Values and preferences for oral antithrombotic therapy in patients with atrial fibrillation: physician and patient perspectives

Country and health expenditure are major predictors of withholding anticoagulation in atrial fibrillation patients at high risk of stroke

BACKGROUND

Guidelines for patients with atrial fibrillation (AF) at high thromboembolic risk recommend oral anticoagulants (OACs) for preventing stroke and systemic embolism (SE). The reasons for guideline non-adherence are still unclear.

AIM

The aim is to identify clinical, demographic and non-patient characteristics associated with withholding OAC in patients with AF at high stroke risk.

METHODS

Patients in the Global Anticoagulant Registry in the FIELD-AF, newly diagnosed with AF between March 2010 and August 2016, and with CHA2DS2-VASc Score≥2 (excluding sex), were grouped by OAC treatment at enrolment. Factors associated with OAC non-use were analysed by multivariable logistic regression.

RESULTS

Of 40 416 eligible patients, 12 126 (30.0%) did not receive OACs at baseline. Globally, OAC prescription increased over time, from 60.4% in 2010-2011 to 74.7% in 2015-2016. Country of enrolment was the major predictor for OAC withholding (χ2-df=2576). Clinical predictors of OAC non-use included type of AF (χ2-df=404), history of bleeding (χ2-df=263) and vascular disease (χ2-df=99). OACs were used most frequently around the age of 75 years and decreasingly with younger as well as older age beyond 75 years (χ2-df=148). Non-cardiologists (χ2-df=201) and emergency room physicians (χ2-df=14) were less likely to prescribe OACs. OAC prescription correlated positively with country health expenditure.

CONCLUSIONS

Approximately one out of three AF patients did not receive OAC, while eligible according to the guidelines. Country of enrolment was the major determinant of anticoagulation strategy, while higher country health expenditure was associated with lower likelihood of withholding anticoagulation.

Importance of patient engagement in the conduct of pragmatic multicenter randomized controlled trials: The ADAPTABLE experience

BACKGROUND/AIMS

Actively engaging patient partners in the conduct of trials is crucial to ensure the studies answer genuine, patient-centered, unmet clinical needs, and to facilitate participant recruitment and retention. The aim of this article is to demonstrate the feasibility of patient engagement within a large pragmatic multicenter randomized controlled trial, specifically for the purposes of dissemination of study information/updates and to favorize recruitment and retention.

METHODS

In the patient-centric, pragmatic ADAPTABLE randomized trial, transparent and timely dissemination of information on the study updates to the trial participants was undertaken to create meaningful engagement and to facilitate retention. A national panel of patient partners, the Adaptors, were directly involved in this information dissemination strategy, and study participants were engaged both nationally and locally to design recruitment methods iteratively during the conduct of the trial. All Adaptors had a lived experience with cardiovascular disease.

RESULTS

Adaptors attended bi-weekly meetings facilitated by the director of the study's patient-powered research network. They drafted and/or edited newsletters and ad hoc educational information written in a lay-friendly manner for study participants, which were regularly distributed to the ADAPTABLE community, in addition to online forums where participants could share their experience of their involvement in ADAPTABLE. To spur recruitment, a patient-driven initiative was to draft letters sharing their story, which were distributed by the local study teams. Patient partners thought that using patients' voice to provide their perspectives on why they believed this project was important would be more engaging for prospective participants than traditional approaches.

CONCLUSIONS

ADAPTABLE's experience has demonstrated the feasibility of engaging patients as partners in the conduct of a large-scale, multi-center, pragmatic randomized controlled trial. Future trials should embrace and iteratively improve this model by engaging patient partners as early as study protocol development and funding applications, and quantify its impact on the effectiveness and value of the trial.

Psychometric Validation of the Chinese Version of the Atrial Fibrillation Knowledge Scale in Chinese Patients With Atrial Fibrillation

BACKGROUND

Assessment of patients' knowledge on atrial fibrillation (AF) and its management is important for evaluating their learning needs. However, a validated and comprehensive instrument to be used among Chinese patients is yet to be developed.

OBJECTIVES

The aim of this study was to develop and validate the Chinese version of the Atrial Fibrillation Knowledge Scale (AFKS-C) in Chinese patients.

METHODS

The 11-item AFKS was translated, and then content and face validations were conducted by an expert panel and patients with AF. A sample of 255 patients with AF was recruited from a university-affiliated hospital to evaluate its psychometric properties. The internal consistency and test-retest reliability were evaluated using the Kuder-Richardson formula 20 and κ statistics. Item analysis determined the item difficulty index and item discrimination coefficients. Factorial and discriminant validity were evaluated using exploratory factor analysis and the known-groups method.

RESULTS

The content validity index of the AFKS-C was 0.94, and the Kuder-Richardson formula 20 value was 0.60. The difficulty indices of the items ranged from 0.36 to 0.89, and the point-biserial coefficients of the items ranged from 0.122 to 0.255, indicating sufficient discriminatory ability. The test-retest reliability was acceptable, because the κ values ranged from 0.234 to 0.710. The principal axis factoring analysis indicated a 3-factor structure that explained 50.4% of the total variance. The AFKS-C also demonstrated satisfactory discriminant validity, having yielded significantly different scores between patients with newly diagnosed and established AF.

CONCLUSION

The AFKS-C has acceptable psychometric properties and can be used to measure the knowledge of patients and evaluate the effects of patient education programs.

Assessment and Mitigation of Bleeding Risk in Atrial Fibrillation and Venous Thromboembolism: Executive Summary of a European and Asia-Pacific Expert Consensus Paper

While there is a clear clinical benefit of oral anticoagulation in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision for initiating and continuing anticoagulation is often based on a careful assessment of both thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static "one-off" assessment based on baseline factors but is dynamic, being influenced by aging, incident comorbidities, and drug therapies. In this executive summary of a European and Asia-Pacific Expert Consensus Paper, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with a view to summarizing "best practice" when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, and review established bleeding risk factors and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism, are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.

