1
|
Atwater BD, Guo JD, Keshishian A, Delinger R, Russ C, Rosenblatt L, Jiang J, Yuce H, Ferri M. Temporal trends in anticoagulation use and clinical outcomes among medicare beneficiaries with non-valvular atrial fibrillation. J Thromb Thrombolysis 2024; 57:1-10. [PMID: 37530955 PMCID: PMC10830709 DOI: 10.1007/s11239-023-02838-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE Oral anticoagulants effectively prevent stroke/systemic embolism among patients with non-valvular atrial fibrillation but remain under-prescribed. This study evaluated temporal trends in oral anticoagulant use, the incidence of stroke/systemic embolism and major bleeding, and economic outcomes among elderly patients with non-valvular atrial fibrillation and CHA2DS2-VASc scores ≥ 2. METHODS Retrospective analyses were conducted on Medicare claims data from January 1, 2012 through December 31, 2017. Non-valvular atrial fibrillation patients aged ≥ 65 years with CHA2DS2-VASc scores ≥ 2 were stratified by calendar year (2013-2016) of care to create calendar-year cohorts. Patient characteristics were evaluated across all cohorts during the baseline period (12 months before diagnosis). Treatment patterns and clinical and economic outcomes were evaluated during the follow-up period (from diagnosis through 12 months). RESULTS Baseline patient characteristics remained generally similar between 2013 and 2016. Although lack of oral anticoagulant prescriptions among eligible patients remained relatively high, utilization did increase progressively (53-58%). Among treated patients, there was a progressive decrease in warfarin use (79-52%) and a progressive increase in overall direct oral anticoagulant use (21-48%). There were progressive decreases in the incidence of stroke/systemic embolism 1.9-1.4 events per 100 person years) and major bleeding (4.6-3.3 events per 100 person years) as well as all-cause costs between 2013 and 2016. CONCLUSIONS The proportions of patients with non-valvular atrial fibrillation who were not prescribed an oral anticoagulant decreased but remained high. We observed an increase in direct oral anticoagulant use that coincided with decreased incidence of clinical outcomes as well as decreasing total healthcare costs.
Collapse
Affiliation(s)
- Brett D Atwater
- Inova Heart and Vascular Institute, 4Th Floor Medical Directors Suite, 3300 Gallows Road, Falls Church, VA, 22042, USA.
| | | | | | | | | | | | - Jenny Jiang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, USA
| | | |
Collapse
|
2
|
Shaikh F, Wynne R, Castelino RL, Inglis SC, Davidson PM, Ferguson C. Practices, beliefs, and attitudes of clinicians in prescribing direct oral anticoagulants for obese adults with atrial fibrillation: a qualitative study. Int J Clin Pharm 2023:10.1007/s11096-023-01583-z. [PMID: 37253952 PMCID: PMC10228882 DOI: 10.1007/s11096-023-01583-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 03/24/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) and obesity affect over 60 and 650 million people, respectively. AIM This study aimed to explore clinician practices, beliefs, and attitudes towards the use of direct oral anticoagulants (DOACs) in obese adults (BMI ≥ 30 kg/m2) with AF. METHOD Semi-structured interviews via video conference were conducted with multidisciplinary clinicians from across Australia, with expertise in DOAC use in adults with AF. Clinicians were invited to participate using purposive and snowball sampling techniques. Data were analysed in NVIVO using thematic analysis. RESULTS Fifteen clinicians including cardiologists (n = 5), hospital and academic pharmacists (n = 5), general practitioners (n = 2), a haematologist, a neurologist and a clinical pharmacologist participated. Interviews were on average 31 ± 9 min. Key themes identified were: Health system factors in decision-making Disparities between rural and metropolitan geographic areas, availability of health services, and time limitations for in-patient decision-making, were described; Condition-related factors in decision-making Clinicians questioned the significance of obesity as part of decision-making due to the practical limitations of dose modification, and the rarity of the extremely obese cohort; Decision-making in the context of uncertainty Clinicians reported limited availability, reliability and awareness of primary evidence including limited guidance from clinical guidelines for DOAC use in obesity. CONCLUSION This study highlights the complexity of decision-making for clinicians, due to the limited availability, reliability and awareness of evidence, the intrinsic complexity of the obese cohort and limited guidance from clinical guidelines. This highlights the urgent need for contemporary research to improve the quality of evidence to guide informed shared decision-making.
