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Guraya SS, Yusoff MSB, Rashid-Doubell F, Harkin DW, Al-Amad SH, Fredericks S, Halabi MOO, Abdullah N, Moussa H, Mallah SIY, Sefen JAN, AlKoheji HKARMI, Althawadi MEA, Alabbasi LA, Nor MZM, Reguig F, Guraya SY. Changing Professional Behaviors in the Digital World Using the Medical Education e-Professionalism (MEeP) Framework-A Mixed Methods Multicentre Study. Front Med (Lausanne) 2022; 9:846971. [PMID: 35425778 PMCID: PMC9004460 DOI: 10.3389/fmed.2022.846971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background: There is increasing evidence on the exponential use of technology-based social media in medical field that has led to a proliferation of unprofessional behaviors in digital realm. Educating, training, and changing the behaviors of healthcare professionals are essential elements to restrain the rising unprofessional incidents. Therefore, this research was designed to determine the impact of an interventional workshop on the medical and dental students in improving their professional behaviors in the digital world using the newly developed medical Education e-Professionalism (MEeP) framework. Methods We adopted the Theory of Planned Behavior (TPB) as a benchmark reference which explores constructs intertwined with the mission-based MEeP framework; values (whistleblowing-raising concerns), behaviors (being responsible in the digital world) and identity (reflective practice in the digital world). A multicentre 3-phased mixed-method study was conducted using a pre-workshop survey, an online interventional workshop, and a post-workshop survey. SPSS and NVivo were the tools used for the data analysis. Results A total of 130 students registered for workshop out of which 120 completed the pre-workshop survey, 62 joined the workshop and 59 completed the workshop and post-workshop survey. From the whistleblowing – raising concern perspective, we found that attitudes and perceived behavioral control had a significant relationship. While for responsible in digital world category, attitude and perceived behavioral control had a significant bearing on the intentions. Third, for reflective practice, attitude and subjective norms significantly enhanced the intention of participants. A multi layered thematic analysis yielded four overarching themes of attitudes, subjective norms, perceived behavioral control and intentions. Most students showed positive attitudes of being reflective, self-directed, and humane. Students realized the subjective norms had made them conscientious, self-aware and conformative. While perceived behavioural control manifested as identity and Intentions were heavily reliant on self-actualization. Conclusion Our mixed method study found that the interventional workshop using MEeP framework significantly improved attitudes, subjective norms, perceived behavioral control, and intentions. This study provides valuable evidence of MEeP framework evaluation using the theoretical underpinning of TPB by reporting positive changes in professional values, behaviors, and identities of undergraduate medical and dental students.
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Affiliation(s)
- Shaista Salman Guraya
- Royal College of Surgeons Ireland, Medical University of Bahrain, Busaiteen, Bahrain.,Department of Medical Education, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | | | - Fiza Rashid-Doubell
- Royal College of Surgeons Ireland, Medical University of Bahrain, Busaiteen, Bahrain
| | - Denis W Harkin
- Faculty of Medicine and Health Sciences, Royal College of Surgeons Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Suhail H Al-Amad
- College of Dental Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Salim Fredericks
- Royal College of Surgeons Ireland, Medical University of Bahrain, Busaiteen, Bahrain
| | | | - Natasya Abdullah
- Faculty of Medicine and Health Sciences, Universiti Sains Islam Malaysia, Nilai, Malaysia
| | - Hatem Moussa
- Department of Surgery, American Hospital Dubai, Dubai, United Arab Emirates
| | | | | | | | | | | | - Mohd Zarawi Mat Nor
- Department of Medical Education, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Farida Reguig
- Department of Surgery, American Hospital Dubai, Dubai, United Arab Emirates
| | - Salman Yousuf Guraya
- Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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Osasu YM, Cooper R, Mitchell C. Patients' and clinicians' perceptions of oral anticoagulants in atrial fibrillation: a systematic narrative review and meta-analysis. BMC FAMILY PRACTICE 2021; 22:254. [PMID: 34937557 PMCID: PMC8697449 DOI: 10.1186/s12875-021-01590-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 11/22/2021] [Indexed: 11/10/2022]
Abstract
Background Atrial fibrillation (AF) increases the risk of developing a stroke by 20%. AF related strokes are associated with greater morbidity. Historically, warfarin was the anticoagulant of choice for stroke prevention in patients with AF but lately patients are being switched or started on direct oral anticoagulants (DOACs). DOACs are promoted as safer alternatives to warfarin and it is expected that they will be associated with fewer challenges both for patients and healthcare professionals. This systematic narrative review aimed to explore perspectives of patients and professionals on medicines optimisation of oral anticoagulation with vitamin K antagonists and DOACs in atrial fibrillation. Methods Prospero registration CRD42018091591. Systematic searches undertaken of research studies (qualitative and quantitative), published February 2018 to November 2020 from several databases (Web of Science, Scopus, Medline Via Ovid, CINHAL via Ebsco, and PubMED via NCBI) following PRISMA methodology. Data were organised using Covidence software. Two reviewers independently assessed the quality of the included studies and synthesized the findings (thematic analysis approach). Results Thirty-four studies were included. Studies were critically appraised using established critical appraisal tools (Qualsyst) and a risk of bias was assigned. Clinicians considered old age and the associated complexities such as co-morbidities and the increased potential for bleeding as potential barriers to optimising anticoagulation. Whereas patients’ health and medication beliefs influenced adherence. Notably, structured patient support was important in enhancing safety and effective anticoagulation. For both patients and clinicians, confidence and experience of safe anticoagulation was influenced by the presence of co-morbidities, poor knowledge and understanding of AF and the purpose of anticoagulation. Conclusion Age, complex multimorbidity and polypharmacy influence prescribing, with DOACs being perceived to be safer than warfarin. This systematic narrative review suggests that interventions are needed to support patient self-management. There are residual anxieties associated with long term anticoagulation in the context of complexities. Trial registration Not applicable.
Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01590-x.
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Affiliation(s)
- Yeyenta Mina Osasu
- Academic Unit of Primary Medical Care, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, S5 7AU, UK.
| | | | - Caroline Mitchell
- Academic Unit of Primary Medical Care, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, S5 7AU, UK
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Chaterji S, Lian LG, Lee TY, Chua L, Wee SYM, Yap SL, K DL, Tan NC. Factors influencing primary care physicians' prescribing behavior of anticoagulant therapy for the management of patients with non-valvular atrial fibrillation in Singapore: a qualitative research study. BMC FAMILY PRACTICE 2021; 22:101. [PMID: 34034648 PMCID: PMC8146184 DOI: 10.1186/s12875-021-01453-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/05/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Oral anticoagulant therapy use in patients with atrial fibrillation (AF) remains suboptimal in Singapore, despite the availability of both warfarin and non-vitamin K antagonist oral anticoagulants (NOACs). Primary care physicians' (PCP) decision-making to initiate and select appropriate anticoagulant medication is pivotal in reducing complications among patients with AF. This study explored the factors influencing PCPs' decision-making in anticoagulant initiation and anticoagulant switch for patients with non-valvular AF. METHOD The study design is qualitative research based on the theoretical framework of the Generalist Wheel of Knowledge, Understanding and Inquiry. In-depth interviews or focus group discussions were conducted with 27 PCPs in general practice in urban Singapore. The audio-recordings were transcribed and coded to identify themes, which are framed according to the "clinician", "patient", "medical condition and treatment" and "healthcare system and policy" domains. RESULTS Personal training and experience with anticoagulant therapy; understanding patient risk-stratification; AF detection during clinical practice; medication cost; clinical support services for anticoagulation monitoring and constraints in existing care model influenced PCPs in their anticoagulant prescription. PCPs preferred to seek guidance from cardiologists in managing patients with newly diagnosed AF and attempted to engage their patients in decision-making regarding anticoagulant therapy. Some PCPs perceived sub-specialized primary care clinics focusing on AF co-management with cardiologists as an ideal setting for initiation and maintenance of anticoagulant therapy. CONCLUSIONS PCPs are influenced by multiple interrelated factors while making decisions on anticoagulant initiation and anticoagulant switch for patients with AF. Their proposed care model to address the barriers awaits feasibility and acceptance assessment in future research.