Management of Antiplatelet and Anticoagulant Agents before and after Polypectomy

Antithrombotic medications, including antiplatelet drugs and anticoagulants, are widely prescribed to prevent thromboembolic disease. There is limited evidence informing gastroenterologists of the management of patients on antithrombotic medications undergoing colonoscopy and polypectomy. A patient's risk of thromboembolism versus postpolypectomy bleeding should be carefully considered, incorporating patient preferences concerning benefits and harms of temporary antithrombotic interruption. We will review the available consensus guidelines, current literature, and strategies to mitigate the risk of bleeding following polypectomy. These will be interpreted in the framework of shared decision-making with the patient to arrive at the safest solution best aligned with the patient's preferences.

Assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A Position Paper from the ESC Working Group on Thrombosis, in collaboration with the European Heart Rhythm Association, the Association for Acute CardioVascular Care and the Asia-Pacific Heart Rhythm Society

Whilst there is a clear clinical benefit of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision to initiate and continue anticoagulation is often based on a careful assessment of both the thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static 'one off' assessment based on baseline factors but is dynamic, being influenced by ageing, incident comorbidities, and drug therapies. In this Consensus Document, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with the view to summarizing 'best practice' when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, review established bleeding risk factors, and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.

Patients' and clinicians' perceptions of oral anticoagulants in atrial fibrillation: a systematic narrative review and meta-analysis

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.

[GRADE guidelines 20: Assessing the certainty of evidence in the importance of outcomes or values and preferences-inconsistency, imprecision, and other domains]

OBJECTIVE

To provide Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidance for assessing inconsistency, imprecision, and other domains for the certainty of evidence about the relative importance of outcomes.

STUDY DESIGN AND SETTING

We applied the GRADE domains to rate the certainty of evidence in the importance of outcomes to several systematic reviews, iteratively reviewed draft guidance, and consulted GRADE members and other stakeholders for feedback.

RESULTS

We describe the rationale for considering the remaining GRADE domains when rating the certainty in a body of evidence for the relative importance of outcomes. As meta-analyses are not common in this context, inconsistency and imprecision assessments are challenging. Furthermore, confusion exists about inconsistency, imprecision, and true variability in the relative importance of outcomes. To clarify this issue, we suggest that the true variability is neither equivalent to inconsistency nor imprecision. Specifically, inconsistency arises from population, intervention, comparison and outcome and methodological elements that should be explored and, if possible, explained. The width of the confidence interval and sample size inform judgments about imprecision. We also provide suggestions on how to detect publication bias and discuss the domains to rate up the certainty.

CONCLUSION

We provide guidance and examples for rating inconsistency, imprecision, and other domains for a body of evidence describing the relative importance of outcomes.

[GRADE Guidelines: 19. Assessing the certainty of evidence in the importance of outcomes or values and preferences: Risk of bias and indirectness]

OBJECTIVES

The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group defines patient values and preferences as the relative importance patients place on the main health outcomes. We provide GRADE guidance for assessing the risk of bias and indirectness domains for certainty of evidence about the relative importance of outcomes.

STUDY DESIGN AND SETTING

We applied the GRADE domains to rate the certainty of evidence in the importance of outcomes to several systematic reviews, iteratively reviewed draft guidance and consulted GRADE members and other stakeholders for feedback.

RESULTS

This is the first of two articles. A body of evidence addressing the importance of outcomes starts at "high certainty"; concerns with risk of bias, indirectness, inconsistency, imprecision, and publication bias lead to downgrading to moderate, low, or very low certainty. We propose the following subdomains of risk of bias: selection of the study population, missing data, the type of measurement instrument, and confounding; we have developed items for each subdomain. The population, intervention, comparison, and outcome elements associated with the evidence determine the degree of indirectness.

CONCLUSION

This article provides guidance and examples for rating the risk of bias and indirectness for a body of evidence summarizing the importance of outcomes.

What are the Relevant Outcomes of the Periodic Health Examination? A Comparison of Citizens' and Experts' Ratings

PURPOSE

Despite evidence from clinical guideline development that physicians and patients show discordance in what they consider important in outcome selection and prioritization, it is unclear to what extent outcome preferences are concordant between experts and citizens when it comes to the context of primary prevention. Therefore, the objective of this study was to assess whether expert judgments about the importance of beneficial and harmful outcomes differ from citizen preferences when considering intervention options for a periodic health examination (PHE) program.

PARTICIPANTS AND METHODS

We conducted an online survey using a modified Delphi approach. The target population for the survey consisted of citizens who had attended the PHE (n=18) and experts who made evidence-based recommendations (n=11). Citizens and experts assigned a score on a 9-point Likert scale for each outcome of 14 interventions. We analyzed the intragroup agreement based on Krippendorff's alpha and the intergroup agreement using the cube root product measure (CRPm). We further tested for significant differences between the groups using the Mann U-test.

RESULTS

Agreements within the groups of citizens and experts varied across the interventions and tended to be poor (α ≤0 to 0.20) or fair (α = 0.21 to 0.40), with three exceptions showing moderate agreement (α = 0.44 to 0.55). The agreements between the citizens and experts across the interventions was fair (CRPm = 0.28) during the first Delphi rating round. The mean differences between the citizens and experts on the Likert scale ranged from 0.0 to 3.8 during the first rating round and from 0.0 to 3.3 during the second. Across interventions, the citizens rated the outcomes as more important than the experts did (p<0.01). Individual participants' ratings varied substantially.

CONCLUSION

Because experts generally underestimated the outcomes' importance to citizens, the involvement of citizens in guideline panels for preventive services is important.

Improving the Design of Future PCI Trials for Stable Coronary Artery Disease: JACC State-of-the-Art Review

The role of percutaneous coronary interventions in addition to medical therapy for patients with stable coronary artery disease continues to be debated in routine clinical practice, despite more than 2 decades of randomized controlled trials. The residual uncertainty arises from particular challenges facing revascularization trials. Which endpoint do doctors care about, and which do patients care about? Which participants should be enrolled? What background medical therapy should we use? When is placebo control relevant? In this paper, we discuss how these questions can be approached and examine the merits and disadvantages of possible options. Engaging multiple stakeholders, including patients, researchers, regulators, and funders, to ensure the design elements are methodologically valid and clinically meaningful should be an aspirational goal in the development of future trials.

