. METHODS: This observational retrospective cohort study used a large primary care database in Catalonia. Patients with NVAF who were newly prescribed a DOAC between January 2009 and December 2015 were identified, and primary nonadherence was measured by comparing prescribing records to pharmacy claims data. Multivariable logistic regression was used to determine associated factors. RESULTS: A total of 12,257 patients met the inclusion and exclusion criteria; of these, 1,276 (10.4%) were primary nonadherent. Primary nonadherence was found to be 12.8% for apixaban, 8.6% for dabigatran, and 10.8% for rivaroxaban. Multivariable logistic regression indicated higher odds of primary nonadherence with apixaban and rivaroxaban compared to dabigatran (apixaban: OR = 1.61, 95% CI = 1.39-1.87; rivaroxaban: OR = 1.28, 95% CI = 1.11-1.47). Patients aged at least 80 years showed lower odds of primary nonadherence compared to those aged less than 65 years (OR = 0.78, 95% CI = 0.66-0.93). A diagnosis of chronic kidney disease was associated with primary nonadherence (OR = 1.27, 95% CI = 1.08-1.50). Whereas, diabetes (OR = 0.85, 95% CI = 0.74-0.97), hypertension (OR = 0.79, 95% CI = 0.70-0.91), and stroke/transient ischemic attack (OR = 0.70, 95% C I =0.59-0.82) were inversely associated with primary nonadherence. CONCLUSIONS: Overall, 10.4% of patients prescribed DOACs were primary nonadherent, failing to collect the first prescription. The percentage could have serious implications for patient outcomes and the real-world cost-effectiveness of prescribing DOACs in NVAF. Rates of primary nonadherence and associated factors may provide useful information for the design and evaluation of adherence interventions. DISCLOSURES: No outside funding was received for this study. The data for this study came from the European Medicines Agency PE-PV project (Grant/Award Number EMA/2015/27/PH). The authors have nothing to disclose. A preliminary version of this work was presented at the European Drug Utilisation Research Group (EuroDURG) Conference, Szeged, Hungary, March 5, 2020.
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Affiliation(s)
- Alethea Charlton
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron, Barcelona, Spain; Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany; and Pettenkofer School of Public Health, Munich, Germany
| | - Xavier Vidal
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron; Autonomous University of Barcelona; and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Mònica Sabaté
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron; Autonomous University of Barcelona; and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Elena Bailarín
- Fundació Institut Català de Farmacologia (FICF) and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Lina María Leguízamo Martínez
- Autonomous University of Barcelona and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Luisa Ibáñez
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron; Autonomous University of Barcelona; and Clinical Pharmacology Department, Vall d'Hebron University Hospital, Barcelona, Spain
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17
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Iftimi AA, Rodríguez-Bernal CL, Peiró S, Bonanad S, Ferrero-Gregori A, Hurtado I, García-Sempere A, Sanfélix-Gimeno G. Association of Vitamin K and Non-Vitamin K Oral Anticoagulant Use and Cancer Incidence in Atrial Fibrillation Patients. Clin Pharmacol Ther 2021; 111:200-208. [PMID: 34242404 PMCID: PMC9291805 DOI: 10.1002/cpt.2362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/27/2021] [Indexed: 12/01/2022]
Abstract
The association between the use of vitamin K antagonists (VKAs) and cancer risk reduction remains unclear. We aimed to assess the association between the use of VKAs or direct oral anticoagulants (DOACs) and the incidence of cancer in a large cohort of patients with atrial fibrillation (AF) by means of a population‐based, propensity‐weighted cohort study using population‐wide databases including patients diagnosed with nonvalvular AF (NVAF) followed for up of 5 years (median 2.94 years). We created two cohorts based on the initiation therapy (VKA or DOAC). Initiation with VKA or DOAC was defined as filling a prescription with no previous exposure in the preceding 12 months. Cancer diagnoses of any type and for specific tumors (lung, colon, prostate, bladder, and breast). We included 39,989 patients, 31,200 (78.0%) in the VKA cohort. Incidence rate for any cancer was 12.45 per 1,000 person‐year in the DOAC cohort vs. 14.55 in the VKA cohort (adjusted hazard ratio (HR): 1.16, 95% confidence interval (CI): 1.02–1.32). In secondary outcomes, no differences were found for specific types of cancer, such as lung (HR: 1.28, CI: 0.89–1.83), colon (HR: 0.84, CI: 0.62–1.13), prostate (HR: 1.40, CI: 0.94–2.10), bladder (HR: 1.07, CI: 0.76–1.52), and breast (HR: 1.05, CI: 0.66–1.69). Sensitivity analyses yielded similar results. Subgroup analyses also produced consistent findings, except for men, for whom VKA was associated with a lower risk of colon cancer (HR: 0.68, 95% CI: 0.48–0.96). Our results do not confirm a chemoprotective effect of VKA when compared with DOAC in a large, real‐world cohort of patients with NVAF followed for up to 5 years.
