Assessment of Patient Adherence to Direct Oral Anticoagulant vs Warfarin Therapy

Patel, Salma; Cherington, Chad; Scherber, Robyn M.; Barr, Kathryn; McLemore, Ryan; Morisky, Donald E.; Cha, Stephen; Mookadam, Farouk; Shamoun, Fadi

doi:10.7556/jaoa.2017.002

Cited by 22 publications

(17 citation statements)

References 45 publications

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“…In clinical practice, there are frequent warfarin dosage adjustments between 2 dispensations that are based on INR monitoring. Our findings suggest that, under the reasonable assumption of similar adherence between warfarin and DOACs users at the population level, the high variation in refill gaps for warfarin is due to inadequate capture in the dispensation data of the periods covered by the number of dispensed pills. This can be explained by lack of communication between treating physician, who adjust warfarin, and dispensing pharmacists.…”

Section: Discussionmentioning

confidence: 87%

Methodological challenges in assessment of current use of warfarin among patients with atrial fibrillation using dispensation data from administrative health care databases

Sinyavskaya

Matteau

Johnson

et al. 2018

Pharmacoepidemiology and Drug

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Section: Discussionmentioning

confidence: 87%

Methodological challenges in assessment of current use of warfarin among patients with atrial fibrillation using dispensation data from administrative health care databases

Sinyavskaya

Matteau

Johnson

et al. 2018

Pharmacoepidemiology and Drug

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“…Studies aimed at evaluating OAC adherence in everyday clinical practice have commonly measured adherence using either prescription fill data or patient self-reports, each of which is subject to limitations. Patient self-reports are subjective and may be influenced by errors in recall, 16 – 18 whereas objective claims-based prescription fill data may contain coding errors, and documentation of a prescription fill is not proof that the patient took the medication as prescribed. 3 , 10 , 11 , 19 , 20 To our knowledge, no studies have assessed OAC adherence using both prescription claims and patient-reported data.…”

Section: Introductionmentioning

confidence: 99%

Comparison of claims vs patient-reported adherence measures and associated outcomes among patients with nonvalvular atrial fibrillation using oral anticoagulant therapy

Stephenson¹,

Shinde²,

Kwong³

et al. 2018

PPA

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ObjectiveTo compare oral anticoagulant (OAC) adherence among patients with nonvalvular atrial fibrillation (NVAF) using patient-reported and claims-based measures, and to evaluate the effect of OAC adherence on health care costs and patient satisfaction with OAC therapy.MethodsThis was a hybrid US observational study consisting of a longitudinal cohort survey followed by linkage and analysis of respondents’ administrative claims data. Patients with NVAF receiving warfarin, dabigatran, rivaroxaban, or apixaban completed an initial survey and follow-up surveys at 4, 8, and 12 months. Patient-reported adherence was measured at each survey by Morisky Medication Adherence Scale (MMAS-8) and pharmacy claims-determined adherence by the proportion of days covered (PDC) for the 12-month period following the initial survey date; adherence was defined as MMAS-8 score =8 and PDC ≥80%. Patient satisfaction with OAC therapy was assessed by the Duke Anticoagulation Satisfaction Scale (DASS).ResultsOverall, 675 patients completed at least the initial survey (warfarin, n=271; dabigatran, n=266; rivaroxaban, n=128; apixaban, n=10). Fewer than half (47.9%) were PDC adherent, 37.2% were MMAS-8 adherent, and 19.4% were adherent by both measures. Total medical costs of PDC-adherent patients were significantly lower vs PDC-nonadherent patients (US$640 vs $993 per-patient per-month, respectively, p<0.05). MMAS-8-adherent patients reported higher treatment satisfaction; total DASS score was significantly lower among MMAS-8-adherent than MMAS-8-nonadherent patients (37.3 vs 42.9, respectively, p<0.001).ConclusionUsing claims-based or patient-reported methods to measure OAC adherence may lead to different results when assessing impact on health care costs and satisfaction with anticoagulation medication. These results underscore the importance of considering both claims-based and patient-reported measures when evaluating treatment adherence in real-world settings.

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“… 7 Early research suggests that adherence to the newer agents may be similar to adherence to warfarin. 25 , 26 This implies that missing doses of direct oral anticoagulants may subject patients to the risk of breakthrough PE, just as with missing doses of warfarin. The half-lives of the direct oral anticoagulants are significantly shorter than that of warfarin (6–17 hours vs. 20–60 hours), suggesting less tolerance for non-adherence.…”

Section: Discussionmentioning

confidence: 99%

Acute Pulmonary Embolism in Emergency Department Patients Despite Therapeutic Anticoagulation

Liu¹,

Ballard²,

Huang³

et al. 2018

WestJEM

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IntroductionEmergency department (ED) patients with acute pulmonary embolism (PE) despite therapeutic anticoagulation at the time of diagnosis are uncommonly encountered and present a diagnostic and management challenge. Their characterization and outcomes are poorly described. We sought to describe the prevalence and characteristics of therapeutically anticoagulated patients among a population of patients with acute PE in a community setting and to describe treatment changes and 30-day outcomes.MethodsFrom a large retrospective cohort of adults with acute, objectively-confirmed PE across 21 EDs between 01/2013 and 04/2015, we identified patients who arrived on direct oral or injectable anticoagulants, or warfarin with an initial ED international normalized ratio (INR) value ≥2.0. Patients were excluded from the larger cohort if they had received a diagnosis of venous thromboembolism (VTE) in the prior 30 days. We gathered demographic and clinical variables from electronic health records and structured manual chart review. We report discharge anticoagulation regimens and major 30-day adverse outcomes.ResultsAmong 2,996 PE patients, 36 (1.2%) met study criteria. Mean age was 63 years. Eleven patients (31%) had active cancer and 25 (69%) were high risk on the PE Severity Index (Classes III–V), comparable to the larger cohort (p>0.1). Reasons for pre-arrival anticoagulation were VTE treatment or prevention (n=21), and atrial fibrillation or flutter (n=15). All patients arrived on warfarin and one was also on enoxaparin: 32 had a therapeutic INR (2.0–3.0) and four had a supratherapeutic INR (>3.0). Fifteen patients (42%) had at least one subtherapeutic INR (<2.0) in the 14 days preceding their diagnostic visit. Two patients died during hospitalization. Of the 34 ultimately discharged, 22 underwent a change in anticoagulation drug or dosing, 19 of whom received injectables, either to replace or to supplement warfarin. Four patients also received inferior vena cava filters. Thirty-day outcomes included one major hemorrhage and one additional death. No patients experienced recurrent or worsening VTE.ConclusionWe found a low prevalence of therapeutic anticoagulation at the time of acute PE diagnosis. Most patients with breakthrough PE underwent a change in therapy, though management varied widely. Subtherapeutic anticoagulation levels in the preceding weeks were common and support the importance of anticoagulation adherence.

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Assessment of Patient Adherence to Direct Oral Anticoagulant vs Warfarin Therapy

Abstract: Similar adherence was noted between DOACs and warfarin regardless of the frequency of serum level monitoring.

Cited by 22 publications

References 45 publications

Methodological challenges in assessment of current use of warfarin among patients with atrial fibrillation using dispensation data from administrative health care databases

Methodological challenges in assessment of current use of warfarin among patients with atrial fibrillation using dispensation data from administrative health care databases

Comparison of claims vs patient-reported adherence measures and associated outcomes among patients with nonvalvular atrial fibrillation using oral anticoagulant therapy

Acute Pulmonary Embolism in Emergency Department Patients Despite Therapeutic Anticoagulation

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