Using the Threshold Technique to Elicit Patient Preferences: An Introduction to the Method and an Overview of Existing Empirical Applications

Patient preference information (PPI) is a topic of interest to regulators and industry. One of many known methods for eliciting PPI is the threshold technique (TT). However, empirical studies of the TT differ from each other in many ways and no effort to date has been made to summarize them or the evidence regarding the performance of the method. We sought to describe the TT and summarize the empirical applications of the method. Forty-three studies were reviewed. Most studies estimated the minimum level of benefit required to make a treatment worthwhile, and over half estimated the maximum level of risk patients would accept to achieve a treatment benefit. The evidence demonstrates that the TT can be used to elicit multiple types of thresholds and can be used to explore preference heterogeneity and preference non-linearity. Some evidence suggests that the method may be sensitive to anchoring and shift-framing effects; however, no evidence suggests that the method is more or less sensitive to these potential biases than other stated-preference methods. The TT may be a viable method for eliciting PPI to support regulatory decision-making; however, additional understanding of the performance of this method may be needed. Future research should focus on TT performance compared with other stated-preference methods, the extent to which results predict patient choice, and the ability of the TT to inform individual treatment decisions at the point of healthcare delivery.

Measure of clinical improvement in children and adolescents with psychiatric disorders: an evaluation of multiple perspectives with HoNOSCA

Introduction

Routine outcome assessment is helpful to inform decision-making, resource allocation, and health policy design. Routine outcome assessment in the hospital setting for children and adolescents with psychiatric disorders remains limited. The clinical instrument HoNOSCA (Health of the Nation Outcome Scales for Children and Adolescents), which has recently become available in Spanish and Catalan, allows outcome assessment in this population from the perspective of patients, their parents or legal guardians, and clinicians. HoNOSCA measures 13 areas of health and psychosocial functioning.

Objectives

The aim of this study was to assess mental health outcomes in psychiatric day hospital pediatric patients from three perspectives (patient, par-ent/legal guardian, clinician), using the Spanish and Catalan versions of HoNOSCA.

Methods

We recruited patients up to 18 years old with any psychiatric disorder at the day unit of the Salut Mental Parc Taulí Hospital Universitari (Sabadell, Catalonia, Spain). We obtained admission and discharge HoNOSCA scores for the patients, their parents or legal guardians, and their clinicians.

Results

We recruited 99 patients over the study period (January 2015 to December 2017), 11 of which were lost to follow-up. Among the remaining 88, we found significant improvement in HoNOSCA scores from admission to discharge. Agreement between the HoNOSCA scores for the three different groups of evaluators (patients, parents/legal guardians, and clinicians) was weak at admission but better at discharge. In general, evaluations from patients and their parents or legal guardians had lower HoNOSCA scores (indicating a better mental health status) at admis-sion compared to those from clinicians. At discharge, however, the scores were more homogenous across the three groups of stakeholders.

Conclusions

Use of HoNOSCA allows for routine evaluation of mental health outcomes in the psychiatric day hospital setting from the perspective of pa-tients, their parents or legal guardians, and clinicians.

Colorectal cancer guidelines seldom include the patient perspective

OBJECTIVES

This study aimed to describe how colorectal practice guidelines (PGs) incorporate the patient perspective.

STUDY DESIGN AND SETTING

We searched in the Guidelines International Network library, MEDLINE, National Guideline Clearinghouse, NHS Evidence database, and TRIP database. Two authors independently selected the PGs. We considered recommendations rated or worded as weak or conditional or suggesting multiple options, as potentially preference sensitive. Two authors independently evaluated if, in potentially sensitive recommendations, the patient perspective was incorporated.

RESULTS

We included 28 PGs that contained 588 recommendations, being 256 potentially preference sensitive. Ten PGs (36%) included patients in the development process, and 12 (43%) provided information about patients' perspectives. Nine PGs (32%) included recommendations in which the patient perspective was explicitly considered, and 13 (46.4%) that recommended a discussion with the patient. From a total of 588 recommendations, 9.7% (25/256) of potentially preference-sensitive recommendations considered the patient perspective. The inclusion of patients in the development process was associated with a more frequent incorporation of the patient perspective in potentially preference sensitive recommendations (70% vs. 0%; P < 0.001).

CONCLUSIONS

Guideline users should be aware that the incorporation of the patient perspective in colorectal cancer PGs is suboptimal. Guideline developers should make efforts to incorporate the patient perspective, especially in preference-sensitive recommendations.

A nurse-coordinated integrated care model to support decision-making and self-care in patients with atrial fibrillation: A study protocol

AIM

This study aims to evaluate the effects of a nurse-coordinated, empowerment-based integrated care model on self-care behaviours and psychosocial outcomes in patients with atrial fibrillation and to explore how this intervention affects patients' self-care behaviours and quality of life.

DESIGN

This mixed-methods study comprises a randomized controlled trial and an exploratory qualitative study.

METHODS

A total of 392 community-dwelling patients aged ≥65 years with a confirmed diagnosis of atrial fibrillation, a high stroke risk and no oral anticoagulants treatment will be recruited from the medical outpatient clinics of a university-affiliated hospital. The patients will be randomly allocated to intervention or control groups, which will receive treatment via the nurse-coordinated integrated care model or standard care, respectively. We hypothesize that compared with patients receiving standard care, atrial fibrillation patients exposed to the nurse-coordinated care model will be more likely to achieve compatible patient and physician decisions regarding the use of oral anticoagulants, better changes in medication adherence, anxiety, depression and health-related quality of life after the intervention. A subsample of 30 participants in the intervention group will also participate in a qualitative interview to provide their views and perceptions about the intervention. The ethical approval has obtained on 5 July 2018. This study is supported by a grant from the Research Grants Council of the Hong Kong Special Administrative Region on 29 June 2018.