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Affiliation(s)
- Shera Chaterji
- SingHealth Polyclinics, 167, Jalan Bukit Merah, Connection One, Tower 5, #15-10, Singapore, 150167, Singapore.
| | - Lay Geok Lian
- SingHealth Polyclinics, 167, Jalan Bukit Merah, Connection One, Tower 5, #15-10, Singapore, 150167, Singapore
| | - Ting Yee Lee
- SingHealth Polyclinics, 167, Jalan Bukit Merah, Connection One, Tower 5, #15-10, Singapore, 150167, Singapore
| | - Liwei Chua
- SingHealth Polyclinics, 167, Jalan Bukit Merah, Connection One, Tower 5, #15-10, Singapore, 150167, Singapore
| | - Sabrina Yi-Mei Wee
- SingHealth Polyclinics, 167, Jalan Bukit Merah, Connection One, Tower 5, #15-10, Singapore, 150167, Singapore.,SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore, Singapore
| | - Sui Ling Yap
- SingHealth Polyclinics, 167, Jalan Bukit Merah, Connection One, Tower 5, #15-10, Singapore, 150167, Singapore
| | - Dhana Letchimy K
- SingHealth Polyclinics, 167, Jalan Bukit Merah, Connection One, Tower 5, #15-10, Singapore, 150167, Singapore
| | - Ngiap Chuan Tan
- SingHealth Polyclinics, 167, Jalan Bukit Merah, Connection One, Tower 5, #15-10, Singapore, 150167, Singapore.,SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore, Singapore
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4
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Clinicians' views and experiences of prescribing oral anticoagulants for stroke prevention in atrial fibrillation: A qualitative meta-synthesis. PLoS One 2020; 15:e0232484. [PMID: 32379847 PMCID: PMC7205240 DOI: 10.1371/journal.pone.0232484] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 04/15/2020] [Indexed: 11/20/2022] Open
Abstract
Background Globally, over 33 million people have atrial fibrillation (AF). In eligible patients, oral anticoagulation (OAC) is recommended for stroke risk reduction. Despite recent increases in OAC prescribing, global under-prescription to high-risk AF patients and inappropriate prescription to low-risk patients is leading to unnecessary risk of stroke and haemorrhage. This meta-synthesis explored clinicians’ beliefs and experiences regarding OAC prescription to AF patients, highlighting barriers to stroke prevention and informing future clinician-focused interventions. Methods and results A qualitative meta-synthesis exploring clinicians’ views and experiences of prescribing OACs for stroke prevention in AF patients. Databases including MEDLINE, EMBASE, PsychINFO and CINAHL were searched to June 2018, with a further Medline search to February 2020. Thematic synthesis was performed with data coding, descriptive theme categorisation and generation of analytical themes. From 3499 records, 101 full text papers were screened, with 13 eligible studies identified. Four analytical themes were found to affect clinicians’ prescribing: (i) ‘Clinicians’ intellectual and emotional responses to the evidence’; (ii) ‘Prescribing in primary and secondary care’; (iii) ‘Clinicians’ views of how patients’ characteristics and opinions influence prescribing’; and (iv) ‘Clinicians’ views on their interactions with patients’. Conclusions This review highlights focal points for future clinician-focused interventions to improve guideline-adherent OAC prescription in AF patients. Interventions should aim to improve clinicians’ knowledge around NOAC prescription and stroke and haemorrhage risk assessment tools as well as their emotional responses to difficult prescribing scenarios. Multidisciplinary interventions promoting cohesive care and input from different clinicians to overcome time-related barriers may increase guideline-adherent OAC prescription for AF patients.
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Fangel MV, Nielsen PB, Larsen TB, Christensen B, Overvad TF, Lip GYH, Goldhaber SZ, Jensen MB. Type 1 versus type 2 diabetes and thromboembolic risk in patients with atrial fibrillation: A Danish nationwide cohort study. Int J Cardiol 2019; 268:137-142. [PMID: 30041778 DOI: 10.1016/j.ijcard.2018.05.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/08/2018] [Accepted: 05/14/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Atrial fibrillation is a common cause of stroke, and diabetes increases stroke risk. Stroke risk may vary depending on the type of diabetes. We investigated whether type 1 and type 2 diabetes are associated with different risks of thromboembolism among patients with atrial fibrillation. METHODS We used data from Danish nationwide registries to identify patients with a prior diagnosis of diabetes and an incident nonvalvular atrial fibrillation diagnosis in the period of January 1, 2005 to December 31, 2015. Cox regression analysis was used to estimate hazard ratios (HR) for the outcome thromboembolism. RESULTS The study population included 10,058 patients with a prior diagnosis of diabetes and an incident diagnosis of atrial fibrillation. At three-year follow-up, type 2 diabetes was not associated with a higher risk of thromboembolism compared to type 1 diabetes, with an adjusted HR of 1.15 (95% CI: 0.91-1.44). In an age-stratified analysis, patients aged below 65 years of age had an adjusted HR of 1.97 (95% CI: 1.07-3.61), whereas patients aged 65-74 years or ≥75 years had adjusted HRs of 0.99 (95% CI: 0.67-1.46) and 1.10 (95% CI: 0.80-1.51), respectively. CONCLUSION We found no overall credible association between the type of diabetes and risk of thromboembolism in this cohort of non-anticoagulated patients with incident atrial fibrillation. Nonetheless, the subset of patients aged below 65 years of age displayed a higher risk of thromboembolism among patients with type 2 diabetes as compared to patients with type 1 diabetes.
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Affiliation(s)
- Mia V Fangel
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Peter B Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Cardiology, Atrial Fibrillation Study Group, Aalborg University Hospital, Aalborg, Denmark
| | - Torben B Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Cardiology, Atrial Fibrillation Study Group, Aalborg University Hospital, Aalborg, Denmark
| | - Bo Christensen
- Department of Public Health, Section for General Practice, Aarhus University, Aarhus, Denmark
| | - Thure F Overvad
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Samuel Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Martin B Jensen
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Fried TR, Mecca MC. Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of Appropriate Polypharmacy. J Am Geriatr Soc 2019; 67:1123-1127. [PMID: 30697698 DOI: 10.1111/jgs.15798] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/26/2018] [Accepted: 12/31/2018] [Indexed: 11/29/2022]
Abstract
Older adults are prescribed a growing number of medications. Polypharmacy, commonly considered the receipt of five or more medications, is associated with a range of adverse outcomes. There is a debate about the reason(s) why. On one side is the assertion that older persons are being prescribed too many medications, with the number of medications increasing the risk of adverse events. On the other side is the observation that polypharmacy is associated both with overprescribing of inappropriate medications and underprescribing of appropriate medications. This leads to the concept of "inappropriate" vs "appropriate" polypharmacy, with the latter resulting from the prescription of many correct medications to persons with multiple chronic conditions. Few studies have examined the health outcomes associated with adding and/or removing medications to address this debate directly. The criteria used to identify underutilized medications are based on results of randomized controlled trials that may not be generalizable to older adults. Several randomized controlled trials and many more observational studies provide evidence that these criteria overestimate medication benefits and underestimate harms. In addition, evidence suggests that the marginal effects of medications added to an already complex regimen differ from their effects when considered individually. Although in selected circumstances adding medications results in benefit to patients, patients with multimorbidity and frailty/disability have susceptibilities that can decrease the likelihood of medication benefit and increase the likelihood of harms. The identification of appropriate polypharmacy requires more robust criteria to evaluate the net effects of complex medication regimens.
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Affiliation(s)
- Terri R Fried
- VA Connecticut Healthcare System, Clinical Epidemiology Research Center and Geriatrics & Extended Care, West Haven, Connecticut.,Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Marcia C Mecca
- VA Connecticut Healthcare System, Clinical Epidemiology Research Center and Geriatrics & Extended Care, West Haven, Connecticut.,Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
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Veinot TC, Senteio CR, Hanauer D, Lowery JC. Comprehensive process model of clinical information interaction in primary care: results of a "best-fit" framework synthesis. J Am Med Inform Assoc 2018; 25:746-758. [PMID: 29025114 PMCID: PMC7646963 DOI: 10.1093/jamia/ocx085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 07/18/2017] [Accepted: 08/01/2017] [Indexed: 01/04/2023] Open
Abstract
Objective To describe a new, comprehensive process model of clinical information interaction in primary care (Clinical Information Interaction Model, or CIIM) based on a systematic synthesis of published research. Materials and Methods We used the "best fit" framework synthesis approach. Searches were performed in PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Library and Information Science Abstracts, Library, Information Science and Technology Abstracts, and Engineering Village. Two authors reviewed articles according to inclusion and exclusion criteria. Data abstraction and content analysis of 443 published papers were used to create a model in which every element was supported by empirical research. Results The CIIM documents how primary care clinicians interact with information as they make point-of-care clinical decisions. The model highlights 3 major process components: (1) context, (2) activity (usual and contingent), and (3) influence. Usual activities include information processing, source-user interaction, information evaluation, selection of information, information use, clinical reasoning, and clinical decisions. Clinician characteristics, patient behaviors, and other professionals influence the process. Discussion The CIIM depicts the complete process of information interaction, enabling a grasp of relationships previously difficult to discern. The CIIM suggests potentially helpful functionality for clinical decision support systems (CDSSs) to support primary care, including a greater focus on information processing and use. The CIIM also documents the role of influence in clinical information interaction; influencers may affect the success of CDSS implementations. Conclusion The CIIM offers a new framework for achieving CDSS workflow integration and new directions for CDSS design that can support the work of diverse primary care clinicians.