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Affiliation(s)
- Adina A Iftimi
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain.,Department of Statistics and Operations Research, Universidad de Valencia, València, Spain
| | - Clara L Rodríguez-Bernal
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Salvador Peiró
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Santiago Bonanad
- Haemostasis and Thrombosis Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Andreu Ferrero-Gregori
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
| | - Isabel Hurtado
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Aníbal García-Sempere
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
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18
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Zielinski GD, van Rein N, Teichert M, Klok FA, Rosendaal FR, van der Meer FJM, Huisman MV, Cannegieter SC, Lijfering WM. Adherence to direct oral anticoagulant treatment for atrial fibrillation in the Netherlands: A surveillance study. Pharmacoepidemiol Drug Saf 2021; 30:1027-1036. [PMID: 33822401 PMCID: PMC8360064 DOI: 10.1002/pds.5242] [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: 08/06/2020] [Accepted: 03/30/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Adherence to direct oral anticoagulants (DOACs) in patients with atrial fibrillation in every day practice may be less than in clinical trials. AIMS To assess adherence to DOACs in atrial fibrillation patients in every day practice and identify predictors for non-adherence. METHODS Individual linked dispensing data of atrial fibrillation patients who used DOACs were obtained from the Foundation for Pharmaceutical Statistics covering the Netherlands between 2012 and 2016. One year adherence to DOAC was calculated for initial DOAC as proportion of days covered (PDC) ≥80% and the association between clinical variables and adherence was assessed using logistic regression. In addition, we measured non-persistence, that is, patients who completely stopped their initial DOAC within 1 year follow-up. RESULTS A total of 4797 apixaban-, 20 454 rivaroxaban- and 18 477 dabigatran users were included. The mean age was 69 years (n = 43 910), which was similar for the DOAC types. The overall proportion of patients with PDC ≥80% was 76%, which was highest for apixaban- (87%), followed by dabigatran- (80%) and rivaroxaban (69%) users. Multivariable analyses revealed that age ≤60 years, no concomitant drug use were predictors for non-adherence. Of atrial fibrillation patients who continued treatment, 97% had a PDC ≥80%, compared with only 56% for those who discontinued their DOAC treatment within 1 year. CONCLUSIONS Non-adherence to DOACs was associated with age ≤60 years and no concomitant drugs use. Non-adherence was higher in patients who later discontinued DOAC treatment. Results of our study support research into interventions to improve adherence.
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Affiliation(s)
- Gilda D Zielinski
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke van Rein
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martina Teichert
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Felix J M van der Meer
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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19
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García-Sempere A, Orrico-Sánchez A, Muñoz-Quiles C, Hurtado I, Peiró S, Sanfélix-Gimeno G, Diez-Domingo J. Data Resource Profile: The Valencia Health System Integrated Database (VID). Int J Epidemiol 2021; 49:740-741e. [PMID: 31977043 PMCID: PMC7394961 DOI: 10.1093/ije/dyz266] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 12/10/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Anibal García-Sempere
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, FISABIO (the Valencia Foundation for the Promotion of Health and Biomedical Research), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, REDISSEC (Network for Health Services Research on Chronic Patients), Valencia, Spain
| | - Alejandro Orrico-Sánchez
- Vaccines Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, FISABIO (the Valencia Foundation for the Promotion of Health and Biomedical Research), Valencia, Spain
| | - Cintia Muñoz-Quiles
- Vaccines Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, FISABIO (the Valencia Foundation for the Promotion of Health and Biomedical Research), Valencia, Spain
| | - Isabel Hurtado
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, FISABIO (the Valencia Foundation for the Promotion of Health and Biomedical Research), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, REDISSEC (Network for Health Services Research on Chronic Patients), Valencia, Spain
| | - Salvador Peiró
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, FISABIO (the Valencia Foundation for the Promotion of Health and Biomedical Research), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, REDISSEC (Network for Health Services Research on Chronic Patients), Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, FISABIO (the Valencia Foundation for the Promotion of Health and Biomedical Research), Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, REDISSEC (Network for Health Services Research on Chronic Patients), Valencia, Spain
| | - Javier Diez-Domingo
- Vaccines Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, FISABIO (the Valencia Foundation for the Promotion of Health and Biomedical Research), Valencia, Spain
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20
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Gabet A, Chatignoux E, Grave C, Vallée A, Tuppin P, Béjot Y, Olié V. Stroke Incidence and Death in Atrial Fibrillation Patients Newly Treated with Direct Oral Anticoagulants. Clin Epidemiol 2021; 13:131-140. [PMID: 33642879 PMCID: PMC7903960 DOI: 10.2147/clep.s290707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/08/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The objectives were to analyse the determinants of stroke incidence and mortality as a competing event in AF patients newly treated with DOAC and to assess the impact of non-adherence to DOAC treatment. Methods It is a population-based retrospective cohort study using the French national healthcare data system. AF patients aged >20 years were affiliated to the general health insurance scheme (66% of the French population) and newly treated with DOAC between 2012 and 2015 were included and followed for 2 years. Results Overall 76,795 AF patients were newly treated with DOAC in 2015. Stroke incidence reached 10.1 (95% CI: 9.6–10.6) per 1000 person-year and death 39.7 (95% CI: 38.6–40.8) as a competitive risk. Female sex was associated with a lower risk of death but not of stroke. Non-adherence to DOAC treatment increased the risk of both stroke (42%) and death (38%). Acute coronary syndrome was associated with an increased risk of stroke alone, whereas heart failure decompensation, social deprivation, and haemorrhage were associated with an increased risk of death alone. Conclusion Both stroke and death risks remain non-negligible in AF patients treated with DOAC. Non-adherence was associated with an increased risk of stroke and death.