DISCUSSION

This study will uniquely adopt an empowerment-based approach to equip patients as active agents in atrial fibrillation management through a nurse-coordinated integrated care model that comprehensively addresses their needs.

IMPACT

Patients with atrial fibrillation are currently receiving inadequate guideline-recommended care. This study will address this important evidence-practice gap by optimizing oral anticoagulant prescription and therapeutic effects and promotes effective patient self-care, so as to achieve worldwide reductions in atrial fibrillation-related morbidity, mortality, and healthcare burdens.

CLINICAL TRIAL REGISTRATION

This study has been registered at ClinicalTrials.gov (NCT03924739).

Developing a Conversation Aid to Support Shared Decision Making: Reflections on Designing Anticoagulation Choice

Patient-centered care requires that treatments respond to the problematic situation of each patient in a manner that makes intellectual, emotional, and practical sense, an achievement that requires shared decision making (SDM). To implement SDM in practice, tools-sometimes called conversation aids or decision aids-are prepared by collating, curating, and presenting high-quality, comprehensive, and up-to-date evidence. Yet, the literature offers limited guidance for how to make evidence support SDM. Herein, we describe our approach and the challenges encountered during the development of Anticoagulation Choice, a conversation aid to help patients with atrial fibrillation and their clinicians jointly consider the risk of thromboembolic stroke and decide whether and how to respond to this risk with anticoagulation.

Patient Values and Preferences Regarding Continuous Subcutaneous Insulin Infusion and Artificial Pancreas in Adults with Type 1 Diabetes: A Systematic Review of Quantitative and Qualitative Data

OBJECTIVE

We produced, through a systematic review of quantitative and qualitative evidence, a synthesis of the issues of importance (values and preferences) to adult patients with type 1 diabetes regarding treatment with automated insulin delivery systems.

METHODS

We searched MEDLINE, CINAHL, EMBASE, and PsycINFO from the inception of each database through September 2018. We included studies examining patient values and preferences for outcomes related to continuous subcutaneous insulin infusion or artificial pancreas treatment. We compiled structured summaries of the results and assessed the relative importance of each outcome. GRADE (Grading of Recommendations, Assessment Development, and Evaluation) and CERQual (Confidence in Evidence from Reviews of Qualitative research) approaches provided the structure for the evaluation of the quality of evidence and confidence in the findings. A mixed-methods result-based convergent design provided the structure for integration and presentation of results.

RESULTS

We reviewed 1665 unique citations; 19 studies (8 quantitative and 11 qualitative) proved eligible. Glycemic control is the key attribute that drives patients' preference. Reduction of glycemic variability and decreased incidence of hypoglycemia and chronic complications proved of intermediate importance and were ranked similarly to components of treatment burden, including the size and appearance of devices, cost, ease of use, and the embarrassment of public use.

CONCLUSIONS

Clinician guidance may play a crucial role in determining patient values and preferences (for instance, patients' priority in glucose control rather than avoiding diabetic complications). Our results provide guidance for clinicians in discussing preferred insulin delivery systems with patients with type 1 diabetes.

Canadian Nephrologist Views Regarding Stroke and Systemic Embolism Prevention in Dialysis Patients With Nonvalvular Atrial Fibrillation: A Survey

Background:

Nonvalvular atrial fibrillation (NVAF) is an independent risk factor for ischemic stroke and is common in chronic kidney disease (CKD) and dialysis patients. The use of oral anticoagulation to prevent stroke and systemic embolism in the setting of kidney disease is controversial. Novel alternatives to vitamin K antagonists include left atrial appendage occlusion devices (LAAOD) and apixaban.

Objective:

We sought to elicit Canadian nephrologist views regarding stroke and systemic embolism prevention therapies in CKD and dialysis patients with NVAF.

Design:

Survey.

Setting:

Online via https://www.surveymonkey.com.

Participants:

Canadian Society of Nephrology members actively treating adult dialysis patients with NVAF.

Measurements:

Management questions were asked with response options consisting of a Likert scale ranging from 1 to 8 (with 1 being definitely would not and 8 being definitely would).

Methods:

We randomly allocated each respondent to 2 of 4 cases that varied by stroke and bleeding risks (using varying CHADS2 and HASBLED scores, respectively).

Results:

There were 91 responses (36.3% response rate) from mostly university (83.5%) and also community with university affiliation (12.1%) and community (4.4%) nephrologists. Warfarin was more likely to be recommended in individuals at high stroke risk and low bleeding risk (mean = 5.47, 95% confidence interval = 4.87-6.07) and less likely to be recommended in individuals at moderate stroke risk and high bleeding risk (mean = 2.89, 95% confidence interval = 2.37-3.41). The likelihood of recommending LAAOD did not vary by stroke or bleeding risks (means ranging from 3.92-4.90). Apixaban was not likely to be recommended in any case (means ranging from 2.60-3.50). However, nephrologists felt there was equipoise regarding anticoagulation strategies allowing participation in appropriate randomized controlled trials (RCTs).

Limitations:

The survey only involved nephrologists and only 4 cases with dichotomized risk categories were presented instead of complete range of stroke and bleeding risk combinations. As with any survey, there was the potential for responder bias and treatment decisions are not anchored directly to patient management.

Conclusions:

Nephrologists caring for patients with kidney disease appear willing to include patients in clinical trials examining alternatives to warfarin for stroke and systemic embolism prevention for NVAF in the setting of kidney disease.

Electronic physician notifications to improve guideline-based anticoagulation in atrial fibrillation: a randomized controlled trial

BACKGROUND

Oral anticoagulants reduce the risk of stroke in patients with atrial fibrillation. However, many patients with atrial fibrillation at elevated stroke risk are not treated with oral anticoagulants.

OBJECTIVE

To test whether electronic notifications sent to primary care physicians increase the proportion of ambulatory patients prescribed oral anticoagulants.

