1
|
Adelakun AR, De Vera MA, McGrail K, Turgeon RD, Barry AR, Andrade JG, MacGillivray J, Deyell MW, Kwan L, Chua D, Lum E, Smith R, Loewen P. Development and Application of an Attribute-Based Taxonomy on the Benefits of Oral Anticoagulant Switching in Atrial Fibrillation: A Delphi Study. Adv Ther 2024:10.1007/s12325-024-02859-0. [PMID: 38658484 DOI: 10.1007/s12325-024-02859-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/25/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Patients with atrial fibrillation (AF) often switch between oral anticoagulants (OACs). It can be hard to know why a patient has switched outside of a clinical setting. Medication attribute comparisons can suggest benefits. Consensus on terms and definitions is required for inferring OAC switch benefits. The objectives of the study were to generate consensus on a taxonomy of the potential benefits of OAC switching in patients with AF and apply the taxonomy to real-world data. METHODS Nine expert clinicians (seven clinical pharmacists, two cardiologists) with at least 3 years of clinical and research experience in AF participated in a Delphi process. The experts rated and commented on a proposed taxonomy on the potential benefits of OAC switching. After each Delphi round, ratings were analyzed with the RAND Corporation/University of California, Los Angeles (RAND/UCLA) appropriateness method. Median ratings, disagreement index, and comments were used to modify the taxonomy. The resulting taxonomy from the Delphi process was applied to a cohort of patients with AF who switched OACs in a population-based administrative health dataset from 1996 to 2019 in British Columbia, Canada. RESULTS The taxonomy was finalized in two Delphi rounds, reaching consensus on five switch benefit categories: safety, effectiveness, convenience, economic considerations, and drug interactions. Safety benefit (a switch that could lower the risk of adverse drug events) had three subcategories: major bleeding, intracranial hemorrhage (ICH), and gastrointestinal (GI) bleeding. Effectiveness benefit had four subcategories: stroke and systemic embolism (SSE), ischemic stroke, myocardial infarction (MI), and all-cause mortality. Real-world OAC switches revealed that more OAC switches had convenience (72.6%) and drug interaction (63.0%) benefits compared to effectiveness (SSE 22.0%, ischemic stroke 11.1%, MI 3.1%, all-cause mortality 10.1%), safety (major bleeding 24.3%, GI bleeding 10.6%, ICH 48.5%), and economic benefits (12.1%). CONCLUSIONS The Delphi-based taxonomy identified five criteria for the beneficial effects of OAC switching, aiding in characterizing real-world OAC switching.
Collapse
Affiliation(s)
- Adenike R Adelakun
- Faculty of Pharmaceutical Sciences, University of British Columbia (UBC), Vancouver, Canada
- UBC Collaboration for Outcomes Research and Evaluation, Vancouver, Canada
| | - Mary A De Vera
- Faculty of Pharmaceutical Sciences, University of British Columbia (UBC), Vancouver, Canada
- UBC Collaboration for Outcomes Research and Evaluation, Vancouver, Canada
| | - Kim McGrail
- UBC School of Population and Public Health, Vancouver, Canada
- UBC Centre for Health Services and Policy Research, Vancouver, Canada
| | - Ricky D Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia (UBC), Vancouver, Canada
- UBC Collaboration for Outcomes Research and Evaluation, Vancouver, Canada
| | - Arden R Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia (UBC), Vancouver, Canada
- Jim Pattison Outpatient Care and Surgery Centre, Surrey, Canada
| | - Jason G Andrade
- Vancouver General Hospital, Vancouver, Canada
- Department of Medicine, The University of British Columbia, Vancouver, Canada
- Centre for Cardiovascular Innovation, Vancouver, Canada
| | | | - Marc W Deyell
- Department of Medicine, The University of British Columbia, Vancouver, Canada
- Centre for Cardiovascular Innovation, Vancouver, Canada
- St. Paul's Hospital, Vancouver, Canada
| | - Leanne Kwan
- Royal Columbian Hospital, New Westminster, Canada
| | | | - Elaine Lum
- Vancouver General Hospital, Vancouver, Canada
| | | | - Peter Loewen
- Faculty of Pharmaceutical Sciences, University of British Columbia (UBC), Vancouver, Canada.