Collapse
Affiliation(s)
- Fahad Shaikh
- School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, NSW, Australia.
| | - Rochelle Wynne
- School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, NSW, Australia
- The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Ronald L Castelino
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pharmacy Department, Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, Australia
| | - Sally C Inglis
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Sydney, NSW, Australia
| | | | - Caleb Ferguson
- School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, NSW, Australia
| |
Collapse
|
3
|
Deitelzweig S, Keshishian A, Kang A, Jenkins A, Atreja N, Schuler P, Jiang J, Yuce H, Sun X, Lip GYH. Delaying clinical events among patients with non-valvular atrial fibrillation treated with oral anticoagulants: Insights from the ARISTOPHANES study. Eur J Intern Med 2023; 108:37-42. [PMID: 36456387 DOI: 10.1016/j.ejim.2022.10.021] [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] [Received: 05/26/2022] [Revised: 09/30/2022] [Accepted: 10/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Oral anticoagulants (OACs) mitigate stroke and systemic embolism (SE) risk in non-valvular atrial fibrillation (AF) patients but can increase the risk of major bleeding (MB). This study analyzed the gains in event-free time for these outcomes among OAC treatment options represented in the ARISTOPHANES study. METHODS This sub-analysis consisted of NVAF patients who initiated warfarin, apixaban, dabigatran, or rivaroxaban from 01JAN2013-30SEP2015, with data pooled from Medicare and 4 US commercial claims databases. Propensity score matching was conducted between non-vitamin K antagonist OAC (NOAC) and warfarin cohorts in each database and results were pooled. Laplace regression was used to evaluate the delay in time to stroke/SE and MB events between NOACs and warfarin and between NOACs after the first 12-months of follow-up. RESULTS The population included 466,991 patients (167,413 warfarin; 108,852 apixaban; 37,724 dabigatran; and 153,002 rivaroxaban). Event-free time gain (95% confidence interval) for apixaban versus warfarin was 101 days (78- 124) for stroke/SE and 116 (103- 130) days for MB. The gain in event-free time for dabigatran versus warfarin was 45 days (3- 87) for stroke/SE and 92 (68- 116) days for MB. The gain in event-free time for rivaroxaban versus warfarin was 63 days (42- 84) for stroke/SE but event-free time decreased by 18 (-31-6) days for MB. CONCLUSIONS Over 12 months after initiation, apixaban and dabigatran conferred progressive increases in event free time for stroke/SE and MB vs warfarin, whereas rivaroxaban conferred an increase in stroke/SE-free time but a loss in MB-free time vs warfarin.
Collapse
Affiliation(s)
- Steven Deitelzweig
- Ochsner Clinic Foundation, Department of Hospital Medicine, New Orleans, LA, USA and The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA.