DESIGN

Randomized controlled trial conducted from February to May 2017 within 18 practices in an academic primary care network.

PARTICIPANTS

Primary care physicians (n = 175) and their patients with atrial fibrillation, at elevated stroke risk, and not prescribed oral anticoagulants.

INTERVENTION

Patients of each physician were randomized to the notification or usual care arm. Physicians received baseline email notifications and up to three reminders with patient information, educational material and primary care guidelines for anticoagulation management, and surveys in the notification arm.

MAIN MEASURES

The primary outcome was the proportion of patients prescribed oral anticoagulants at 3 months in the notification (n = 972) vs. usual care (n = 1364) arms, compared using logistic regression with clustering by physician. Secondary measures included survey-based physician assessment of reasons why patients were not prescribed oral anticoagulants and how primary care physicians might be influenced by the notification.

KEY RESULTS

Over 3 months, a small proportion of patients were newly prescribed oral anticoagulants with no significant difference in the notification (3.9%, 95% CI 2.8-5.3%) and usual care (3.2%, 95% CI 2.4-4.2%) arms (p = 0.37). The most common, non-exclusive reasons why patients were not on oral anticoagulants included atrial fibrillation was transient (30%) or paroxysmal (12%), patient/family declined (22%), high bleeding risk (20%), fall risk (19%), and frailty (10%). For 95% of patients, physicians stated they would not change their management after reviewing the alert.

CONCLUSIONS

Electronic physician notification did not increase anticoagulation in patients with atrial fibrillation at elevated stroke risk. Primary care physicians did not prescribe anticoagulants because they perceived the bleeding risk was too high or stroke risk was too low.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02950285.

Patients' Perceptions of Atrial Fibrillation, Stroke Risk, and Oral Anticoagulation Treatment: An International Survey

Background  Global differences exist in the management of atrial fibrillation (AF), and cultural differences may influence patients' expectations and perceptions of healthcare. This survey investigated whether country-specific differences in patients' perceptions of AF and oral anticoagulation (OAC) exist and if recent stroke influences these perceptions. Methods  Cross-sectional survey of 937 adults with nonvalvular AF receiving OAC for stroke prevention was conducted across United States, Canada, Germany, France, and Japan. Thirty-minute online interviews conducted between April and November 2015 included AF patients with recent stroke, and newly diagnosed AF and established AF, both without recent stroke. Results  U.S. patients and those with recent stroke perceived AF as more serious (54.0 and 55.2%, respectively) and were more concerned about stroke (50.0 and 68.0%, respectively). Japanese patients were more likely to perceive AF as not serious (41.0%), but 50.4% were frequently concerned about stroke. Patients in the United States, Canada, and Germany and those without recent stroke preferred to be involved in OAC treatment decisions (either shared decision making or patient's choice), while French and Japanese patients and those with recent stroke preferred their doctor to choose. For all country groups, stroke prevention was the most important factor when choosing OAC. Conclusion  In this international cohort of AF patients, country-specific differences exist in patients' perceptions of AF, concerns about stroke, and preference for involvement in OAC treatment decisions; recent experience of stroke significantly influenced patients' values and preferences regarding AF and treatment. Stroke prevention was rated as the most important factor when choosing OAC treatment.

Treatment Preferences in Germany Differ Among Apheresis Patients with Severe Hypercholesterolemia

BACKGROUND

Severe hypercholesterolemia is a major risk factor of death in patients with coronary heart disease. New adjunctive drug therapies (proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) have gained approval in Europe and the USA.

OBJECTIVE

In this empirical study, we documented preferences regarding adjuvant drug therapy in apheresis-treated patients with severe familial hypercholesterolemia.

METHODS

We conducted a systematic literature search to identify patient-relevant outcomes in patients with severe hypercholesterolemia currently undergoing apheresis. Data were used to generate a semi-structured qualitative interview that enabled seven patient-relevant characteristics with three levels each to be identified. For the discrete choice experiment, an experimental design (7 × 3) was generated using NGene Software that consisted of 96 choices divided into eight blocks. The survey was conducted between November 2015 and April 2016 using computer-assisted personal interviews.

RESULTS

The survey was completed by 348 patients (64.9% male). The random parameter logit estimation showed predominance for the attribute 'reduction of LDL-C (low-density lipoprotein cholesterol) level'. 'Risk of myopathy' and 'frequency of apheresis' dominated next. Within the random parameter logit estimation, all coefficients were significant (P ≤ 0.01). The latent class analysis identified three patient groups. The first group (126 patients) found 'reduction of LDL-C level in blood' to be most important. This group focused solely on this treatment outcome independently of apheresis frequency or additional injections. The second group (106 patients) focused on three attributes: 'frequency of apheresis', 'risk of myopathy', and 'reduction of LDL-C level in blood'. Respondents clearly considered a high frequency of apheresis to have a negative impact. The third group (116 patients) demonstrated the highest preference for apheresis. These patients have adjusted to apheresis for > 10 years.

CONCLUSION

Regarding patient preference, clinical efficacy seems to dominate. Hence, 'reduction of LDC-C in blood' was ranked highest above patient-relevant modes of administration and adverse effects. In the patient groups identified, reduction of apheresis was important for only a subsegment (30%) of patients. Another 30% wanted effective LDL-C reduction by whatever means necessary. Most strikingly, another 30% preferred higher frequencies of apheresis.

Association between subjective risk perception and objective risk estimation in patients with atrial fibrillation: a cross-sectional study

OBJECTIVE

Oral anticoagulation (OAC) is state-of-the-art therapy for atrial fibrillation (AF), the most common arrhythmia worldwide. However, little is known about the perception of patients with AF and how it correlates with risk scores used by their physicians. Therefore, we correlated patients' estimates of their own stroke and bleeding risk with the objectively predicted individual risk using CHA₂DS₂-VASc and HAS-BLED scores.

DESIGN

Cross-sectional prevalence study using convenience sampling and telephone follow-up.