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Affiliation(s)
- Amélie Gabet
- French Public Health Agency, Saint-Maurice, France
| | | | | | - Alexandre Vallée
- Diagnosis and Therapeutic Center, Hotel Dieu, AP-HP, University Paris Descartes, Paris, France
| | - Philippe Tuppin
- General Health Insurance Scheme (Caisse Nationale d'Assurance Maladie), Paris, France
| | - Yannick Béjot
- Dijon Stroke Registry, EA4184, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - Valérie Olié
- French Public Health Agency, Saint-Maurice, France
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21
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Wirbka L, Haefeli WE, Meid AD. Estimated Thresholds of Minimum Necessary Adherence for Effective Treatment with Direct Oral Anticoagulants - A Retrospective Cohort Study in Health Insurance Claims Data. Patient Prefer Adherence 2021; 15:2209-2220. [PMID: 34594102 PMCID: PMC8478483 DOI: 10.2147/ppa.s324315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/28/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND An essential contribution regarding the prevention of thromboembolic events in patients with (non-valvular) atrial fibrillation (AF) is good adherence to direct oral anticoagulants (DOACs). However, it is an open question what "good" adherence means for DOACs or below which threshold non-adherence is clinically relevant for AF patients. Ultimately, such a classification could prevent strokes and associated costs through adjusted treatment regimens or supportive measures. METHODS We selected 10,092 AF patients from health insurance claims data between 2014 and 2018 who were issued a majority (at least half of the number) of maximum approved strength prescriptions of one of the following DOACs, namely rivaroxaban, apixaban, or dabigatran. Due to the limited sample size, the prescriptions of dabigatran had to be finally excluded for the cut-off analysis. DOAC adherence was calculated as the proportion of days covered (PDC) by dividing the days of theoretical use (days covered) of the drug by the duration in days of the observation interval. PDC cut-off values were derived from stroke risk as a function of continuous PDC values in time-to-event analyses and corresponding dose-response models. The influence of adherence-promoting interventions (targeted and untargeted) on the occurrence of strokes and related costs was then projected, considering intervention costs per patient. RESULTS The population had a mean age of 74.5 years and 50% were female. The median PDC was 0.79 ± 0.28 with a median follow-up time of 1218 days, in which 2% of all DOAC patients had a stroke. The adherence cut-offs for good adherence were identified at 0.78 for rivaroxaban and 0.8 for apixaban. Targeted interventions appeared to be far more cost-effective than untargeted interventions. CONCLUSION Clear adherence cut-offs enable healthcare professionals to identify patients with clinically relevant non-adherence. Interventions based on these cut-offs appear to be a promising means to optimize DOAC treatment.