- UBC Collaboration for Outcomes Research and Evaluation, Vancouver, Canada.
- Centre for Cardiovascular Innovation, Vancouver, Canada.
| |
Collapse
|
2
|
Comín Colet J, Sicras Mainar A, Salazar-Mendiguchía J, Isabel del Campo Alonso M, Echeto A, Vilanova Larena D, Delgado Sánchez O. Influence of the COVID-19 pandemic on patients receiving oral anticoagulants for the treatment of non-valvular atrial fibrillation. Int J Cardiol Heart Vasc 2024; 51:101358. [PMID: 38371309 PMCID: PMC10869899 DOI: 10.1016/j.ijcha.2024.101358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/23/2024] [Accepted: 02/04/2024] [Indexed: 02/20/2024]
Abstract
Background Frequent monitoring of patients declined during the COVID-19 pandemic, harming patients with chronic diseases who critically needed correct monitoring. We evaluated the impact of the COVID-19 pandemic in patients with non-valvular atrial fibrillation (NVAF) receiving treatment with vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC) in clinical practice in Spain. Methods This observational, retrospective study analyzed prevalent patients treated with NOAC/VKA on 14/03/2019 (pre-COVID-19 period) and 14/03/2020 (COVID-19 period), who were followed up to 12 months. The study also considered incident patients who started treatment with NOAC/VKA between 15/03/2019 and 13/03/2020 (pre-COVID-19 period) and from 15/03/2020 to 13/03/2021 (COVID-19 period). Demographic characteristics, comorbidities, effectiveness, treatment patterns, and healthcare resource utilization were considered. Results Prevalent patients amounted to 12,336 and 13,342 patients, whereas 1,612 and 1,602 incident patients were included in the pre-COVID-19 and COVID-19 periods, respectively. Prevalent patients treated with VKA had more strokes, thromboembolism, and major bleeding compared to those receiving NOAC, particularly during the COVID-19 period. NOAC patients had a 12 % lower risk of death than those on treatment with VKA (Hazard ratio = 0.88 [95 % CI: 0.81 - 0.95], p = 0.033). In addition, VKA patients were less persistent after 12 months than NOAC patients (pre-COVID-19 period: 52.1 % vs. 78.9 %, p < 0.001; COVID-19 period: 49.2 % vs. 80.3 %, p < 0.001), and required more healthcare visits and hospitalizations than those on treatment with NOAC. Conclusion Compared to VKA, NOAC seems to have reduced the incidence of severe events and the use of healthcare resources for NVAF, particularly during the pandemic.
Collapse
Affiliation(s)
- Josep Comín Colet
- Cardiology Department, Hospital Universitario de Bellvitge (IDIBELL) and CIBERCV, 08907 Hospitalet del Llobregat, Spain
| | | | | | | | - Ainara Echeto
- Bristol Myers Squibb, Madrid, Spain, 28050 Madrid, Spain
| | - David Vilanova Larena
- Real World Evidence and Outcomes Research, Bristol Myers Squibb, 28050 Madrid, Spain
| | - Olga Delgado Sánchez
- Pharmacy Department, Hospital Universitario Son Espases, IdISBa, 07120 Palma de Mallorca, Spain
| |
Collapse
|
3
|
Narendrula A, Brinza E, Horvat Davey C, Longenecker CT, Webel AR. Relationship between objectively measured physical activity and subclinical cardiovascular disease: a systematic review. BMJ Open Sport Exerc Med 2024; 10:e001596. [PMID: 38292295 PMCID: PMC10826575 DOI: 10.1136/bmjsem-2023-001596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
Introduction The association of physical activity (PA) with subclinical cardiovascular disease (CVD) is unclear. Clarifying this relationship may inform cardiovascular prevention strategies. Methods We performed a systematic review (CRD42021226089) using Medline, Embase, CINAHL and Cochrane (1 January 2000 to 1 September 2023). Studies published with adult populations exploring the relationship between objectively measured PA and subclinical CVD were included. Subclinical CVD was assessed using: ankle-brachial index (ABI); arterial stiffness; carotid artery disease; coronary artery atherosclerosis; endothelial function; and measures of cardiac structure and function. The Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) and Cochrane Risk of Bias tools were used for quality review. Results Of 68 included studies, most supported an inverse relationship between PA and subclinical CVD. Arterial stiffness was the most common outcome (n=40), and 33 studies suggested that less sedentary behaviour (SB), increased PA and/or higher intensity PA was associated with less arterial stiffness. Ten studies of carotid artery disease (total n=18), six of endothelial function (n=10), two of coronary artery disease (n=3) and all of ABI (n=6) suggested that PA or less SB is associated with less subclinical disease. Five studies assessing cardiac structure/function (n=6) suggested alterations in structure/function with PA. Conclusions PA reduces the risk of CVD events, and this systematic review demonstrates that some of the benefits may be mediated by an inverse association between PA and subclinical CVD. Interventions to increase PA are important for CVD prevention, so we provide a comprehensive overview of which surrogate outcome measures may be most useful to assess future CVD prevention interventions. PROSPERO registration number CRD42021226089.