| | | | - Amiee Kang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - Nipun Atreja
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - Jenny Jiang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, USA
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
4
|
Oral anticoagulants: a systematic overview of reviews on efficacy and safety, genotyping, self-monitoring, and stakeholder experiences. Syst Rev 2022; 11:232. [PMID: 36303235 PMCID: PMC9615370 DOI: 10.1186/s13643-022-02098-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/08/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND This systematic overview was commissioned by England's Department of Health and Social Care (DHSC) to assess the evidence on direct (previously 'novel') oral anticoagulants (OACs), compared with usual care, in adults, to prevent stroke related to atrial fibrillation (AF), and to prevent and treat venous thromboembolism (VTE). Specifically, to assess efficacy and safety, genotyping, self-monitoring, and patient and clinician experiences of OACs. METHODS We searched MEDLINE, Embase, ASSIA, and CINAHL, in October, 2017, updated in November 2021. We included systematic reviews, published from 2014, in English, assessing OACs, in adults. We rated review quality using AMSTAR2 or the JBI checklist. Two reviewers extracted and synthesised the main findings from the included reviews. RESULTS We included 49 systematic reviews; one evaluated efficacy, safety, and cost-effectiveness, 17 assessed genotyping, 23 self-monitoring or adherence, and 15 experiences (seven assessed two topics). Generally, the direct OACs, particularly apixaban (5 mg twice daily), were more effective and safer than warfarin in preventing AF-related stroke. For VTE, there was little evidence of differences in efficacy between direct OACs and low-molecular-weight heparin (prevention), warfarin (treatment), and warfarin or aspirin (secondary prevention). The evidence suggested that some direct OACs may reduce the risk of bleeding, compared with warfarin. One review of genotype-guided warfarin dosing assessed AF patients; no significant differences in stroke prevention were reported. Education about OACs, in patients with AF, could improve adherence. Pharmacist management of coagulation may be better than primary care management. Patients were more adherent to direct OACs than warfarin. Drug efficacy was highly valued by patients and most clinicians, followed by safety. No other factors consistently affected patients' choice of anticoagulant and adherence to treatment. Patients were more satisfied with direct OACs than warfarin. CONCLUSIONS For stroke prevention in AF, direct OACs seem to be more effective and safer than usual care, and apixaban (5 mg twice daily) had the best profile. For VTE, there was no strong evidence that direct OACs were better than usual care. Education and pharmacist management could improve coagulation control. Both clinicians and patients rated efficacy and safety as the most important factors in managing AF and VTE. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017084263-one deviation; efficacy and safety were from one review.
Collapse
|
5
|
Al-Maawali MS, Al-Naamani HH, Mokadem LN, Al-Maawali G, Salman B, Al-Zakwani I. Comparative Effectiveness and Safety of Rivaroxaban and Warfarin for Stroke Prevention in Patients with Non-Valvular Atrial Fibrillation in an Omani Tertiary Care Hospital. Open Cardiovasc Med J 2022. [DOI: 10.2174/18741924-v16-e2202281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective:
The aim of the study was to compare the effectiveness and safety of rivaroxaban and warfarin as well as to determine the appropriateness of dosing and prescribing of rivaroxaban in Omani patients with non-valvular atrial fibrillation (NVAF).
Methods:
This retrospective cohort study was conducted using the Royal Hospital data registry. The study included all adults newly diagnosed with NVAF and treated with rivaroxaban or warfarin. The outcomes measured include ischaemic stroke, gastrointestinal bleeding (GIB), non-gastrointestinal bleeding (NGIB), as well as appropriateness of dosing and prescribing of rivaroxaban.
Results:
The analysis included 96 rivaroxaban users and 183 warfarin users; 51% of the cohort included males. There were no significant differences observed in the risk of ischaemic stroke between the two groups (hazard ratio (HR), 1.1; 95% confidence interval (CI): 0.4-3.4; p=0.8). However, those on rivaroxaban exhibited a significantly higher rate of GIB compared to those on warfarin (HR, 5.9; 95% CI: 2.9-11.7; p=0.001). There were no differences observed with regards to NGIB between the two groups (HR, 0.9; 95% CI: 0.4-1.9; p=0.8). Dosing and prescribing of rivaroxaban were found to be appropriate in 89% of the patients, with only 6% being prescribed an inappropriately lower dose.
Conclusion:
The study demonstrated no significant differences in the risk of ischaemic stroke or NGIB between rivaroxaban and warfarin groups in newly diagnosed NVAF patients. However, rivaroxaban users were found to have a significantly higher risk of GIB. Rivaroxaban was appropriately prescribed to the majority of the patients, and only a small proportion of the group received an inappropriately lower dose of rivaroxaban.
Collapse
|
6
|
Farinha JM, Jones ID, Lip GYH. Optimizing adherence and persistence to non-vitamin K antagonist oral anticoagulant therapy in atrial fibrillation. Eur Heart J Suppl 2022; 24:A42-A55. [PMID: 35185408 PMCID: PMC8850710 DOI: 10.1093/eurheartj/suab152] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke, which can be prevented by the use of oral anticoagulation. Although non-vitamin K antagonist oral anticoagulants (NOACs) have become the first choice for stroke prevention in the majority of patients with non-valvular AF, adherence and persistence to these medications remain suboptimal, which may translate into poor health outcomes and increased healthcare costs. Factors influencing adherence and persistence have been suggested to be patient-related, physician-related, and healthcare system-related. In this review, we discuss factors influencing patient adherence and persistence to NOACs and possible problem solving strategies, especially involving an integrated care management, aiming for the improvement in patient outcomes and treatment satisfaction.