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Affiliation(s)
- Lucas Wirbka
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, 69120, Germany
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, 69120, Germany
| | - Andreas Daniel Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, 69120, Germany
- Correspondence: Andreas Daniel Meid Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, GermanyTel +49 6221 56 37113Fax +49 6221 56 4642 Email
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22
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Guo Y, Lane DA, Chen Y, Lip GYH. Regular Bleeding Risk Assessment Associated with Reduction in Bleeding Outcomes: The mAFA-II Randomized Trial. Am J Med 2020; 133:1195-1202.e2. [PMID: 32289310 DOI: 10.1016/j.amjmed.2020.03.019] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The mobile atrial fibrillation application (mAFA-II) randomized trial reported that a holistic management strategy supported by mobile health reduced atrial fibrillation-related adverse outcomes. The present study aimed to assess whether regular reassessment of bleeding risk using the Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile international normalized ratio, Elderly, Drugs or alcohol (HAS-BLED) score would improve bleeding outcomes and oral anticoagulant (OAC) uptake. METHODS Bleeding risk (HAS-BLED score) was monitored prospectively using mAFA, and calculated as 30 days, days 31-60, days 61-180, and days 181-365. Clinical events and OAC changes in relation to the dynamic monitoring were analyzed. RESULTS We studied 1793 patients with atrial fibrillation (mean, standard deviation, age 64 years, 24 years, 32.5% female). Comparing baseline and 12 months, the proportion of atrial fibrillation patients with HAS-BLED ≥3 decreased (11.8% vs 8.5%, P = .008), with changes in use of concomitant nonsteroidal antiinflammatory drugs/antiplatelets, renal dysfunction, and labile international normalized ratio contributing to the decreased proportions of patients with HAS-BLED ≥3 (P < .05). Among 1077 (60%) patients who had 4 bleeding risk assessments, incident bleeding events decreased significantly from days 1-30 to days 181-365 (1.2% to 0.2%, respectively, P < .001). Total OAC usage increased from 63.4% to 70.2% (Ptrend < .001). Compared with atrial fibrillation patients receiving usual care (n = 1136), bleeding events were significantly lower in atrial fibrillation patients with dynamic monitoring of their bleeding risk (mAFA vs usual care, 2.1%, 4.3%, P = .004). OAC use decreased significantly by 25% among AF patients receiving usual care, when comparing baseline to 12 months (P < .001). CONCLUSION Dynamic risk monitoring using the HAS-BLED score, together with holistic App-based management using mAFA-II reduced bleeding events, addressed modifiable bleeding risks, and increased uptake of OACs.
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Affiliation(s)
- Yutao Guo
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Yundai Chen
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Gregory Y H Lip
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China; Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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23
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Kanorskii SG. [How to maintain an adherence to oral anticoagulant in a patient with atrial fibrillation?]. KARDIOLOGIIA 2019; 59:76-83. [PMID: 31849302 DOI: 10.18087/cardio.2019.11.n724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 07/11/2019] [Indexed: 06/10/2023]
Abstract
Less onerous, compared with warfarin, treatment with direct oral anticoagulants (DOA) can lead to better adherence to treatment of patients with atrial fibrillation (AF). However, in a certain number of patients with AF, who were recommended by DOA, cardioembolic stroke recurs, which is largely due to the patients' failure to comply with medical recommendations. The appointment of DOA as first-line drugs does not guarantee a high adherence of patients with non-valvular AF. For elderly and old patients with AF and numerous comorbidities, the proposal of a simpler pharmacotherapy regimen is especially important. In a number of large modern studies performed in clinical practice, high adherence to rivaroxaban therapy has been established, which may be a result of taking this DOA 1 time per day, its safety and effectiveness.
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24
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Lowres N, Giskes K, Hespe C, Freedman B. Reducing Stroke Risk in Atrial Fibrillation: Adherence to Guidelines Has Improved, but Patient Persistence with Anticoagulant Therapy Remains Suboptimal. Korean Circ J 2019; 49:883-907. [PMID: 31535493 PMCID: PMC6753021 DOI: 10.4070/kcj.2019.0234] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/24/2022] Open
Abstract
Atrial fibrillation (AF) is a significant risk factor for avoidable stroke. Among high-risk patients with AF, stroke risk can be mitigated using oral anticoagulants (OACs), however reduction is largely contingent on physician prescription and patient persistence with OAC therapy. Over the past decade significant advances have occurred, with revisions to clinical practice guidelines relating to management of stroke risk in AF in several countries, and the introduction of non-vitamin K antagonist OACs (NOACs). This paper summarises the evolving body of research examining guideline-based clinician prescription over the past decade, and patient-level factors associated with OAC persistence. The review shows clinicians' management over the past decade has increasingly reflected guideline recommendations, with an increasing proportion of high-risk patients receiving OACs, driven by an upswing in NOACs. However, a treatment gap remains, as 25–35% of high-risk patients still do not receive OAC treatment, with great variation between countries. Reduction in stroke risk directly relates to level of OAC prescription and therapy persistence. Persistence and adherence to OAC thromboprophylaxis remains an ongoing issue, with 2-year persistence as low as 50%, again with wide variation between countries and practice settings. Multiple patient-level factors contribute to poor persistence, in addition to concerns about bleeding. Considered review of individual patient's factors and circumstances will assist clinicians to implement appropriate strategies to address poor persistence. This review highlights the interplay of both clinician's awareness of guideline recommendations and understanding of individual patient-level factors which impact adherence and persistence, which are required to reduce the incidence of preventable stroke attributable to AF.
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Affiliation(s)
- Nicole Lowres
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Katrina Giskes
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,School of Medicine, The University of Notre Dame, Sydney, Australia
| | - Charlotte Hespe
- School of Medicine, The University of Notre Dame, Sydney, Australia
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Cardiology, Concord Hospital, The University of Sydney Concord Clinical School, Concord, Australia
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