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Affiliation(s)
- Tiffany C Veinot
- School of Information and School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Charles R Senteio
- Department of Library and Information Science, School of Communication and Information, Rutgers University, New Brunswick, NJ, USA
| | - David Hanauer
- Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Julie C Lowery
- Center for Clinical Management, Research, VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA
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Hansen CK, Christensen A, Rodgers H, Havsteen I, Kruuse C, Christensen H. Does the Primary Imaging Modality-Computed Tomography or Magnetic Resonance Imaging-Influence Stroke Physicians' Certainty on Whether or Not to Give Thrombolysis to Randomized Acute Stroke Patients? J Stroke Cerebrovasc Dis 2017; 27:926-935. [PMID: 29198901 DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 10/26/2017] [Accepted: 10/29/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Door-to-needle time of 20 minutes to stroke patients with intravenous tissue plasminogen activator (iv-tPA) is feasible when computed tomography (CT) is used as first-line of brain imaging. Magnetic resonance imaging (MRI)-based assessment is more time-consuming but superior in detecting acute ischemia. The certainty with which stroke physicians prescribe or refrain from giving iv-tPA treatment to CT- versus MRI-examined patients has not previously been studied. The aim of the present study was to determine the effect of a primary imaging strategy of CT or MRI on clinicians' certainty to prescribe or refrain from giving iv-tPA to patients with suspected acute stroke. METHOD Consecutive patients with suspected stroke were quasi-randomized to either CT- or MRI-based assessment before potential iv-tPA treatment. The influence of (1) the clinical findings and (2) the image findings, and (3) the certainty with which the stroke physician prescribed or refrained from giving iv-tPA treatment were assessed with visual analog scales (VAS). Predictors of treatment certainty were identified with a random-effect model. RESULTS Four-hundred forty-four consecutive patients were quasi-randomized. MRI influenced the final treatment decision more than CT (P = .002). Compared with CT-examined patients (mean VAS score 8.6, SD ±1.6) stroke physicians were significantly more certain when prescribing or refraining from giving iv-tPA to MRI-examined patients (mean VAS score 9.0, SD ±1.2) (P = .014). No differences in modified Rankin scale or mortality were detected at 3 months in CT- versus MRI-examined iv-tPA-treated patients. CONCLUSIONS Stroke physicians were significantly more certain when prescribing iv-tPA to MRI-examined stroke patients, and MRI influences the final treatment decision significantly more compared with CT, although no difference in mortality and functional outcome at 3 months was detected between CT- and MRI-examined patients treated with iv-tPA.
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Affiliation(s)
- Christine Krarup Hansen
- Department of Neurology, Bispebjerg-Frederiksberg-Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Anders Christensen
- Department of Radiology, Bispebjerg-Frederiksberg-Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle, United Kingdom
| | - Inger Havsteen
- Department of Radiology, Bispebjerg-Frederiksberg-Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christina Kruuse
- Department of Neurology, Neurovascular Research Unit, Herlev-Gentofte-Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Hanne Christensen
- Department of Neurology, Bispebjerg-Frederiksberg-Hospital, University of Copenhagen, Copenhagen, Denmark
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Ogilvie IM, Cowell W, Lip GYH, Welner SA. Ischaemic stroke and bleeding rates in ‘real-world’ atrial fibrillation patients. Thromb Haemost 2017; 106:34-44. [PMID: 21614409 DOI: 10.1160/th10-10-0674] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 04/22/2011] [Indexed: 11/05/2022]
Abstract
SummaryStroke prevention guidelines recommend oral anticoagulants (OAC) for atrial fibrillation (AF) patients at moderate/high risk of stroke, and antiplatelet or no therapy for those at low/moderate risk. Outcomes for AF patients receiving antiplatelet/no therapy in ‘real-life’ clinical practice were explored. This study compared clinical event rates (stroke/bleeding) for AF patients treated with OAC therapy, antiplatelets or no therapy in usual clinical practice to event rates in OAC-treated AF patients from optimally-monitored ‘real-life’ settings (anticoagulation clinics). We searched biomedical literature (1994–2010) using PubMed to identify ‘real-world’ studies of clinical event rates for AF patients receiving OAC therapy, antiplatelets, or no therapy; event rates were extracted for each treatment and setting. We identified 136 studies of thromboembolic events and 86 of bleeding events. Ischaemic stroke rates (30 studies) were higher for AF patients receiving no therapy (median: 4.45/100 person-years; range: 0.25–5.9) or antiplatelet-therapy (median: 4.45/100 person-years; range: 2.0–10) compared to OACtreated patients monitored in anticoagulation clinics (median: 1.72/100 person-years; range: 0.97–2.00), or from a non-specialized setting (median 1.66/100 person-years; range: 0–4.9). Major bleeding rates (32 studies) for patients receiving antiplatelet/no therapy were similar to OAC-treated patients from both clinical settings. As in randomised clinical trials, AF patients in ‘real-world’ clinical practice receiving antiplatelet/no therapy have higher rates of ischaemic stroke than OAC-treated patients. Antiplatelet/no therapy was associated with similar bleeding rates to OAC therapy. Increasing utilisation of anticoagulants in clinical practice could improve patient outcomes.
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Vinereanu D, Al-Khalidi HR, Rao MP, He W, Lopes RD, Bahit CM, Ciobanu AO, Fox KA, Pokorney SD, Xian Y, Jiang J, Kamath DY, Berwanger O, Tajer C, Huo Y, Xavier D, Granger CB. Regional differences in presentation and antithrombotic treatment of patients with atrial fibrillation: Baseline characteristics from a clustered randomized trial to IMProve treatment with AntiCoagulanTs in patients with atrial fibrillation (IMPACT-AF). Am Heart J 2017; 192:38-47. [PMID: 28938962 DOI: 10.1016/j.ahj.2017.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 07/12/2017] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide. However, there are few contemporary comparative data on AF from middle-income countries. METHODS Baseline characteristics of the IMPACT-AF trial were analyzed to assess regional differences in presentation and antithrombotic treatment of AF from 5 middle-income countries (Argentina, Brazil, China, India, and Romania) and factors associated with antithrombotic treatment prescription. RESULTS IMPACT-AF enrolled 2281 patients (69 ± 11 years, 47% women) at 48 sites. Overall, 66% of patients were on anticoagulation at baseline, ranging from 38% in China to 91% in Brazil. The top 3 reasons for not prescribing an anticoagulant were patient preference/refusal (26%); concomitant antiplatelet therapy (15%); and risks outweighing the benefits, as assessed by the physician (13%). In a multivariable model, the most significant factors associated with prescription of oral anticoagulants were no prior major bleeding (odds ratio [OR] = 4.34; 95% CI = 2.22-8.33), no alcohol abuse (OR = 2.27; 95% CI = 1.12-4.55), and history of rheumatic valvular heart disease (OR = 2.10; 95% CI = 1.36-3.26), with a strong predictive accuracy (c statistic = 0.85), whereas the most significant factors associated with prescription of a combination of oral anticoagulants and antiplatelet drugs were prior coronary revascularization (OR = 5.10; 95% CI = 2.88-9.05), prior myocardial infarction (OR = 2.24; 95% CI = 1.38-3.63), and no alcohol abuse (OR = 2.22; 95% CI = 1.11-4.55), with a good predictive accuracy (c statistic = 0.76). CONCLUSIONS IMPACT-AF provides contemporary data from 5 middle-income countries regarding antithrombotic treatment of AF. Lack of prior major bleeding and coronary revascularization were the most important factors associated with prescription of oral anticoagulants and their combination with antiplatelet drugs, respectively.