Collapse
Affiliation(s)
- José Maria Farinha
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Ian D Jones
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- School of Nursing and Allied Health, Liverpool John Moores University, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Capiau A, Mehuys E, Dhondt E, De Backer T, Boussery K. Physicians' and pharmacists' views and experiences regarding use of direct oral anticoagulants in clinical practice. Br J Clin Pharmacol 2021; 88:1856-1865. [PMID: 34625983 DOI: 10.1111/bcp.15106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 09/16/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
AIM Direct oral anticoagulants (DOACs) are increasingly used compared to vitamin K antagonists (VKAs). Guidelines advocate a structured multidisciplinary approach in the management of patients treated with DOACs. The aim of this study was to assess the views and experiences of physicians and pharmacists regarding DOAC use in clinical practice. METHODS An online questionnaire was sent to both primary (general practitioners [GPs], community pharmacists) and secondary healthcare professionals (cardiologists, residents in internal medicine and hospital pharmacists) between March and July 2020. The questionnaire covered four topics: (i) current practice, (ii) prescribing behaviour (only for physicians), (iii) self-perceived knowledge about DOACs and (iv) views and opinions about DOACs versus VKAs. RESULTS In total, 110 physicians and 111 pharmacists completed the survey. Healthcare professionals in secondary care had more experience with DOACs and felt more confident with higher self-perceived knowledge about DOACs compared to their colleagues in primary care. Healthcare professionals' self-perceived knowledge was more or less complementary, for example physicians felt less confident in managing drug-drug interactions (DDIs) where pharmacists reported being more confident in this topic. Physicians reported uncertainties on the potential impact of risk factors - such as older age, lower body weight and DDIs - on appropriate DOAC dosing. CONCLUSION Complementarity in physicians' and pharmacists' self-perceived knowledge levels of DOACs may facilitate and necessitate future multidisciplinary collaboration initiatives for the management and follow-up of DOAC patients.
Collapse
Affiliation(s)
- Andreas Capiau
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Els Mehuys
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Eline Dhondt
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Tine De Backer
- Department of Cardiology, Heart Centre, Ghent University Hospital, Ghent, Belgium.,Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Koen Boussery
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
9
|
Shen J, Li M, Cao S, Lu Z, Xia Y, Chen S, Bi Y, Cai Z, Hu B, Cao F. Neurologists' attitudes and options for anticoagulation therapy in central China. Int J Clin Pract 2021; 75:e14305. [PMID: 33930249 DOI: 10.1111/ijcp.14305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 04/27/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS We aim to find out the factors affecting the use of anticoagulants and the intensity of their choices, and to establish a basis for improving neurologists' effective implementation of the guidelines. METHODS A cross-sectional study is conducted in Hubei province in central China. Each neurologist completes a standard-structured anonymous questionnaire through face-to-face interviews. The problems include the attitude and options about anticoagulant therapy. RESULTS A total of 611 neurologists from 38 hospitals respond to this survey. For the best treatment of atrial fibrillation, more than 80% of physicians choose anticoagulant therapy. For patients with atrial fibrillation and cerebral infarction, physicians think that Warfarin is the preferred drug as high as 93.8%. Among the anticoagulant drugs ever used by clinicians, the use rate of Warfarin is 93.8%, but the use rate of direct oral anticoagulants is insufficient. The use of direct oral anticoagulants is related to the educational level and the geographical location of the hospital. Bleeding risk is the first reason influencing clinicians' choice of Warfarin, accounts for 88.9%. 97.7% of the clinicians recommend patients with Warfarin to regularly monitor the INR, but the frequency of monitoring is inconsistent. Clinicians have a high willingness to learn about AF, but the proportion of hospitals that carry out appropriate training is low. CONCLUSIONS There are still some gaps with the guidelines on the choice of anticoagulant drugs. Neurologists have positive attitude towards anticoagulant therapy and a strong willingness to learn, but the corresponding training is lacking. Continuous professional training is necessary.