Collapse
Affiliation(s)
- Aparna Narendrula
- Internal Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Ellen Brinza
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christine Horvat Davey
- Case Western Reserve University Frances Payne Bolton School of Nursing, Cleveland, Ohio, USA
| | - Chris T Longenecker
- Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Allison R Webel
- University of Washington School of Nursing, Seattle, Washington, USA
| |
Collapse
|
4
|
Escobar C, Bover Freire R, García-Moll Marimón X, González-Juanatey C, Morillas M, Valle Muñoz A, Gómez Doblas JJ. A Delphi consensus on the management of anticoagulation in the COVID-19 pandemic: the MONACO study. Cardiovasc Diagn Ther 2023; 13:777-791. [PMID: 37941839 PMCID: PMC10628427 DOI: 10.21037/cdt-23-76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 09/15/2023] [Indexed: 11/10/2023]
Abstract
Background During the COVID-19 pandemic, guideline documents on the management of anticoagulation were rapidly published. However, these documents did not follow a structured methodology, and significant differences existed between the guidelines. The aim of this expert consensus was to provide recommendations on the clinical management of oral anticoagulation in patients in the context of the COVID-19 pandemic. Methods A two-round Delphi study was conducted using an online survey. In the first round, panellists expressed their level of agreement with the items on a 9-point Likert scale. Items were selected if they received approval from ≥66.6% of panellists and if they were agreed by the scientific committee. In the second round, panellists revaluated those items that did not meet consensus in the first round. Results A total of 147 panellists completed the first round, and 144 of them completed the second round. Consensus was reached on 161 items included in five dimensions. These dimensions addressed: (I) management of anticoagulation in patients with atrial fibrillation (AF) without mechanical valves or moderate/severe mitral stenosis during COVID-19 infection; (II) thromboprophylaxis in patients hospitalised for COVID-19; (III) management of anticoagulation at hospital discharge/after COVID-19; (IV) anticoagulation monitoring in the COVID-19 pandemic setting; and (V) role of telemedicine in the management and follow-up of patients with AF in the COVID-19 pandemic setting. Conclusions These areas of collective agreement could specially guide clinicians in making decisions regarding anticoagulation in patients with COVID-19 during hospitalisation and at discharge, where results from clinical trials are still limited and, in some cases, conflicting.