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Affiliation(s)
- Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania.
| | | | - Meena P Rao
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Wensheng He
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Federal University of São Paulo, São Paulo, Brazil; Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil
| | | | - Andrea O Ciobanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania
| | - Kathleen A Fox
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Sean D Pokorney
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Ying Xian
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC
| | - Jie Jiang
- Peking University First Hospital, Beijing, China
| | - Deepak Y Kamath
- St John's Medical College and Research Institute, Bangalore, India
| | - Otavio Berwanger
- Federal University of São Paulo, São Paulo, Brazil; Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil
| | | | - Yong Huo
- Peking University First Hospital, Beijing, China
| | - Denis Xavier
- St John's Medical College and Research Institute, Bangalore, India
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11
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Baicus C, Delcea C, Dima A, Oprisan E, Jurcut C, Dan GA. Influence of decision aids on oral anticoagulant prescribing among physicians: a randomised trial. Eur J Clin Invest 2017; 47:649-658. [PMID: 28682461 DOI: 10.1111/eci.12786] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 07/04/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Oral anticoagulants (OAC) are underused in treatment of atrial fibrillation (AF), with differences in patient and physician preferences. For risk communication, the graphic showing risks on treatment contains all the information, therefore, the graphic showing risks without treatment may not be necessary. Here, our objective was to assess whether decision aids require information of risks without treatment and specifically whether presentation of 5-year stroke risk in patients with AF increases use of OACs compared with presentation of 1-year risk and whether decisions on treatment are different when physicians decide their own treatment vs. that of the patient. DESIGN Randomised controlled trial with 23 factorial design, performed at 12 university hospitals, one internal medicine course and one national medical conference. RESULTS Of 968 physicians who participated, 83·3% prescribed anticoagulation therapy. Treatment decisions were not influenced by the number of graphics or by the time frame of risk estimation, with risk differences of 0·5% (95% confidence interval, -4·0% to 5·4%) and 3·4% (-1·3% to 8·1%). However, physician-to-patient prescription rates were 5·4% (0·2-10·6%) more frequent after seeing the 5-year risk graphic. Physician-to-self intentions to prescribe occurred less frequently, with risk difference of 15·4% (10·8-20%). Physicians considered the baseline risk and the absolute risk reduction only when prescribing to patients but not to themselves. CONCLUSIONS Risks could be communicated using decision aids with only one graphic. Showing the risk of stroke at 5 years could increase the prescription of OACs to patients with AF. Faced with the same risk of stroke, physicians prescribed less to themselves than to patients.
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Affiliation(s)
- Cristian Baicus
- Department of Internal Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Colentina Clinical Hospital, Bucharest, Romania.,Réseau d'Epidémiologie Clinique International Francophone (RECIF), Bucharest, Romania
| | - Caterina Delcea
- Department of Internal Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Réseau d'Epidémiologie Clinique International Francophone (RECIF), Bucharest, Romania
| | - Alina Dima
- Department of Internal Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Réseau d'Epidémiologie Clinique International Francophone (RECIF), Bucharest, Romania
| | - Emilia Oprisan
- Faculty of Psychology and Educational Sciences, University of Bucharest, Bucharest, Romania
| | - Ciprian Jurcut
- Réseau d'Epidémiologie Clinique International Francophone (RECIF), Bucharest, Romania.,Carol Davila Central University Emergency Military Hospital, Bucharest, Romania
| | - Gheorghe Andrei Dan
- Department of Internal Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Colentina Clinical Hospital, Bucharest, Romania
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Shah R, Li S, Stamplecoski M, Kapral MK. Low Use of Oral Anticoagulant Prescribing for Secondary Stroke Prevention: Results From the Ontario Stroke Registry. Med Care 2017; 54:907-12. [PMID: 27367867 DOI: 10.1097/mlr.0000000000000589] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Oral anticoagulation reduces the risk of stroke in atrial fibrillation but is often underused. OBJECTIVES To identify factors associated with oral anticoagulant prescribing and adherence after stroke or transient ischemic attack (TIA). RESEARCH DESIGN Retrospective cohort study using linked Ontario Stroke Registry and prescription claims data. SUBJECTS Consecutive patients with atrial fibrillation and ischemic stroke/TIA admitted to 11 stroke centers in Ontario, Canada between 2003 and 2011. MEASURES We used modified Poisson regression models to determine predictors of anticoagulant prescribing and multiple logistic regression to determine predictors of 1-year adherence. RESULTS Of the 5781 patients in the study cohort, 4235 (73%) were prescribed oral anticoagulants at discharge. Older patients were less likely to receive anticoagulation [adjusted relative risk (aRR) for each additional year=0.997; 95% confidence interval (CI), 0.995-0.998], as were those with TIA compared with ischemic stroke (aRR=0.904; 95% CI, 0.865-0.945), prior gastrointestinal bleed (aRR=0.778; 95% CI, 0.693-0.873), dementia (aRR=0.912; 95% CI, 0.856-0.973), and those from a long-term care facility (aRR=0.810; 95% CI, 0.737-0.891). After limiting the sample to those without obvious contraindications to anticoagulation, age, dementia, and long-term care residence continued to be associated with lower prescription of oral anticoagulants. One-year adherence to therapy was similar across most patient groups. CONCLUSIONS Age, dementia, and long-term care residence are predictors of lower oral anticoagulant use for secondary stroke prevention and represent key target areas for quality improvement initiatives.
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Affiliation(s)
- Reema Shah
- *Department of Medicine, McMaster University, Hamilton †Institute for Clinical Evaluative Sciences ‡Institute of Health Policy, Management and Evaluation, University of Toronto §Division of General Internal Medicine, Women's Health Program, and Toronto General Research Institute, University Health Network ∥Department of Medicine, Division of General Internal Medicine, University of Toronto, Toronto, ON, Canada
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13
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Mas Dalmau G, Sant Arderiu E, Enfedaque Montes MB, Solà I, Pequeño Saco S, Alonso Coello P. Patients' and physicians' perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review. BMC FAMILY PRACTICE 2017; 18:3. [PMID: 28086887 PMCID: PMC5234257 DOI: 10.1186/s12875-016-0574-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 12/07/2016] [Indexed: 11/17/2022]
Abstract
Background Oral anticoagulant therapy reduces the risk of stroke in patients with atrial fibrillation, but many patients are still not prescribed this therapy. The causes of underuse of vitamin K antagonists oral anticoagulants are not clear but could be related, in part, to patients’ and physicians’ perceptions and attitudes towards the benefits and downsides of this treatment. The purpose of this systematic review was to evaluate and synthesize patients’ and physicians’ perceptions and attitudes towards the benefits and downsides of vitamin K antagonist, in order to explore potential factors related with its underuse. Methods We included studies that used qualitative or mixed methods and focused on patients’ and/or physicians’ perceptions and attitudes towards oral anticoagulation. We systematically searched PubMed, EMBASE, ISI WoK, and PsycINFO from their inception until May 2013. Two reviewers independently assessed the quality of the included studies and synthesized results using a thematic analysis approach. Results We included a total of nine studies. In four studies, the quality assessed was excellent and in five was moderate. We identified three themes that were of interest to both physicians and patients: information to reinforce anticoagulation use, balance of benefits and downsides, roles in decision-making and therapy management. Three additional themes were of interest to patients: knowledge and understanding, impact on daily life, and satisfaction with therapy. The main difficulties with the use of anticoagulant treatment according to physicians were the perceived uncertainty, need of individualised decision-making, and the feeling of delegated responsibility as their main concerns. The main factors for patients were the lack of information and understanding. Conclusion Physicians’ and patients’ perceptions and attitudes might be potential factors in the underuse of treatment with vitamin K antagonists. Improving the quality and usability of clinical guidelines, developing tools to help with the decision-making, enhancing coordination between primary care and hospital care, and improving information provided to patients could help improve the underuse of anticoagulation. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0574-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gemma Mas Dalmau
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.