Collapse
Affiliation(s)
- Jing Shen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Neurology, The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Man Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiyi Cao
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zuxun Lu
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuanpeng Xia
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shengcai Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Bi
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhuoyuan Cai
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fei Cao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Murphy A, Brosnan S, McCarthy S, O'Raghallaigh P, Bradley C, Kirby A. World Café approach: exploring the future vision of oral anticoagulants for patients with atrial fibrillation (AF) in Ireland. BMJ Open 2020; 10:e036493. [PMID: 32973054 PMCID: PMC7517561 DOI: 10.1136/bmjopen-2019-036493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/08/2020] [Accepted: 08/20/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To explore and reflect on the current anticoagulation therapy offered to patients with atrial fibrillation (AF), potential challenges and the future vision for oral anticoagulants for patients with AF and healthcare professionals in Ireland. DESIGN A multistakeholder focus group using a World Café approach. PARTICIPANTS Nine participants from academic, clinical and health backgrounds attended the focus group together with a facilitator. RESULTS Enhanced patient empowerment; more effective use of technology and developing system-based medical care pathways would provide improved supports for AF management. The challenges in providing these include cost and access issues, the doctor-patient relationship and the provision of education. While consensus for developing evidence-based pathways to maximise efficiency and effectiveness of AF treatment was evident, it would require a shared vision between stakeholders of integrated care. The benefits of embracing technological advances for clinicians and patients were evident; however, clinicians indicate this can increase pressure on already stretched resources; coupled with institutional barriers (including scarce resources) arising from the complex nature of anticoagulation for patients with AF, which emerged strongly. Including the unpredictable nature of warfarin, hidden costs associated with monitoring, adverse clinical effects, different patient cohorts (including those prescribed anticoagulant for the first time vs those switching from warfarin to a new oral anticoagulant (NOAC)), non-adherence concerns and undesirable impacts on patients' daily lives. CONCLUSIONS While anticoagulation therapy for patients with AF using NOACs has been widely adopted and is diffusing into routine practice, significant operationalisation issues and barriers to effective treatment/management persist. The reflections reported in this study are a catalyst for future discussion and research.
Collapse
Affiliation(s)
- Aileen Murphy
- Department of Economics, Cork University Business School, University College Cork, Cork, Ireland
| | - Stephen Brosnan
- Department of Economics, Cork University Business School, University College Cork, Cork, Ireland
| | - Stephen McCarthy
- Department of Business Information Systems, Cork University Business School, University College Cork, Cork, Ireland
| | - Paidi O'Raghallaigh
- INFANT Research Centre, University College Cork, Cork, Ireland
- Cork University Business School, University College London, London, UK
| | - Colin Bradley
- Department of General Practice, University College Cork, Cork, Ireland
| | - Ann Kirby
- Department of Economics, Cork University Business School, University College Cork, Cork, Ireland
| |
Collapse
|
12
|
Hillarp A, Strandberg K, Gustafsson KM, Lindahl TL. Unveiling the complex effects of direct oral anticoagulants on dilute Russell's viper venom time assays. J Thromb Haemost 2020; 18:1866-1873. [PMID: 32294291 DOI: 10.1111/jth.14829] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/02/2020] [Accepted: 04/02/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Dilute Russell viper venom time (dRVVT) assays can be affected by direct oral anticoagulants (DOACs), which may cause false-positive results. However, there are conflicting results indicating significant differences between different reagents and DOACs. OBJECTIVES To evaluate the effect of DOACs on dRVVT assays. MATERIAL AND METHODS Samples were prepared by adding DOAC (dabigatran, rivaroxaban, apixaban, or edoxaban) to pooled normal plasma in the concentration range 0 to 800 µg/L. Six integrated dRVVT reagents were used, all composed of a screen assay (low phospholipid content) and a confirm assay (high phospholipid content). The screen/confirm dRVVT results were expressed as normalized ratios. To further evaluate the observed differences between tests and DOACs, addition of synthetic phospholipids was used. RESULTS The dRVVT ratios increased dose dependently for all DOACs, with four of the six tests and the DOAC rivaroxaban having the greatest effect. With one test, the ratios were almost unaffected with increasing DOAC concentration, whereas another test revealed a negative dose dependency for all DOACs. Variable DOAC effects can be explained by different effects on dRVVT screen and confirm clotting time. Adding synthetic phospholipids to samples containing rivaroxaban resulted in greatly reduced screen clotting times and thereby lower calculated dRVVT ratios. CONCLUSIONS There is a great variability in the dRVVT test result with different DOACs. The dRVVT ratios are unaffected for some reagents and this can be explained by an equal dose-dependent effect on both screen and confirm assays. The phospholipid type and content of the different reagents may contribute to the observed differences.