Collapse
Affiliation(s)
- Carlos Escobar
- Cardiology Department, Hospital Universitario La Paz, Madrid, Spain
| | | | | | | | - Miren Morillas
- Cardiology Department, Hospital de Galdakao, Galdakao, Spain
| | | | - Juan José Gómez Doblas
- Cardiology Department, Hospital Universitario Virgen de la Victoria, CIBERCV, Málaga, Spain
| |
Collapse
|
5
|
Higuchi T, Shin JH, Takada D, Morishita T, Kunisawa S, Imanaka Y. The Japanese Guide affected the prescription of steroids for COVID-19 inpatients during the COVID-19 epidemic in Japan. Sci Rep 2023; 13:9041. [PMID: 37270639 DOI: 10.1038/s41598-023-36199-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 05/31/2023] [Indexed: 06/05/2023] Open
Abstract
Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, guidance ("Japanese Guide") has been published by a working group of several academic societies and announced by the Ministry of Health, Labour, and Welfare. Steroids as a candidate treatment for COVID-19 were noted in the Japanese Guide. However, the prescription details for steroids, and whether the Japanese Guide changed its clinical practice, were unclear. This study aimed to examine the impact of the Japanese Guide on the trends in the prescription of steroids for COVID-19 inpatients in Japan. We selected our study population using Diagnostic Procedure Combination (DPC) data from hospitals participating in the Quality Indicator/Improvement Project (QIP). The inclusion criteria were patients discharged from hospital between January 2020 and December 2020, who had been diagnosed with COVID-19, and were aged 18 years or older. The epidemiological characteristics of cases and the proportion of steroid prescriptions were described on a weekly basis. The same analysis was performed for subgroups classified by disease severity. The study population comprised 8603 cases (410 severe cases, 2231 moderate II cases, and 5962 moderate I/mild cases). The maximum proportion of cases prescribed with dexamethasone increased remarkably from 2.5 to 35.2% in the study population before and after week 29 (July 2020), when dexamethasone was included in the guidance. These increases were 7.7% to 58.7% in severe cases, 5.0% to 57.2% in moderate II cases, and 1.1% to 19.2% in moderate I/mild cases. Although the proportion of cases prescribed prednisolone and methylprednisolone decreased in moderate II and moderate I/mild cases, it remained high in severe cases. We showed the trends of steroid prescriptions in COVID-19 inpatients. The results showed that guidance can influence drug treatment provided during an emerging infectious disease pandemic.
Collapse
Affiliation(s)
- Takuya Higuchi
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Kyoto, 606-8501, Japan
| | - Jung-Ho Shin
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Kyoto, 606-8501, Japan
| | - Daisuke Takada
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Kyoto, 606-8501, Japan
| | - Tetsuji Morishita
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Kyoto, 606-8501, Japan
| | - Susumu Kunisawa
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Kyoto, 606-8501, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Kyoto, 606-8501, Japan.
| |
Collapse
|
6
|
Fisher L, Hopcroft LEM, Rodgers S, Barrett J, Oliver K, Avery AJ, Evans D, Curtis H, Croker R, Macdonald O, Morley J, Mehrkar A, Bacon S, Davy S, Dillingham I, Evans D, Hickman G, Inglesby P, Morton CE, Smith B, Ward T, Hulme W, Green A, Massey J, Walker AJ, Bates C, Cockburn J, Parry J, Hester F, Harper S, O’Hanlon S, Eavis A, Jarvis R, Avramov D, Griffiths P, Fowles A, Parkes N, Goldacre B, MacKenna B. Changes in medication safety indicators in England throughout the covid-19 pandemic using OpenSAFELY: population based, retrospective cohort study of 57 million patients using federated analytics. BMJ Med 2023; 2:e000392. [PMID: 37303488 PMCID: PMC10254692 DOI: 10.1136/bmjmed-2022-000392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/16/2023] [Indexed: 06/13/2023]
Abstract
Objective To implement complex, PINCER (pharmacist led information technology intervention) prescribing indicators, on a national scale with general practice data to describe the impact of the covid-19 pandemic on safe prescribing. Design Population based, retrospective cohort study using federated analytics. Setting Electronic general practice health record data from 56.8 million NHS patients by use of the OpenSAFELY platform, with the approval of the National Health Service (NHS) England. Participants NHS patients (aged 18-120 years) who were alive and registered at a general practice that used TPP or EMIS computer systems and were recorded as at risk of at least one potentially hazardous PINCER indicator. Main outcome measure Between 1 September 2019 and 1 September 2021, monthly trends and between practice variation for compliance with 13 PINCER indicators, as calculated on the first of every month, were reported. Prescriptions that do not adhere to these indicators are potentially hazardous and can cause gastrointestinal bleeds; are cautioned against in specific conditions (specifically heart failure, asthma, and chronic renal failure); or require blood test monitoring. The percentage for each indicator is formed of a numerator of patients deemed to be at risk of a potentially hazardous prescribing event and the denominator is of patients for which assessment of the indicator is clinically meaningful. Higher indicator percentages represent potentially poorer performance