| | - Elisenda Sant Arderiu
- Consorci d'Atenció Primària de Salut de l'Eixample (CAPSE), CAP Casanova, Barcelona, Spain
| | | | - Ivan Solà
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Sandra Pequeño Saco
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain
| | - Pablo Alonso Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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14
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Mas Dalmau G, Sant Arderiu E, Enfedaque Montes MB, Solà I, Pequeño Saco S, Alonso Coello P. Patients' and physicians' perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review. BMC FAMILY PRACTICE 2017. [PMID: 28086887 DOI: 10.1186/s12875‐016‐0574‐0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Oral anticoagulant therapy reduces the risk of stroke in patients with atrial fibrillation, but many patients are still not prescribed this therapy. The causes of underuse of vitamin K antagonists oral anticoagulants are not clear but could be related, in part, to patients' and physicians' perceptions and attitudes towards the benefits and downsides of this treatment. The purpose of this systematic review was to evaluate and synthesize patients' and physicians' perceptions and attitudes towards the benefits and downsides of vitamin K antagonist, in order to explore potential factors related with its underuse. METHODS We included studies that used qualitative or mixed methods and focused on patients' and/or physicians' perceptions and attitudes towards oral anticoagulation. We systematically searched PubMed, EMBASE, ISI WoK, and PsycINFO from their inception until May 2013. Two reviewers independently assessed the quality of the included studies and synthesized results using a thematic analysis approach. RESULTS We included a total of nine studies. In four studies, the quality assessed was excellent and in five was moderate. We identified three themes that were of interest to both physicians and patients: information to reinforce anticoagulation use, balance of benefits and downsides, roles in decision-making and therapy management. Three additional themes were of interest to patients: knowledge and understanding, impact on daily life, and satisfaction with therapy. The main difficulties with the use of anticoagulant treatment according to physicians were the perceived uncertainty, need of individualised decision-making, and the feeling of delegated responsibility as their main concerns. The main factors for patients were the lack of information and understanding. CONCLUSION Physicians' and patients' perceptions and attitudes might be potential factors in the underuse of treatment with vitamin K antagonists. Improving the quality and usability of clinical guidelines, developing tools to help with the decision-making, enhancing coordination between primary care and hospital care, and improving information provided to patients could help improve the underuse of anticoagulation.
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Affiliation(s)
- Gemma Mas Dalmau
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.
| | - Elisenda Sant Arderiu
- Consorci d'Atenció Primària de Salut de l'Eixample (CAPSE), CAP Casanova, Barcelona, Spain
| | | | - Ivan Solà
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Sandra Pequeño Saco
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain
| | - Pablo Alonso Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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15
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LeBlanc T, Howson A, Turell W, Sheldon P, Locke S, Tuchman S, Gasparetto C, Kaura S, Khan Z, Abernethy A. Risk stratification, treatment selection, and transplant eligibility in multiple myeloma: a qualitative study of the perspectives and self-reported practices of oncologists. Curr Oncol 2016; 23:e598-e604. [PMID: 28050150 PMCID: PMC5176387 DOI: 10.3747/co.23.3298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Since the early 2000s, treatment options for multiple myeloma have rapidly expanded, adding significant complexity to the management of this disease. To our knowledge, no systematic qualitative research on clinical decision-making in multiple myeloma has been published. We sought to characterize how physicians view and implement guidelines and incorporate novel approaches into patient care. METHODS We designed a semi-structured qualitative interview guide informed by literature review and an expert advisory panel. We conducted 60-minute interviews with a diverse sample of oncology physicians in the southeast United States. We used a constant comparative method to code and analyze interview transcripts. The research team and advisory panel discussed and validated emergent themes. RESULTS Participants were 13 oncologists representing 5 academic and 4 community practices. Academic physicians reported using formal risk-stratification schemas; community physicians typically did not. Physicians also described differences in eligibility criteria for transplantation; community physicians emphasized distance, social support, and psychosocial capacity in making decisions about transplantation referral; the academic physicians reported using more specific clinical criteria. All physicians reported using a maintenance strategy both for post-transplant and for transplant-ineligible patients; however, determining the timing of maintenance therapy initiation and the response were reported as challenging, as was recognition or definition of relapse, especially in terms of when treatment re-initiation is indicated. CONCLUSIONS Practices reported by both academic and community physicians suggest opportunities for interventions to improve patient care and outcomes through optimal multiple myeloma management and therapy selection. Community physicians in particular might benefit from targeted education interventions about risk stratification, transplant eligibility, and novel therapies.
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Affiliation(s)
- T.W. LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, and
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, U.S.A
| | | | | | | | - S.C. Locke
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, U.S.A
| | - S.A. Tuchman
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, and
| | - C. Gasparetto
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, and
| | - S. Kaura
- Celgene Corporation, Summit, NJ, U.S.A
| | - Z.M. Khan
- Celgene Corporation, Summit, NJ, U.S.A
| | - A.P. Abernethy
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, U.S.A
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16
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Raut MK, Nelson WW, Wang SW, Coleman CI, Lu L, Patel D, Schein JR, Xiang J, Damaraju CV. Prescribers' behavior following below- versus above-range international normalized ratio values in warfarin-treated deep vein thrombosis patients. Curr Med Res Opin 2016; 32:1213-5. [PMID: 26960249 DOI: 10.1185/03007995.2016.1164678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Maintaining acceptable international normalized ratio (INR) control among deep vein thrombosis (DVT) patients taking warfarin is challenging. We evaluated prescribers' behavior to out-of-range INRs in DVT patients following initial INR stabilization. Following INR stabilization, a below-range INR was associated with fewer subsequent measurements and warfarin-dosing adjustments, and a longer time to re-achieve a therapeutic INR compared to an above-range INR.
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Affiliation(s)
- Monika K Raut
- a Janssen Scientific Affairs LLC , Raritan , NJ , USA
| | | | - Sheng-Wei Wang
- b Janssen Research and Development LLC , Raritan , NJ , USA
| | - Craig I Coleman
- c The University of Connecticut Evidence-Based Practice Center , Hartford , CT , USA
- d University of Connecticut School of Pharmacy , Storrs , CT , USA
| | - Lang Lu
- b Janssen Research and Development LLC , Raritan , NJ , USA
| | - Dhaval Patel
- e University of the Sciences, Philadelphia College of Pharmacy , Philadelphia , PA , USA
| | - Jeff R Schein
- a Janssen Scientific Affairs LLC , Raritan , NJ , USA
| | - Jim Xiang
- b Janssen Research and Development LLC , Raritan , NJ , USA
| | - C V Damaraju
- b Janssen Research and Development LLC , Raritan , NJ , USA
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17
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Wang Y, Bajorek B. Decision-making around antithrombotics for stroke prevention in atrial fibrillation: the health professionals' views. Int J Clin Pharm 2016; 38:985-95. [PMID: 27286973 DOI: 10.1007/s11096-016-0329-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 05/30/2016] [Indexed: 11/30/2022]
Abstract
Background For stroke prevention in patients with atrial fibrillation (AF), the decision-making around antithrombotic therapy has been complicated by older age, multiple comorbidities, polypharmacy and the different pharmacological properties of warfarin and the nonvitamin K antagonist oral anticoagulants (NOACs). The complexity of decision-making has been associated with a reluctance by health professionals to use antithrombotic therapy, leading to poor clinical outcomes. In order to improve stroke prevention in patients with AF, the contemporary perspectives of health professionals on the decision-making around antithrombotic therapy needs exploration. Objective To elicit emerging themes describing health professionals' perspectives on the decision-making around antithrombotic therapy for stroke prevention in patients with AF. Setting Sydney metropolitan area of New South Wales, Australia. Method A qualitative study based on face-to-face interviews was conducted from August to October 2014. Seven pharmacists, seven specialists, six general practitioners and six nurses practising in the Sydney metropolitan area and managing antithrombotic therapy for AF were interviewed until theme saturation was achieved in each subgroup. Interview transcripts were analysed using manual inductive coding. Main outcome measure Emerging themes describing health professionals' perspectives on the decision-making around antithrombotic therapy for stroke prevention in patients with AF. Results Three overarching themes emerged. (1) Comprehensive assessment is necessary for decision-making but is not always implemented. Health professionals mostly focused on stroke risk assessment, not on the bleeding risk and medication safety issues. (2) Health professionals from different disciplines have different preferences for antithrombotic therapies. Although the majority of health professionals considered warfarin as the first-line therapy, NOACs were preferred by neurologists and haematologists. (3) Health professionals focused on different aspects of the decision making process: GPs and specialists were concerned about the appropriate prescription of antithrombotics, while pharmacists and nurses focused on daily medication management by patients. Conclusion The decision-making process appears to be partially preference based rather than systematic, and health professionals from various disciplines focus on different parts of the decision-making process.