Collapse
Affiliation(s)
- Andreas Hillarp
- Department of Clinical Chemistry and Transfusion Medicine, Halland County Hospital, Halmstad, Sweden
| | - Karin Strandberg
- Clinical Chemistry, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Kerstin M Gustafsson
- Department of Biomedical and Clinical Sciences, Clinical Chemistry, Linköping University, Linköping, Sweden
| | - Tomas L Lindahl
- Department of Biomedical and Clinical Sciences, Clinical Chemistry, Linköping University, Linköping, Sweden
| |
Collapse
|
13
|
Bonaldo G, Vaccheri A, Motola D. Direct‐acting oral anticoagulants and alopecia: The valuable support of postmarketing data. Br J Clin Pharmacol 2020; 86:1654-1660. [DOI: 10.1111/bcp.14221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/19/2019] [Accepted: 01/02/2020] [Indexed: 12/31/2022] Open
Affiliation(s)
- Giulia Bonaldo
- Unit of Pharmacology, Department of Medical and Surgical SciencesUniversity of Bologna Bologna Italy
| | - Alberto Vaccheri
- Unit of Pharmacology, Department of Medical and Surgical SciencesUniversity of Bologna Bologna Italy
| | - Domenico Motola
- Unit of Pharmacology, Department of Medical and Surgical SciencesUniversity of Bologna Bologna Italy
| |
Collapse
|
14
|
El Hussein MT, Cuncannon A. DARE to Prescribe: Strategy to Guide Direct Oral Anticoagulant Therapy. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
15
|
Generalova D, Cunningham S, Leslie SJ, Rushworth GF, Mciver L, Stewart D. Prescribers' perceptions of benefits and limitations of direct acting oral anticoagulants in non-valvular atrial fibrillation. Pharm Pract (Granada) 2020; 18:1936. [PMID: 32587643 PMCID: PMC7308911 DOI: 10.18549/pharmpract.2020.2.1936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 06/08/2020] [Indexed: 11/23/2022] Open
Abstract
Background: There is an acknowledged lack of robust and rigorous research focusing on the perspectives of those prescribing direct acting oral anticoagulants (DOACs) for non-valvular atrial fibrillation (AF). Objective: The objective was to describe prescribers’ experiences of using DOACs in the management of non-valvular AF, including perceptions of benefits and limitations. Methods: A cross-sectional survey of prescribers in a remote and rural area of Scotland. Among other items, the questionnaire invited free-text description of positive and negative experiences of DOACs, and benefits and limitations. Responses were independently analysed by two researchers using a summative content analysis approach. This involved counting and comparison, via keywords and content, followed by interpretation and coding of the underlying context into themes. Results: One hundred and fifty-four responses were received, 120 (77.9%) from physicians, 18 (11.7%) from nurse prescribers and 10 (6.4%) from pharmacist prescribers (6 unidentified professions). Not having to monitor INR was the most cited benefit, particularly for prescribers and patients in remote and rural settings, followed by potentially improved patient adherence. These benefits were reflected in respondents’ descriptions of positive experiences and patient feedback. The main limitations were the lack of reversal agents, cost and inability to monitor anticoagulation status. Many described their experiences of adverse effects of DOACs including fatal and non-fatal bleeding, and upper gastrointestinal disturbances. Conclusions: While prescribers have positive experiences and perceive benefits of DOACs, issues such as adverse effects and inability to monitor anticoagulation status merit further monitoring and investigation. These issues are particularly relevant given the trajectory of increased prescribing of DOACs.