on medication safety. Results The PINCER indicators were successfully implemented across general practice data for 56.8 million patient records from 6367 practices in OpenSAFELY. Hazardous prescribing remained largely unchanged during the covid-19 pandemic, with no evidence of increases in indicators of harm as captured by the PINCER indicators. The percentage of patients at risk of potentially hazardous prescribing, as defined by each PINCER indicator, at mean quarter 1 (Q1) 2020 (representing before the pandemic) ranged from 1.11% (age ≥65 years and non-steroidal anti-inflammatory drugs) to 36.20% (amiodarone and no thyroid function test), while Q1 2021 (representing after the pandemic) percentages ranged from 0.75% (age ≥65 years and non-steroidal anti-inflammatory drugs) to 39.23% (amiodarone and no thyroid function test). Transient delays occurred in blood test monitoring for some medications, particularly angiotensin-converting enzyme inhibitors (where blood monitoring worsened from a mean of 5.16% in Q1 2020 to 12.14% in Q1 2021, and began to recover in June 2021). All indicators substantially recovered by September 2021. We identified 1 813 058 patients (3.1%) at risk of at least one potentially hazardous prescribing event. Conclusion NHS data from general practices can be analysed at national scale to generate insights into service delivery. Potentially hazardous prescribing was largely unaffected by the covid-19 pandemic in primary care health records in England.
Collapse
Affiliation(s)
- Louis Fisher
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Lisa EM Hopcroft
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sarah Rodgers
- PRIMIS, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - James Barrett
- PRIMIS, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Kerry Oliver
- PRIMIS, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Anthony J Avery
- Centre for Academic Primary Care, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Dai Evans
- PRIMIS, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Helen Curtis
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Richard Croker
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Orla Macdonald
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Jessica Morley
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Amir Mehrkar
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sebastian Bacon
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Simon Davy
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Iain Dillingham
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - David Evans
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - George Hickman
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Peter Inglesby
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Caroline E Morton
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Becky Smith
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Tom Ward
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - William Hulme
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Amelia Green
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Jon Massey
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Alex J Walker
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | - Ben Goldacre
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Brian MacKenna
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| |
Collapse
|
7
|
Medlinskiene K, Richardson S, Petty D, Stirling K, Fylan B. Barriers and enablers to healthcare system uptake of direct oral anticoagulants for stroke prevention in atrial fibrillation: a qualitative interview study with healthcare professionals and policy makers in England. BMJ Open 2023; 13:e069575. [PMID: 37185196 PMCID: PMC10151893 DOI: 10.1136/bmjopen-2022-069575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE To better understand the factors influencing the uptake of direct oral anticoagulants (DOACs) across different health economies in National Health Service England from the perspective of health professionals and other health economy stakeholders. DESIGN Qualitative interview study using a critical realism perspective and informed by the Diffusion of Innovations in Service Organisations model. SETTING Three health economies in the North of England, United Kingdom. PARTICIPANTS Healthcare professionals involved in the management of patients requiring oral anticoagulants, stakeholders involved in the implementation of DOACs and representatives of pharmaceutical industry companies and patient support groups. INTERVENTION Semistructured interviews (face-to-face or telephone) were conducted with 46 participants. Interviews were analysed using the Framework method. RESULTS Identified factors having an impact on the uptake of DOACs were grouped into four themes: perceived value of the innovation, clinician practice environment, local health economy readiness for change, and the external health service context. Together, these factors influenced what therapy options were offered and prescribed to patients with atrial fibrillation. The interviews also highlighted strategies used to improve or restrict the uptake of DOACs and tensions between providing patient-centred care and managing financial implications for commissioners. CONCLUSIONS The findings contribute to the wider literature by providing a new and in-depth understanding on the uptake of DOACs. The findings may be applicable to other new medicines used in chronic health conditions.