SETTINGS

Eight hospital departments and one general practitioner in Austria. Patients' perception of stroke and bleeding risk was opposed to commonly used risk scoring.

PARTICIPANTS

Patients with newly diagnosed AF and indication for anticoagulation.

MAIN OUTCOME MEASURES

Comparison of subjective risk perception with CHA₂DS₂-VASc and HAS-BLED scores showing possible discrepancies between subjective and objective risk estimation. Patients' judgement of their own knowledge on AF and education were also correlated with accuracy of subjective risk appraisal.

RESULTS

Ninety-one patients (age 73±11 years, 45% female) were included in this study. Subjective stroke and bleeding risk estimation did not correlate with risk scores (ρ=0.08 and ρ=0.17). The majority of patients (57%) underestimated the individual stroke risk. Patients feared stroke more than bleeding (67% vs 10%). There was no relationship between accurate perception of stroke and bleeding risks and education level. However, we found a correlation between the patients' judgement of their own knowledge of AF and correct assessment of individual stroke risk (ρ=0.24, p=0.02). During follow-up, patients experienced the following events: death (n=5), stroke (n=2), bleeding (n=1). OAC discontinuation rate despite indication was 3%.

CONCLUSIONS

In this cross-sectional analysis of OAC-naive patients with AF, we found major differences between patients' perceptions and physicians' assessments of risks and benefits of OAC. To ensure shared decision-making and informed consent, more attention should be given to evidence-based and useful communication strategies.

TRIAL REGISTRATION NUMBER

NCT03061123.

Evidence for underuse of effective medical services around the world

Underuse-the failure to use effective and affordable medical interventions-is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.

Clinical Practice Guidelines: Incorporating Input From a Patient Panel

OBJECTIVE

To describe the integral role of a Patient Panel in the development of the 2017 American College of Rheumatology (ACR)/American Association of Hip and Knee Surgeons (AAHKS) clinical practice guideline.

METHODS

We convened a Panel of 11 patients with rheumatoid arthritis and juvenile idiopathic arthritis, all of whom had undergone 1 or more arthroplasties, to review the evidence and provide guidance on recommendations for the 2017 ACR/AAHKS guideline to address the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. The guideline used the Grading of Recommendations Assessment, Development, and Evaluation methodology that acknowledges the critical role of patient values and preferences when the quality of the evidence base is low or when there are important trade-offs between benefits and harms. The Patient Panel considered the relative importance of complications including perioperative infection versus rheumatic disease flare and voted on the recommendations. Before the Voting Panel's own discussion of the recommendations, they reviewed a summary of the Patient Panel's discussion, including their perioperative experience, the relative importance they placed on infections versus flares in the perioperative period, and their votes on the recommendations.

RESULTS

The Patient Panel placed higher importance on avoiding an infection than a disease flare despite the far greater frequency of flares than infections. The decisions of the Voting Panel were concordant with those of the Patient Panel. For the 7 recommendations that both Panels voted on, the Panels agreed on the direction as well as the strength of recommendation (which was conditional for all recommendations).

CONCLUSION

The Voting Panel considered the importance that the patients placed on risk of infection. The Patient Panel's values informed the direction and strength of the recommendations in the final 2017 ACR/AAHKS guideline.

Incorporating patients' views in guideline development: a systematic review of guidance documents

OBJECTIVES

To assess how guidance documents for developing clinical guidelines (CGs) address the incorporation of patients' views in CGs.

STUDY DESIGN AND SETTING

Systematic review to identify the methodology provided in guidance documents for incorporating (1) patients or representatives and (2) patients' views in the CG development process. The search was performed in 2017 in five databases. Two authors selected the studies, and data extraction was double-checked.

RESULTS

We included guidance documents from 56 institutions. Of those, 40 (71.4%) recommended the inclusion of patients or their representatives, mainly for developing recommendations (14/40, 35.0%); reviewing the final version (13/40, 32.5%); formulating clinical questions (13/40, 32.5%); defining the scope and objectives (10/40, 25.0%); and dissemination and implementation (10/40, 25.0%). Concrete methods on how to incorporate patients were provided by 47.5% (19/40) of institutions. Forty (71.4%) institutions provided additional strategies to incorporate patients' views. The majority (30/40, 75.0%) suggested sources for obtaining these views (consultation with patients [24/40, 60.0%], using panels' judgment [10/40, 25.0%], conducting de novo research [10/40, 25.0%], or a systematic review [9/40, 22.5%]).

CONCLUSION

Although most institutions suggest incorporating patients and their views when developing CGs, little detail is provided on how to do this. Institutions should provide more guidance as this could have a positive impact in guideline applicability.

Prevalence, predictors, and prognostic implications of residual impairment of functional capacity after transcatheter aortic valve implantation

Background

Patients with degenerative aortic stenosis (AS) referred for transcatheter aortic valve implantation (TAVI) typically have advanced cardiac and vascular adverse remodeling and multiple comorbidities and, therefore, might not recover a normal functional capacity after valve replacement. We sought to investigate the prevalence, the predictors, and the prognostic impact of residual impairment of functional capacity after TAVI.

Methods and results

Out of 790 patients undergoing TAVI with impaired functional capacity (NYHA II–IV) at baseline, NYHA functional class improved in 592 (86.5%) and remained unchanged/worsened in 92 (13.5%) at follow-up [median (IQR): 419 (208–807) days] after TAVI. Normal functional capacity (NYHA I) was recovered in 65.5% (n = 448) of patients, while the rest had variable degrees of residual impairment. On multivariable regression analysis, atrial fibrillation [odds ratio-OR, 2.08 (1.21–3.58), p = 0.008], low-flow–low-gradient AS [OR, 1.97 (1.09–3.57), p = 0.026], chronic obstructive pulmonary disease [OR, 1.92 (1.19–3.12), p = 0.008], and lower hemoglobin at baseline [OR, 1.11 (1.01–1.21) for each g% decrement, p = 0.036] were independently associated with residual impairment of functional capacity. All-cause and cardiac mortality were significantly higher in those with residual impairment of functional capacity than in those in NYHA I class [hazard ratio-HR: 2.37 (95% CI: 1.51–3.72), p < 0.001 and 2.16 (95% CI: 1.08–4.35), p = 0.030, respectively]. Even mild residual functional impairment (NYHA II) was associated with a higher all-cause [HR: 2.02 (95% CI: 1.10–3.72), p = 0.023] and cardiac [HR: 2.08 (95% CI: 1.42–3.07), p < 0.001] mortality.