Collapse
Affiliation(s)
- Daria Generalova
- MSc. School of Pharmacy and Life Sciences, Robert Gordon University. Aberdeen (United Kingdom).
| | - Scott Cunningham
- PhD. School of Pharmacy and Life Sciences, Robert Gordon University. Aberdeen (United Kingdom).
| | - Stephen J Leslie
- PhD. Department of Medicine, Raigmore Hospital. Inverness (United Kingdom).
| | - Gordon F Rushworth
- MSc. Highland Pharmacy Education and Research Centre, Centre for Health Science. Inverness (United Kingdom).
| | - Laura Mciver
- MSc. Healthcare Improvement Scotland. Glasgow (United Kingdom).
| | - Derek Stewart
- PhD. College of Pharmacy, QU Health, Qatar University. Doha (Qatar).
| |
Collapse
|
16
|
Nyamu DG, Guantai AN, Osanjo GO, Godman B, Aklillu E. Profiles of patients on warfarin anticoagulation therapy in a leading tertiary referral hospital in Kenya; findings and implications for Kenya. Expert Rev Cardiovasc Ther 2020; 18:165-173. [DOI: 10.1080/14779072.2020.1734452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- David Gitonga Nyamu
- Department of Pharmaceutics & Pharmacy Practice, School of Pharmacy, University of Nairobi, Nairobi, Kenya
| | - Anastasia Nkatha Guantai
- Department of Pharmacology & Pharmacognosy, School of Pharmacy, University of Nairobi, Nairobi, Kenya
| | - George Oyamo Osanjo
- Department of Pharmacology & Pharmacognosy, School of Pharmacy, University of Nairobi, Nairobi, Kenya
| | - Brian Godman
- Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Department of Pharmacy, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
| |
Collapse
|
17
|
Generalova D, Cunningham S, Leslie SJ, Rushworth G, McIver L, Stewart D. Prescribers' views and experiences of using direct acting oral anticoagulants in the management of nonvalvular atrial fibrillation: A survey in remote and rural Scotland. Br J Clin Pharmacol 2019; 85:2414-2422. [PMID: 31313317 DOI: 10.1111/bcp.14069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/03/2019] [Accepted: 07/12/2019] [Indexed: 12/25/2022] Open
Abstract
AIMS A recent systematic review highlighted the lack of robust studies on prescribers' perspectives of direct-acting oral anticoagulants (DOACs) for nonvalvular atrial fibrillation. The aim was to determine prescribers' views and experiences of prescribing DOACs. METHODS A cross-sectional survey of prescribers in a remote and rural area of Scotland. Survey items were: demographics; prescribing of DOACs; views of potential influences on DOAC prescribing; knowledge of prescribing guidelines; and experiences. Items on potential influences were based on the Theoretical Domains Framework. Data were analysed using descriptive and inferential statistics, and content analysis of responses to open questions. Principal component analysis was performed on the items of potential influences. RESULTS In total, 154 responses were received, 120 (77.9%) from doctors, 18 (11.7%) from nurse prescribers and 10 (6.4%) from pharmacist prescribers (6 missing). Principal component analysis of the Theoretical Domains Framework items of potential influences gave 4 components. Component scores for (i) role of professionals, their knowledge and skills and (ii) influences on prescribing were positive. Those for (iii) consequences of prescribing and (iv) monitoring for safety and effectiveness were more neutral. There were low levels of agreement for statements relating to DOACs being more effective, safer and cost-effective than warfarin. There were similar responses around the complexity of bleeding management and detection of over and under-anticoagulation. CONCLUSION This study has identified several key issues of DOAC prescribing (e.g. bleeding management) hence further emphasis is required in continuing professional development and during guideline implementation and evaluation.