Collapse
Affiliation(s)
- Kristina Medlinskiene
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, West Yorkshire, UK
- Medicine Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Susan Richardson
- Department of Management, Huddersfield Business School, University of Huddersfield, Huddersfield, UK
| | - Duncan Petty
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, West Yorkshire, UK
| | - Katherine Stirling
- Medicine Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Beth Fylan
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, West Yorkshire, UK
- Yorkshire Quality and Safety Research Group, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, Yorkshire, UK
| |
Collapse
|
8
|
Dale CE, Takhar R, Carragher R, Katsoulis M, Torabi F, Duffield S, Kent S, Mueller T, Kurdi A, Le Anh TN, McTaggart S, Abbasizanjani H, Hollings S, Scourfield A, Lyons RA, Griffiths R, Lyons J, Davies G, Harris D, Handy A, Mizani MA, Tomlinson C, Thygesen JH, Ashworth M, Denaxas S, Banerjee A, Sterne JAC, Brown P, Bullard I, Priedon R, Mamas MA, Slee A, Lorgelly P, Pirmohamed M, Khunti K, Morris AD, Sudlow C, Akbari A, Bennie M, Sattar N, Sofat R. The impact of the COVID-19 pandemic on cardiovascular disease prevention and management. Nat Med 2023; 29:219-225. [PMID: 36658423 DOI: 10.1038/s41591-022-02158-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 11/28/2022] [Indexed: 01/21/2023]
Abstract
How the Coronavirus Disease 2019 (COVID-19) pandemic has affected prevention and management of cardiovascular disease (CVD) is not fully understood. In this study, we used medication data as a proxy for CVD management using routinely collected, de-identified, individual-level data comprising 1.32 billion records of community-dispensed CVD medications from England, Scotland and Wales between April 2018 and July 2021. Here we describe monthly counts of prevalent and incident medications dispensed, as well as percentage changes compared to the previous year, for several CVD-related indications, focusing on hypertension, hypercholesterolemia and diabetes. We observed a decline in the dispensing of antihypertensive medications between March 2020 and July 2021, with 491,306 fewer individuals initiating treatment than expected. This decline was predicted to result in 13,662 additional CVD events, including 2,281 cases of myocardial infarction and 3,474 cases of stroke, should individuals remain untreated over their lifecourse. Incident use of lipid-lowering medications decreased by 16,744 patients per month during the first half of 2021 as compared to 2019. By contrast, incident use of medications to treat type 2 diabetes mellitus, other than insulin, increased by approximately 623 patients per month for the same time period. In light of these results, methods to identify and treat individuals who have missed treatment for CVD risk factors and remain undiagnosed are urgently required to avoid large numbers of excess future CVD events, an indirect impact of the COVID-19 pandemic.
Collapse
Affiliation(s)
- Caroline E Dale
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Rohan Takhar
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Raymond Carragher
- Strathclyde Institute of Pharmacy & Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Michail Katsoulis
- MRC Unit for Lifelong Health and Ageing, Institute of Cardiovascular Science, University College London, London, UK
| | - Fatemeh Torabi
- Population Data Science, Swansea University Medical School, Faculty of Medicine, Health & Life Science, Swansea University, Swansea, UK
| | | | - Seamus Kent
- National Institute for Health and Care Excellence, London, UK
| | - Tanja Mueller
- Strathclyde Institute of Pharmacy & Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy & Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
| | - Thu Nguyen Le Anh
- Strathclyde Institute of Pharmacy & Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | | | - Hoda Abbasizanjani
- Population Data Science, Swansea University Medical School, Faculty of Medicine, Health & Life Science, Swansea University, Swansea, UK
| | | | | | - Ronan A Lyons
- Population Data Science, Swansea University Medical School, Faculty of Medicine, Health & Life Science, Swansea University, Swansea, UK
| | - Rowena Griffiths
- Population Data Science, Swansea University Medical School, Faculty of Medicine, Health & Life Science, Swansea University, Swansea, UK
| | - Jane Lyons
- Population Data Science, Swansea University Medical School, Faculty of Medicine, Health & Life Science, Swansea University, Swansea, UK
| | - Gareth Davies
- Population Data Science, Swansea University Medical School, Faculty of Medicine, Health & Life Science, Swansea University, Swansea, UK
| | - Daniel Harris
- Population Data Science, Swansea University Medical School, Faculty of Medicine, Health & Life Science, Swansea University, Swansea, UK
| | - Alex Handy
- Institute of Health Informatics, University College London, London, UK
| | - Mehrdad A Mizani
- Institute of Health Informatics, University College London, London, UK
- British Heart Foundation Data Science Centre, Health Data Research UK, London, UK
| | | | - Johan H Thygesen
- Institute of Health Informatics, University College London, London, UK
| | | | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
- British Heart Foundation Data Science Centre, Health Data Research UK, London, UK
- Health Data Research UK, London, UK
- BHF Accelerator, University College London, London, UK
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Jonathan A C Sterne
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, Bristol, UK
- Health Data Research UK South-West, Bristol, UK
| | | | | | - Rouven Priedon
- British Heart Foundation Data Science Centre, Health Data Research UK, London, UK
| | | | | | - Paula Lorgelly
- Department of Applied Health Research, University College London, London, UK
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | | | - Cathie Sudlow
- British Heart Foundation Data Science Centre, Health Data Research UK, London, UK
| | - Ashley Akbari
- Population Data Science, Swansea University Medical School, Faculty of Medicine, Health & Life Science, Swansea University, Swansea, UK
| | - Marion Bennie
- Strathclyde Institute of Pharmacy & Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Reecha Sofat
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK.