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Affiliation(s)
- Yishen Wang
- Graduate School of Health-Pharmacy, The University of Technology Sydney, Sydney, NSW, 2007, Australia.
| | - Beata Bajorek
- Graduate School of Health-Pharmacy, The University of Technology Sydney, Sydney, NSW, 2007, Australia.,Department of Pharmacy, Royal North Shore Hospital, Sydney, NSW, Australia
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18
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Amin A, Deitelzweig S. A case-based approach to implementing guidelines for stroke prevention in patients with atrial fibrillation: balancing the risks and benefits. Thromb J 2015; 13:29. [PMID: 26300695 PMCID: PMC4546218 DOI: 10.1186/s12959-015-0056-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 05/25/2015] [Indexed: 12/23/2022] Open
Abstract
Atrial fibrillation (AF) puts patients at risk of complications, including stroke. Warfarin therapy has been the mainstay of antithrombotic treatment for reducing the risk of stroke in AF. However, warfarin has limitations that have motivated development of several novel oral anticoagulants (NOACs), including dabigatran, rivaroxaban, apixaban, and edoxaban. Clinical trials demonstrate that the NOACs offer efficacy and safety that are equivalent to, or better than, those of warfarin for reducing the risk of stroke in patients with nonvalvular AF. This review examines stroke risk reduction in patients with AF from the perspective of the clinician balancing the risks and benefits of treatment options, evaluates the most recent guidelines, and discusses 2 hypothetical patient cases to better illustrate how clinicians may apply available data in the clinical setting. We reviewed guidelines for the reduction of stroke risk in AF and data from clinical trials on the NOACs. Choosing antithrombotic treatment involves assessing the benefits of therapy versus its risks. Risk indexes, including CHADS2, CHA2DS2-VASc, and HAS-BLED can help determine how to treat patients with AF. Current guidelines suggest using these risk indexes to customize treatment to individual patients. Many current treatment guidelines also incorporate recommendations for the use of NOACs as an alternative to warfarin. As additional data emerge and guidelines are updated, these recommendations will likely evolve. In the interim, clinicians may consider published guidelines and clinical trial results on NOACs. Real-world experience will provide clinicians with additional insight into their treatment decisions.
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Affiliation(s)
- Alpesh Amin
- />Department of Medicine, Executive Director, Hospitalist Program, University of California, UCIMC, 101 The City Drive South, Building 26, Room 1005, ZC-4076H, Mail Code: 4076, Irvine, CA 92868 USA
| | - Steven Deitelzweig
- />University of Queensland, System Chairman of Hospital Medicine, Medical Director for Regional Business Development, Ochsner Health System, New Orleans, LA 70112 USA
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19
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Stambler BS, Ngunga LM. Atrial fibrillation in Sub-Saharan Africa: epidemiology, unmet needs, and treatment options. Int J Gen Med 2015; 8:231-42. [PMID: 26261423 PMCID: PMC4527570 DOI: 10.2147/ijgm.s84537] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Health care in Sub-Saharan Africa is being challenged by a double burden of disease as lifestyle diseases common in the developed world, such as stroke and atrial fibrillation (AF), increase, while, simultaneously, health issues of the developing world in terms of communicable disease persist. The prevalence of AF is lower in Africa than in the developed world but is expected to increase significantly over the next few decades. Patients with AF in Africa tend to be younger and have a higher prevalence of rheumatic valvular heart disease than patients with AF in other regions. Permanent AF is the most prevalent type of AF in Africa, possibly due to the lower use of rhythm control strategies than in the developed world. Mortality rates of patients with AF in Africa are high, due largely to poor health care access and suboptimal therapy. The risk of stroke in AF, which is moderate to high in Africans as in the developed world, contributes to the high mortality rate. Patients with AF in Africa are often undertreated with antithrombotics, as cost and access to monitoring are major barriers. Vitamin K antagonists, including warfarin, are the most commonly available oral anticoagulants, but regular monitoring can be challenging, especially for patients in remote areas. Several non-vitamin K antagonist oral anticoagulants (NOACs) have been approved for use in countries across Sub-Saharan Africa and have the potential to reduce stroke burden. The higher cost of newer agents may be offset by the reduced need for regular monitoring, fixed dosing, and lower risk of intracranial bleeding; NOACs could provide a treatment option for patients in remote areas with limited access to regular monitoring. However, NOACs are not indicated in valvular AF. More work is needed to increase understanding of the epidemiology of AF and stroke, as well as to improve management strategies to reduce the burden of cardiovascular disease predicted for Africa.
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Affiliation(s)
- Bruce Sheldon Stambler
- Department of Cardiac Electrophysiology, Piedmont Heart Institute Cardiology/Electrophysiology, Atlanta, GA, USA
| | - Leonard M Ngunga
- Department of Cardiology, Aga Khan University Hospital, Nairobi, Kenya
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20
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Maes F, Dalleur O, Henrard S, Wouters D, Scavée C, Spinewine A, Boland B. Risk scores and geriatric profile: can they really help us in anticoagulation decision making among older patients suffering from atrial fibrillation? Clin Interv Aging 2014; 9:1091-9. [PMID: 25053883 PMCID: PMC4105275 DOI: 10.2147/cia.s62597] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Anticoagulation for the prevention of cardio-embolism is most frequently indicated but largely underused in frail older patients with atrial fibrillation (AF). This study aimed at identifying characteristics associated with anticoagulation underuse. METHODS A cross-sectional study of consecutive geriatric patients aged ≥75 years, with AF and clear anticoagulation indication (CHADS₂ [Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack] ≥2) upon hospital admission. All patients benefited from a comprehensive geriatric assessment. Their risks of stroke and bleeding were predicted using CHADS₂ and HEMORR2HAGES (Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age >75 years), Reduced platelet count or function, Rebleed risk, Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, and Stroke) scores, respectively. RESULTS Anticoagulation underuse was observed in 384 (50%) of 773 geriatric patients with AF (median age 85 years; female 57%, cognitive disorder 33%, nursing home 20%). No geriatric characteristic was found to be associated with anticoagulation underuse. Conversely, anticoagulation underuse was markedly increased in the patients treated with aspirin (odds ratio [OR] [95% confidence interval]: 5.3 [3.8; 7.5]). Other independent predictors of anticoagulation underuse were ethanol abuse (OR: 4.0 [1.4; 13.3]) and age ≥90 years (OR: 2.0 [1.2; 3.4]). Anticoagulation underuse was not inferior in patients with a lower bleeding risk and/or a higher stroke risk and underuse was surprisingly not inferior either in the AF patients who had previously had a stroke. CONCLUSION Half of this geriatric population did not receive any anticoagulation despite a clear indication, regardless of their individual bleeding or stroke risks. Aspirin use is the main characteristic associated with anticoagulation underuse.
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Affiliation(s)
- Frédéric Maes
- Cardiology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Olivia Dalleur
- Pharmacy Department, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium ; Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Séverine Henrard
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - Dominique Wouters
- Pharmacy Department, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Christophe Scavée
- Cardiology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Anne Spinewine
- Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium ; Pharmacy Department, CHU Dinant-Godinne, Université catholique de Louvain, Yvoir, Belgium
| | - Benoit Boland
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium ; Geriatric Medicine, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
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21
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Nicholls SG, Brehaut JC, Arim RG, Carroll K, Perez R, Shojania KG, Grimshaw JM, Poses RM. Impact of stated barriers on proposed warfarin prescription for atrial fibrillation: a survey of Canadian physicians. Thromb J 2014; 12:13. [PMID: 25161388 PMCID: PMC4144316 DOI: 10.1186/1477-9560-12-13] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 06/13/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common cardiac arrhythmia, and leading cause of ischemic stroke. Despite proven effectiveness, warfarin remains an under-used treatment in atrial fibrillation patients. We sought to study, across three physician specialties, a range of factors that have been argued to have a disproportionate effect on treatment decisions. METHODS Cross-sectional survey of Canadian Family Doctors (FD: n = 500), Geriatricians (G: n = 149), and Internal Medicine specialists (IMS: n = 500). Of these, 1032 physicians were contactable, and 335 completed and usable responses were received. Survey questions and clinical vignettes asked about the frequency with which they see patients with atrial fibrillation, treatment practices, and barriers to the prescription of anticoagulants. RESULTS Stated prescribing practices did not significantly differ between physician groups. Falls risk, bleeding risk and poor patient adherence were all highly cited barriers to prescribing warfarin. Fewer geriatricians indicated that history of patient falls would be a reason for not treating with warfarin (G: 47%; FD: 71%; IMS: 72%), and significantly fewer changed reported practice in the presence of falls risk (χ (2) (6) = 45.446, p < 0.01). Experience of a patient having a stroke whilst not on warfarin had a significant impact on vignette decisions; physicians who had had patients who experienced a stroke were more likely to prescribe warfarin (χ (2) (3) =10.7, p = 0.013). CONCLUSIONS Barriers to treatment of atrial fibrillation with warfarin affect physician specialties to different extents. Prior experience of a patient suffering a stroke when not prescribed warfarin is positively associated with intention to prescribe warfarin, even in the presence of falls risk.