Conclusion

Residual impairment of functional capacity is common after TAVI and is independently associated with increased mortality. Predictors of residual impairment of functional status are predominantly patient-rather than procedure-related.

Electronic supplementary material

The online version of this article (doi:10.1007/s00392-017-1119-9) contains supplementary material, which is available to authorized users.

Patient Preferences for Oral Anticoagulation Therapy in Atrial Fibrillation: A Systematic Literature Review

OBJECTIVES

Since the introduction of non-vitamin K antagonist (VKA) oral anticoagulants (NOACs), an additional treatment option, apart from VKAs, has become available for stroke prevention in patients with atrial fibrillation (AF). For various reasons, it is important to consider patients' preferences regarding type of medication, particularly in view of the established relationship between preferences towards treatment, associated burden of treatment, and treatment adherence. This review aimed to systematically analyse the scientific literature assessing the preferences of AF patients with regard to long-term oral anticoagulant (OAC) treatment.

METHODS

We searched the MEDLINE, Scopus and EMBASE databases (from 1980 to 2015), added records from reference lists of publications found, and conducted a systematic review based on all identified publications. Outcomes of interest included any quantitative information regarding the opinions or preferences of AF patients towards OAC treatment, ideally specified according to different clinical or convenience attributes describing different OAC treatment options.

RESULTS

Overall, 27 publications describing the results of studies conducted in 12 different countries were included in our review. Among these, 16 studies analysed patient preferences towards OACs in general. These studies predominantly assessed which benefits (mainly lower stroke risk) AF patients would require to tolerate harms (mainly higher bleeding risk) associated with an OAC. Most studies showed that patients were willing to accept higher bleeding risks if a certain threshold in stroke risk reduction could be reached. Nevertheless, most of the publications also showed that the preferences of AF patients towards OACs may differ from the perspective of clinical guidelines or the perspective of physicians. The remaining 11 studies included in our review assessed the preferences of AF patients towards specific OAC medication options, namely NOACs versus VKAs. Our review showed that AF patients prefer easy-to-administer treatments, such as treatments that are applied once daily without any food/drug interactions and without the need for bridging and frequent blood controls.

CONCLUSION

Stroke risk reduction and a moderate increase in the risk of bleeding are the most important attributes for an AF patient when deciding whether they are for or against OAC treatment. If different anticoagulation options have similar clinical characteristics, convenience attributes matter to patients. In this review, AF patients favour attribute levels that describe NOAC treatment.

Patient values and preferences on transcatheter or surgical aortic valve replacement therapy for aortic stenosis: a systematic review

OBJECTIVE

To investigate patients' values and preferences regarding aortic valve replacement therapy for aortic stenosis.

SETTING

Studies published after transcatheter aortic valve insertion (TAVI) became available (2002).

PARTICIPANTS

Adults with aortic stenosis who are considering or have had valve replacement, either TAVI or via surgery (surgical aortic valve replacement, SAVR).

OUTCOME MEASURES

We sought quantitative measurements, or qualitative descriptions, of values and preferences. When reported, we examined correlations between preferences and objective (eg, ejection fraction) or subjective (eg, health-related quality of life) measures of health.

RESULTS

We reviewed 1348 unique citations, of which 2 studies proved eligible. One study of patients with severe aortic stenosis used a standard gamble study to ascertain that the median hypothetical mortality risk patients were willing to tolerate to achieve full health was 25% (IQR 25-50%). However, there was considerable variability; for mortality risk levels defined by current guidelines, 130 participants (30%) were willing to accept low-to-intermediate risk (≤8%), 224 (51%) high risk (>8-50%) and 85 (19%) a risk that guidelines would consider prohibitive (>50%). Study authors did not, however, assess participants' understanding of the exercise, resulting in a potential risk of bias. A second qualitative study of 15 patients identified the following factors that influence patients to undergo assessment for TAVI: symptom burden; expectations; information support; logistical barriers; facilitators; obligations and responsibilities. The study was limited by serious risk of bias due to authors' conflict of interest (5/9 authors industry-funded).

CONCLUSIONS

Current evidence on patient values and preferences of adults with aortic stenosis is very limited, and no studies have enrolled patients deciding between TAVI and SAVR. On the basis of the data available, there is evidence of variability in individual values and preferences, highlighting the importance of well-informed and shared decision-making with patients facing this decision.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42016041907.

Patient Preferences for Oral Anticoagulation Therapy in Atrial Fibrillation: A Systematic Literature Review

OBJECTIVES

Since the introduction of non-vitamin K antagonist (VKA) oral anticoagulants (NOACs), an additional treatment option, apart from VKAs, has become available for stroke prevention in patients with atrial fibrillation (AF). For various reasons, it is important to consider patients' preferences regarding type of medication, particularly in view of the established relationship between preferences towards treatment, associated burden of treatment, and treatment adherence. This review aimed to systematically analyse the scientific literature assessing the preferences of AF patients with regard to long-term oral anticoagulant (OAC) treatment.

METHODS

We searched the MEDLINE, Scopus and EMBASE databases (from 1980 to 2015), added records from reference lists of publications found, and conducted a systematic review based on all identified publications. Outcomes of interest included any quantitative information regarding the opinions or preferences of AF patients towards OAC treatment, ideally specified according to different clinical or convenience attributes describing different OAC treatment options.