- British Heart Foundation Data Science Centre, Health Data Research UK, London, UK.
| |
Collapse
|
9
|
Torabi F, Harris DE, Bodger O, Akbari A, Lyons RA, Gravenor M, Halcox JP. Identifying unmet antithrombotic therapeutic need, and implications for stroke and systemic embolism in atrial fibrillation patients: a population-scale longitudinal study. Eur Heart J Open 2022; 2:oeac066. [PMID: 36415305 PMCID: PMC9678205 DOI: 10.1093/ehjopen/oeac066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/15/2022] [Indexed: 11/23/2022]
Abstract
Aims Guidelines recommend anticoagulation (AC) in atrial fibrillation (AF) to reduce stroke and systemic embolism (SSE) risk; however, implementation has been slow across many populations. This study aimed to quantify the potential impact of changing prevalence of AF, associated risk, and AC prescribing on SSE hospitalizations and death. Methods and results We evaluated temporal trends of AF, CHA2DS2-VASc, antithrombotic prescriptions, SSE hospitalizations, death, and their associations between 2012 and 2018 in a longitudinal cohort of AF patients in Wales UK. Multi-state Markov models were used to estimate expected SSE rates given the AC coverage, adjusting for CHA2DS2-VASc scores. SSE rates were modelled for various past and future AC scenarios. A total of 107 137 AF patients were evaluated (mean age = 74 years, 45% female). AF prevalence increased from 1.75 to 2.22% (P-value <0.001). SSE hospitalizations decreased by 18% (2.34-1.92%, P-value <0.001). Increased AC coverage from 50 to 70% was associated with a 37% lower SSE rate, after adjustment for individual time-dependent CHA2DS2VASc scores. The observed AC increase accounted for approximately 80 fewer SSE hospitalizations per 100 000/year. If 90% AC coverage had been achieved since 2012, an estimated 279 SSE per 100 000/year may have been prevented. Our model also predicts that improving AC coverage to 90% over the next 9 years could reduce annual SSE rates by 9%. Conclusion We quantified the relationship between observed AC coverage, estimating the potential impact of variation in the timing of large-scale implementation. These data emphasize the importance of timely implementation and the considerable opportunity to improve clinical outcomes in the Wales-AF population.