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Affiliation(s)
- Stuart G Nicholls
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jamie C Brehaut
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada ; Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada
| | - Rubab G Arim
- Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada
| | - Kelly Carroll
- Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada
| | - Richard Perez
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kaveh G Shojania
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada ; Department of Medicine, University of Ottawa, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario, Canada
| | - Roy M Poses
- Foundation for Integrity and Responsibility in Medicine, Warren, Rhode Island, USA ; Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Denford S, Frost J, Dieppe P, Britten N. Doctors' understanding of individualisation of drug treatments: a qualitative interview study. BMJ Open 2013; 3:e002706. [PMID: 23793685 PMCID: PMC3657639 DOI: 10.1136/bmjopen-2013-002706] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 03/28/2013] [Accepted: 04/16/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To explore doctors' understanding of individualisation of drug treatments, and identify the methods used to achieve individualisation. DESIGN In this exploratory study, we used in-depth qualitative interviews with doctors to gain insight into their understanding of the term 'individualised treatments' and the methods that they use to achieve it. PARTICIPANTS 16 general practitioners in 6 rural and 10 urban practices, 2 geriatricians and 2 clinical academics were recruited. SETTING Primary and secondary care in South West of England. RESULTS Understanding of individualisation varied between doctors, and their initial descriptions of individualisation were not always consistent with subsequent examples of the patients they had treated. Understandings of, and methods used to achieve, individualised treatment were frequently discussed in relation to making drug treatment decisions. Few doctors spoke of using strategies to support patients to individualise their own treatments after the consultation. CONCLUSIONS Despite its widespread use, variation in doctors' understanding of the term individualisation highlights the need for it to be defined. Efforts are needed to develop effective methods that would offer a structured approach to support patients to manage their treatments after consultations.
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Affiliation(s)
- S Denford
- University of Exeter Medical School, Institute of Health Services Research, Exeter, UK
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Abstract
There is a high prevalence of atrial fibrillation in the United States, particularly in the elderly population. Patients with atrial fibrillation are at an increased risk of stroke and anticoagulant therapy is recommended. However, many eligible patients are not receiving therapy due to limitations and concerns related to the use of the vitamin K antagonist warfarin, such as slow onset of action, variable drug metabolism, risk of bleeding, and requirement for monitoring. Novel oral anticoagulants (NOACs) have been developed and may be used as an alternative to warfarin. This review article summarizes the current clinical trial data for warfarin compared with the NOACs dabigatran (direct thrombin inhibitor), and rivaroxaban and apixaban (factor Xa inhibitors). Dabigatran (150 mg twice daily) demonstrated superiority in reducing the stroke or systemic embolism rate compared with warfarin (1.53% vs 1.69%; P < 0.001). The risk of major bleeding was similar for dabigatran and warfarin (3.32% per year vs 3.57% per year; P = 0.32). Rivaroxaban (20 mg once daily) demonstrated noninferiority in reducing the stroke or systemic embolism rate compared with warfarin (2.1% vs 2.4%; P < 0.001). There was no significant difference between rivaroxaban and warfarin for the risk of major bleeding and clinically relevant nonmajor bleeding (14.9% per year vs 14.5% per year; P = 0.44). Apixaban (5 mg twice daily) demonstrated superiority compared with warfarin in preventing stroke or systemic embolism (1.27% vs 1.60%; P = 0.01). Apixaban significantly reduced major bleeding compared with warfarin (2.13% per year vs 3.09% per year; P < 0.001). Compared with warfarin, all-cause mortality was numerically lower for dabigatran (P = 0.051) and similar for rivaroxaban (P = 0.15). Apixaban demonstrated significantly lower mortality rates compared with warfarin (3.52% vs 3.94%; P = 0.047). All 3 NOACS--dabigatran, rivaroxaban, and apixaban--significantly reduced intracranial hemorrhage compared with warfarin. Novel oral anticoagulants may be a suitable alternative to warfarin for different patient populations due to minimal drug interactions, lower bleeding risk, and no monitoring requirement.
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Affiliation(s)
- Arnold J Greenspon
- Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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Elstad E, Carpenter DM, Devellis RF, Blalock SJ. Patient decision making in the face of conflicting medication information. Int J Qual Stud Health Well-being 2012; 7:1-11. [PMID: 22943889 PMCID: PMC3430944 DOI: 10.3402/qhw.v7i0.18523] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2012] [Indexed: 12/16/2022] Open
Abstract
When patients consult more than one source of information about their medications, they may encounter conflicting information. Although conflicting information has been associated with negative outcomes, including worse medication adherence, little is known about how patients make health decisions when they receive conflicting information. The objective of this study was to explore the decision making strategies that individuals with arthritis use when they receive conflicting medication information. Qualitative telephone interviews were conducted with 20 men and women with arthritis. Interview vignettes posed scenarios involving conflicting information from different sources (e.g., doctor, pharmacist, and relative), and respondents were asked how they would respond to the situation. Data analysis involved inductive coding to identify emergent themes and deductive contextualization to make meaning from the emergent themes. In response to conflicting medication information, patients used rules of thumb, trial and error, weighed benefits and risks, and sought more information, especially from a doctor. Patients relied heavily on trial and error when there was no conflicting information involved in the vignette. In contrast, patients used rules of thumb as a unique response to conflicting information. These findings increase our understanding of what patients do when they receive conflicting medication information. Given that patient exposure to conflicting information is likely to increase alongside the proliferation of medication information on the Internet, patients may benefit from assistance in identifying the most appropriate decision strategies for dealing with conflicting information, including information about best information sources.
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Affiliation(s)
- Emily Elstad
- Department of Health Behavior and Health Education, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC 27599, USA.
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25
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Borg Xuereb C, Shaw RL, Lane DA. Patients' and health professionals' views and experiences of atrial fibrillation and oral-anticoagulant therapy: a qualitative meta-synthesis. PATIENT EDUCATION AND COUNSELING 2012; 88:330-337. [PMID: 22738822 DOI: 10.1016/j.pec.2012.05.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 04/18/2012] [Accepted: 05/18/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE Atrial fibrillation (AF) patients are prescribed oral-anticoagulant (OAC) therapy, often warfarin, to reduce stroke risk. We explored existing qualitative evidence about patients' and health professionals' experiences of OAC therapy. METHODS Systematic searches of eight bibliographic databases were conducted. Quality was appraised using the Critical Appraisal Skills Programme tool and data from ten studies were synthesised qualitatively. RESULTS Four third-order constructs, emerged from the final step in the analysis process: (1) diagnosing AF and the communication of information, (2) deciding on OAC therapy, (3) challenges revolving around patient issues, and (4) healthcare challenges. Synthesis uncovered perspectives that could not be achieved through individual studies. CONCLUSION Physicians' and patients' experiences present a dichotomy of opinion on decision-making, which requires further exploration and changes in practice. Outcomes of workload pressure on both health professionals and patients should be investigated. The need for on-going support and education to patients and physicians is critical to achieve best practice and treatment adherence. PRACTICE IMPLICATIONS Such research could encourage health professionals to understand and attend better to the needs and concerns of the patient. Additionally these findings can be used to inform researchers and healthcare providers in developing educational interventions with both patients and health professionals.
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Engaging older people in decisions about their healthcare: the case for shared decision making. ACTA ACUST UNITED AC 2012. [DOI: 10.1017/s0959259811000281] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
SummaryShared decision making in clinical practice involves both the healthcare professional, an expert in the clinical condition and the patient who is an expert in what is important to them. A consultation involving shared decision making enables an examination of the options available, consideration of the risks and benefits whilst incorporating the values of the patient into the decision making process. A decision is aimed at, which is both clinically appropriate and is congruent with the patient's values.Older people have been shown to value involvement, to varying degrees, in decisions about their care and treatment. The case of atrial fibrillation shows the opportunities for, and benefits of, sharing with older people decision making about their healthcare.