Collapse
Affiliation(s)
- Daria Generalova
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - Scott Cunningham
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | | | - Gordon Rushworth
- Highland Pharmacy Education and Research Centre, Centre for Health Science, Inverness, UK
| | | | - Derek Stewart
- College of Pharmacy, Qatar University Health, Qatar University, Doha, Qatar
| |
Collapse
|
18
|
Afzal SK, Hasan SS, Babar ZUD. A systematic review of patient-reported outcomes associated with the use of direct-acting oral anticoagulants. Br J Clin Pharmacol 2019; 85:2652-2667. [PMID: 31077431 DOI: 10.1111/bcp.13985] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/02/2019] [Accepted: 04/24/2019] [Indexed: 12/26/2022] Open
Abstract
AIMS Patient-reported outcomes (PROs) are a distinctive method of evaluating patient response to health care or treatment. This systematic review aimed to analyse the impact of PROs in patients on direct oral anticoagulant (DOAC) treatment, prescribed for any indication (e.g. venous thromboembolism treatment or atrial fibrillation) using controlled trials (CT) and real-world observational studies (OS). METHODS A systematic search of articles was conducted according to PRISMA guidelines using databases, with the last update in November 2018. The Cochrane Collaboration tool for assessing bias in randomized CTs and the Newcastle-Ottawa Scale adapted for cross-sectional studies were used. Outcomes evaluated were related to health-related quality of life (HRQoL), satisfaction, adherence and compliance. RESULTS Twenty-one original studies (6 CT, 15 OS) were included. HRQoL was assessed by 6 (1 CT, 5 OS) studies and reported that HRQoL scores were similar in patients on DOACs and warfarin. Patients prescribed DOACs presented higher HRQoL scores which were attributed to lack of intense monitoring required compared with warfarin but this was not statistically significant. The majority of studies (5 CT, 9 OS) investigated patient-reported satisfaction, indicating greater satisfaction with DOACs with significantly lower burden and increased benefit scores for patients on DOACs. Patient-reported expectations, compliance and adherence were similar for patients on DOACs and warfarin. CONCLUSION Patients appear to prefer treatment with DOACs vs warfarin. This is shown by the higher quality of life, satisfaction and adherence described in the studies. However, heterogeneity in the analysed studies does not allow firm conclusions.
Collapse
Affiliation(s)
| | - Syed Shahzad Hasan
- University of Huddersfield, Queensgate, Huddersfield, West Yorkshire, UK
| | | |
Collapse
|
19
|
Generalova D, Cunningham S, Leslie SJ, Rushworth GF, McIver L, Stewart D. A systematic review of clinicians' views and experiences of direct-acting oral anticoagulants in the management of nonvalvular atrial fibrillation. Br J Clin Pharmacol 2018; 84:2692-2703. [PMID: 30112826 DOI: 10.1111/bcp.13739] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/02/2018] [Accepted: 08/06/2018] [Indexed: 12/11/2022] Open
Abstract
AIMS While a plethora of systematic reviews have provided evidence of efficacy, effectiveness and safety of direct-acting oral anticoagulants (DOACs) in the management of nonvalvular atrial fibrillation, there has been little emphasis on clinicians' perspectives. This systematic review aimed to critically appraise, synthesize and present the available evidence of clinicians' views and experiences. METHODS Studies published in English from January 2006 to July 2017 reporting the views and/or experiences of doctors, nurses or pharmacists on any individual DOAC or as a pharmacological group were included. Studies were assessed for quality by two researchers, data extracted and findings synthesized using a narrative approach. RESULTS Following exclusion of duplicates, 777 titles, 394 abstracts and 196 studies were screened. Ten studies were included in the review, nine of which were quantitative (cross-sectional surveys) and one qualitative (semistructured interviews), with marked heterogeneity in outcomes reported. Studies were conducted exclusively in Europe and the USA. In those studies reporting clinician preference, DOACs were first choice over warfarin in naïve patients, based on perceptions of evidence of effectiveness equivalent or superior to warfarin and superior safety. Other advantageous factors were in those with an unstable International Normalized Ratio and likely to miss appointments. There were, however, concerns relating to management of over-anticoagulation and experiences of observed bleeding rates. CONCLUSION There is a limited evidence base of clinicians' perspectives of DOACs, necessitating further research, particularly given the trajectory of increased use worldwide.
Collapse
Affiliation(s)
- Daria Generalova
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - Scott Cunningham
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | | | - Gordon F Rushworth
- Highland Pharmacy Education and Research Centre, Centre for Health Science, Inverness, UK
| | | | - Derek Stewart
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| |
Collapse
|