Collapse
Affiliation(s)
- Fatemeh Torabi
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| | - Daniel E Harris
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| | - Owen Bodger
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| | - Ashley Akbari
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| | - Ronan A Lyons
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| | - Michael Gravenor
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| | - Julian P Halcox
- Population Data Science, Swansea University, Swansea SA2 8PP, UK
| |
Collapse
|
10
|
Mendes A. Changes to anticoagulation during the pandemic. Br J Community Nurs 2022; 27:170-171. [PMID: 35353588 DOI: 10.12968/bjcn.2022.27.4.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Aysha Mendes
- Freelance journalist, specialising in psychology and healthcare
| |
Collapse
|
11
|
Barrett R, Hodgkinson J. Impact of the COVID-19 pandemic on cardiovascular heart disease medication use: time-series analysis of England's prescription data during the COVID-19 pandemic (January 2019 to October 2020). Ther Adv Cardiovasc Dis 2022; 16:17539447221137170. [PMID: 36420815 PMCID: PMC9702971 DOI: 10.1177/17539447221137170] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 10/19/2022] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Management of high blood pressure (BP) typically requires adherence to medication regimes. However, it is known that the COVID-19 pandemic both interrupted access to some routine prescriptions and changed some patient health behaviours. AIM This study, therefore, retrospectively investigated prescription reimbursement of cardiovascular (CVD) medicines as a proxy measure for patient adherence and access to medicines during the pandemic. METHODS A cohort study of all primary care patients in England prescribed CVD medicines. The exposure was to the global pandemic. Prescriptions were compared before and after the pandemic's onset. Statistical variation was the outcome of interest. RESULTS Descriptive statistics show changes to monthly prescriptions, with wide confidence intervals indicating varying underlying practice. Analysis of variance reveals statistically significant differences for bendroflumethiazide, potassium-sparing diuretics, nicorandil, ezetimibe, ivabradine, ranolazine, colesevelam and midodrine. After the pandemic began (March-October 2020), negative parameters are observed for ACE inhibitors, beta-blockers, calcium channel blockers, statins, antiplatelet, antithrombotics, ARBs, loop diuretics, doxazosin, bendroflumethiazide, nitrates and indapamide, indicating decelerating monthly prescription items (statistically significant declines of calcium channel blockers, antithrombotic, adrenoreceptor blockers and diuretics) of CVD medicines within the general population. Many data points are not statistically significant, but fluctuations remain clinically important for the large population of patients taking these medications. CONCLUSION A concerning decline in uptake of CVD therapies for chronic heart disease was observed. Accessible screening and treatment alongside financial relief on prescription levies are needed. A video abstract is (4 min 51 s) available: https://bit.ly/39gvEHi.
Collapse
Affiliation(s)
- Ravina Barrett
- School of Applied Sciences, University of
Brighton, Cockcroft Building, Lewes Road, Moulsecoomb, Brighton BN2 4GJ,
UK
| | - James Hodgkinson
- Murray Learning Centre, Institute of Applied
Health Research, College of Medical and Dental Sciences, University of
Birmingham, Birmingham, UK
| |
Collapse
|
12
|
Anis A, Heneghan C, Aronson JK, DeVito NJ, Richards GC. Deaths from cardiovascular disease involving anticoagulants: a systematic synthesis of coroners' case reports. BJGP Open 2021:BJGPO. [PMID: 34620599 DOI: 10.3399/BJGPO.2021.0150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/26/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The global burden of cardiovascular disease (CVD) is forecast to increase, and anticoagulants will remain important medicines for its management. Coroners' Prevention of Future Death reports (PFDs) provide valuable insights that may enable safer and more effective use of these agents. AIM To identify CVD-related PFDs involving anticoagulants. DESIGN & SETTING Case series of coronial reports in England and Wales between 2013 and 2019. METHOD A total of 3037 PFDs were screened for eligibility. PFDs were included where CVD and an anticoagulant caused or contributed to the death. Included cases were descriptively analysed and content analysis was used to assess concerns raised by coroners and who had responded to them. RESULTS The study identified 113 CVD-related PFDs involving anticoagulants. Warfarin (36%, n = 41), enoxaparin (11%, n = 12), and rivaroxaban (11%, n = 12) were the most common anticoagulants reported. Concerns most frequently raised by coroners included poor systems (31%), poor communication (25%), and failures to keep accurate medical records (25%). These concerns were most often directed to NHS trusts (29%), hospitals (10%), and general practices (8%). Nearly two-thirds (60%) of PFDs had not received responses from such organisations, which are mandatory under regulation 28 of the Coroners' (Investigations) Regulations 2013. A publicly available tool has been created by the authors (https://preventabledeathstracker.net), which displays coroners' reports in England and Wales to streamline access, and identify important lessons to prevent future deaths. CONCLUSION National organisations, healthcare professionals, and prescribers should take actions to address the concerns of coroners in PFDs to improve the safe use of anticoagulants in patients with CVD.
Collapse
|