RESULTS

Overall, 27 publications describing the results of studies conducted in 12 different countries were included in our review. Among these, 16 studies analysed patient preferences towards OACs in general. These studies predominantly assessed which benefits (mainly lower stroke risk) AF patients would require to tolerate harms (mainly higher bleeding risk) associated with an OAC. Most studies showed that patients were willing to accept higher bleeding risks if a certain threshold in stroke risk reduction could be reached. Nevertheless, most of the publications also showed that the preferences of AF patients towards OACs may differ from the perspective of clinical guidelines or the perspective of physicians. The remaining 11 studies included in our review assessed the preferences of AF patients towards specific OAC medication options, namely NOACs versus VKAs. Our review showed that AF patients prefer easy-to-administer treatments, such as treatments that are applied once daily without any food/drug interactions and without the need for bridging and frequent blood controls.

CONCLUSION

Stroke risk reduction and a moderate increase in the risk of bleeding are the most important attributes for an AF patient when deciding whether they are for or against OAC treatment. If different anticoagulation options have similar clinical characteristics, convenience attributes matter to patients. In this review, AF patients favour attribute levels that describe NOAC treatment.

Whose preferences should be elicited for use in health-care decision-making? A case study using anticoagulant therapy

The question of whose preferences to elicit in health-state valuation has been widely discussed in the literature. The importance of this debate lies in the fact that health-state utility values are used in health technology assessment (HTA); therefore, an individual's preferences can influence decision-making. If preferences differ across groups, making decisions based on one group's preferences may be suboptimal for the other. Preferences for benefits, risks, experiences and health states associated with anticoagulant therapies have been elicited by researchers due to the underutilization of warfarin and the introduction of non-vitamin K antagonist oral anticoagulants. The majority of existing studies elicit preferences from patient populations as opposed to other stakeholders such as the general public. This paper extends the preference debate by using this clinical area as a case study, with a particular focus on HTA guidelines and the recent advocacy of the use of preference information in benefit-risk assessments.

Cost-effectiveness analysis of dabigatran and anticoagulation monitoring strategies of vitamin K antagonist

BACKGROUND

Vitamin K antagonists are commonly used for the prevention of thromboembolic events. Patient self-monitoring of vitamin K antagonists has proved superior to usual care. Dabigatran has been shown, relative to warfarin, to reduce thromboembolic events without increasing bleeding.

METHODS

We constructed a Markov model to compare vitamin K self-monitoring strategies to dabigatran including effectiveness and costs of monitoring and complications (thromboembolism and major bleeding). The model was used to project the incidence of these complications, life years, quality-adjusted life years, and health system costs with anticoagulant treatment throughout life. The analysis was conducted from the health system perspective and from the societal perspective.

RESULTS

Low quality evidence suggests that self-monitoring is at least as effective as dabigatran for the outcomes of thrombosis, bleeding and death. Moderate quality evidence that patient self-monitoring is more effective than other forms of monitoring degree of anticoagulation with vitamin K antagonists, reducing the relative risk of thromboembolism by 41% and death by 34%. The cost per quality adjusted year gained relative to other warfarin monitoring strategies is well below 30,000 € in the short term, and is a dominant alternative from the fourth year. In comparison with dabigatran, the lower annual cost and its equivalence in terms of effectiveness made self-monitoring the dominant option. These results were confirmed in the probabilistic sensitivity analysis.

CONCLUSIONS

We have moderate quality evidence that self-monitoring of vitamin K antagonists is a cost-effective alternative compared with hospital and primary care monitoring, and low quality evidence, compared with dabigatran. Our analyses contrast with the available cost analysis of dabigatran and usual care of anticoagulated patients.

Choosing the right drug to fit the patient when selecting oral anticoagulation for stroke prevention in atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and is a growing health problem that is associated with a significantly increased risk of stroke and thromboembolism. Oral anticoagulant (OAC) therapy reduces the risk of stroke and all-cause mortality in patients with AF. OAC therapy is commonly given as a well-controlled vitamin K antagonist (VKA; e.g. warfarin) and can reduce the risk of stroke in AF patients by almost two-thirds. However, the widespread use of VKAs has been hampered by the unpredictable pharmacokinetic and pharmacodynamic properties of the drugs and justifiable concerns about the consequent risk of haemorrhage. The non-VKA OACs (NOACs) have revolutionized thromboprophylaxis in AF by providing therapeutic options with predictable pharmacodynamic and pharmacokinetic properties that are as efficacious as warfarin in the prevention of stroke and thromboembolism but are more convenient to use. In this review, we provide a patient-centred framework to assist clinicians in recommending the right OAC therapy to fit the individual patient with AF, including methods for stratifying the risk of stroke and haemorrhage and the chances of achieving tight control of VKA anticoagulation, and we discuss the properties of the NOACs that favour their use in particular patient cohorts.

Discontinuation of anticoagulant treatment: from clinical trials to medication persistence

BACKGROUND

The new generation, non-vitamin K antagonist oral anticoagulants are used in an increasing frequency, partially replacing the vitamin K antagonists in several fields of anticoagulation. Efficacy of the preventive oral anticoagulant regime, however, may be compromised by patient non-compliance.

METHODS

The authors analyzed treatment discontinuation frequencies in phase 3 trials of anticoagulant treatment in non-valvular atrial fibrillation in a frequentist random effect metaanalysis and in Bayesian multiple treatment network comparison.

RESULTS

Frequency of discontinuations are heterogeneous and highly inconsistent (Chi2 test for heterogeneity p < 0.001, I2 test for inconsistency 95.1%). Discontinuations were the most frequent with dabigatran followed by rivaroxaban, warfarin, edoxaban and apixaban. Rivaroxaban were less frequently discontinued when compared to the two doses of dabigatran. (OR 0.80; 95% CI: 0.71-0.91 versus 150 mg b.i.d., and OR: 0.77; 95% CI: 0.68-0.87 versus 110 mg b.i.d.).

CONCLUSION

Important differences exist among the treatment adherence of different anticoagulant protocols. Discontinuation rates experienced during the clinical trials may predict the real life patient adherence.