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Yates SW. Apixaban for stroke prevention in atrial fibrillation: a review of the clinical trial evidence. Hosp Pract (1995) 2012; 39:7-16. [PMID: 22056819 DOI: 10.3810/hp.2011.10.918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The objective of this review is to summarize data from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) and Apixaban Versus Acetylsalicylic Acid to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment (AVERROES) trials of apixaban for stroke prevention in patients with atrial fibrillation (AF). The ARISTOTLE trial compared apixaban with warfarin in 18 201 patients with AF and ≥ 1 additional risk factor for stroke. The AVERROES trial compared apixaban with aspirin in 5599 patients with AF who were at increased risk of stroke and for whom vitamin K antagonists were unsuitable. In ARISTOTLE, apixaban reduced the risk of stroke or systemic embolism by 21% compared with warfarin (1.27% vs 1.60% per year; hazard ratio, 0.79; 95% confidence interval, 0.66-0.95). The reduction was significant and demonstrated the superiority of apixaban over warfarin for the primary outcome of preventing stroke or systemic embolism (P = 0.01 for superiority). Apixaban also reduced all-cause mortality by 11% (P = 0.047) and major bleeding by 31% (P < 0.001) compared with warfarin. The benefits of apixaban observed in ARISTOTLE are further supported by the results from AVERROES, which demonstrated a 55% reduction in the risk of stroke or systemic embolism compared with aspirin. Risk of major bleeding was not significantly different between apixaban and aspirin. Subgroup analyses in both trials demonstrated that the effects of apixaban are highly consistent across various patient subpopulations. Discontinuation of study medication was significantly lower with apixaban than with either warfarin in ARISTOTLE or aspirin in AVERROES. Apixaban is the first new oral anticoagulant that has been shown to be superior to warfarin in reducing stroke or systemic embolism, all-cause mortality, and major bleeding in patients with AF. Moreover, in patients with AF who are considered unsuitable for warfarin therapy, apixaban was more effective than aspirin for stroke prevention and had a similar rate of major bleeding.
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28
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Pugh D, Pugh J, Mead GE. Attitudes of physicians regarding anticoagulation for atrial fibrillation: a systematic review. Age Ageing 2011; 40:675-83. [PMID: 21821732 DOI: 10.1093/ageing/afr097] [Citation(s) in RCA: 185] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND the efficacy of warfarin for prevention of stroke in patients with atrial fibrillation (AF) is well established, but many people with AF who would benefit from warfarin are not receiving it. This systematic review aims to determine physicians' attitudes to the prescription of warfarin for AF, and identify reasons for its underuse. METHODS an electronic search of MEDLINE (1950-present), EMBASE (1980-present), CINAHL (1994-present), PsycINFO (1987-present) and Web of Knowledge (1970-present) was performed in November 2010 to identify all studies which addressed, via survey, physicians' attitudes regarding anticoagulation for patients with AF. RESULTS a total of 1,375 citations were identified. Of these citations, 44 full text studies were obtained for scrutinisation; 14 of these studies were rejected leaving 30 studies which were included in the review. All included studies were cross-sectional surveys and addressed physicians' opinions of anticoagulation in AF as a primary or secondary aim. Increasing age, increased bleeding risk, previous bleeds, falls risk, co-morbidities and ability to comply with treatment influenced whether physicians would prescribe anticoagulation for AF. CONCLUSION physicians are reticent to recommend warfarin for elderly patients in AF, despite evidence of increased benefit in these patients compared with younger patients. Risk of falls and previous bleeding were also shown to be disproportionate barriers to warfarin prescription. Further studies are required to determine how best to overcome these perceived barriers to appropriate anticoagulation.
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29
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Baysari MT, Westbrook J, Braithwaite J, Day RO. The role of computerized decision support in reducing errors in selecting medicines for prescription: narrative review. Drug Saf 2011; 34:289-98. [PMID: 21417501 DOI: 10.2165/11588200-000000000-00000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This narrative review includes a summary of research examining prescribing errors, prescription decision making and the role computerized decision support plays in this decision-making process. A reduction in medication prescribing errors, specifically a reduction in the selection of inappropriate medications, is expected to result from the implementation of an effective computerized decision support system. Previous research has investigated the impact of the implementation of electronic systems on medication errors more broadly. This review examines the specific characteristics of decision support systems that may contribute to fewer knowledge-based mistakes in prescribing, and critically appraises the large volume of information available on the decision-making process of selecting medicines for prescription. The results highlight a need for work investigating what decision strategies are used by doctors with different levels of expertise in the prescribing of medications. The nature of the relationship between decision support and decision performance is not well understood and future research is needed to determine the mechanisms by which computerized decision support influences medication selection.
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Affiliation(s)
- Melissa T Baysari
- Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney, NSW 2010, Australia.
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30
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Characterization of the proportion of untreated and antiplatelet therapy treated patients with atrial fibrillation. Am J Cardiol 2011; 108:151-61. [PMID: 21545990 DOI: 10.1016/j.amjcard.2011.02.353] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 02/18/2011] [Accepted: 02/18/2011] [Indexed: 11/22/2022]
Abstract
Despite the efficacy of oral anticoagulants for stroke prevention in atrial fibrillation (AF), evidence suggests that many patients with AF who should be treated with vitamin K antagonists (VKAs) are treated with antiplatelet therapy or remain untreated. The aims of this study were to determine the proportion of patients with AF in each treatment category in clinical practice and to ascertain whether treatment is appropriate for stroke risk. An extensive search of the biomedical research published since 1994 was performed. Studies delineating the treatment of patients with AF were captured. Seventy-eight studies pertaining to the treatment of patients with AF were identified; 56 studies, containing data from 1980 to 2007, met the inclusion criteria. Over time, the use of VKA therapy for stroke prevention increased, while the proportion of untreated patients decreased; antiplatelet use remained static. Looking at the more recent data, (collected from 2000 onward), the proportion of patients receiving no therapy ranged from 4% to 48% (median 18%), antiplatelet therapy from 10% to 56% (median 30%), and VKA therapy from 9% to 86% (median 52%). Although most studies showed a decrease in the proportion of antiplatelet-treated and untreated patients with increasing stroke risk (12 of 14 studies), many patients at moderate or high risk for stroke were not treated according to guidelines. In conclusion, this review shows that up to 56% of patients with AF are treated with antiplatelet therapy, and up to 48% receive no therapy regardless of stroke risk level. This may reflect the inconvenience associated with VKA use, inadequate assessment of stroke risk, or poor adherence to treatment guidelines.
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31
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Ogilvie IM, Newton N, Welner SA, Cowell W, Lip GYH. Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med 2010; 123:638-645.e4. [PMID: 20609686 DOI: 10.1016/j.amjmed.2009.11.025] [Citation(s) in RCA: 695] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Revised: 11/04/2009] [Accepted: 11/05/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Atrial fibrillation is associated with substantial mortality and morbidity from stroke and thromboembolism. Despite an efficacious oral anticoagulation therapy (warfarin), atrial fibrillation patients at high risk for stroke are often under-treated. This systematic review compares current treatment practices for stroke prevention in atrial fibrillation with published guidelines. METHODS Literature searches (1997-2008) identified 98 studies concerning current treatment practices for stroke prevention in atrial fibrillation. The percentage of patients eligible for oral anticoagulation due to elevated stroke risk was compared with the percentage treated. Under-treatment was defined as treatment of <70% of high-risk patients. RESULTS Of 54 studies that reported stroke risk levels and the percentage of patients treated, most showed underuse of oral anticoagulants for high-risk patients. From 29 studies of patients with prior stroke/transient ischemic attack who should all receive oral anticoagulation according to published guidelines, 25 studies reported under-treatment, with 21 of 29 studies reporting oral anticoagulation treatment levels below 60% (range 19%-81.3%). Subjects with a CHADS(2) (congestive heart failure, hypertension, age >75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score >or=2 also were suboptimally treated, with 7 of 9 studies reporting treatment levels below 70% (range 39%-92.3%). Studies (21 of 54) using other stroke risk stratification schemes differ in the criteria they use to designate patients as "high risk," such that direct comparison is not possible. CONCLUSIONS This systematic review demonstrates the underuse of oral anticoagulation therapy for real-world atrial fibrillation patients with an elevated risk of stroke, highlighting the need for improved therapies for stroke prevention in atrial fibrillation.
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