Factors associated with primary nonadherence to newly initiated direct oral anticoagulants in patients with nonvalvular atrial fibrillation

Abstract

Nonadherence to medicines is a widely acknowledged problem that limits the effectiveness of treatments and results in poor patient outcomes, including increased mortality, 1-4 hospitalization, 5,6 and higher healthcare costs. [6][7][8] Direct oral anticoagulants (DOACs) are increasingly used for the prevention of stroke in patients with nonvalvular atrial fibrillation (NVAF). 9,10 In addition to the potential clinical implications of nonadherence, when compared to vitamin K antagonists (VKAs), 11,12 adherence to DOACs is a subject of particular interest in light of their reduced monitoring requirements and shorter half-lives.The use of pharmacy claims databases has expanded our ability to conduct large-scale real-world adherence studies.Thus far, however, drug utilization research on DOACs has mainly focused on other adherence measures such as persistence, [13][14][15][16][17][18][19] proportion of days covered, 16,17,[20][21][22][23][24] or medicine possession ratio. 15,25,26 Primary nonadherence, defined as failing to collect the first prescription of a medicine, is the first step to achieving effective treatment. Estimates of primary nonadherence to medicines vary widely. 27 One large study found that 28.3% of patients were primary nonadherent to new medicines, with medication class as a strong predictor of primary adherence. The study also found that medicines for chronic diseases have particularly poor primary adherence rates. 28 Primary nonadherence has been associated with worse patient outcomes, including higher rates of mortality following myocardial infarction 2 and worse control of hemoglobin A1c in diabetes. 29 The reasons for not collecting a prescription may be complex, with possible causes including cost, concern about the medicine, and the perception that the medicine is not necessary. 27 Primary nonadherence to DOACs remains relatively unexplored. Although, one recent study found the rate of nonadherence to DOACs to be 10.8%. 30 The same study, which included VKAs and DOACs, found that primary nonadherence was associated with the type of anticoagulant prescribed, foreign nationality, dementia, and higher coinsurance in older age groups. Lower odds of primary nonadherence were found for patients with liver disease, those taking over six concomitant medicines, or whose prescriptions were transmitted electronically.Information about the rate of primary nonadherence to DOACs can help elucidate the real-world cost-effectiveness of these medicines and highlight a key area for adherence interventions. Furthermore, identifying the determinants of nonadherence can serve as the basis for designing interventions to improve adherence and patient outcomes. This study uses pharmacy claims data from a large primary care database in Catalonia to measure the rate of primary nonadherence to newly prescribed DOACs in NVAF patients and to identify associated factors. Methods DATA SOURCEAll data for this study were obtained from the Information System for the Development of Research in Primary Care (SIDIAP), which co...

Adherence to Direct Oral Anticoagulants in Patients With Non-Valvular Atrial Fibrillation: A Cross-National Comparison in Six European Countries (2008–2015)

“…Polypharmacy, co-payment, and age were inversely related to higher primary non-adherence in the study from Valencia ( Rodriguez-Bernal et al, 2018 ). A specific sub-analysis of our data showed several factors that may influence primary non-adherence, including which DOAC is prescribed, age, and diagnosis of CKD, diabetes, hypertension, or stroke/TIA ( Charlton et al, 2021 ).…”

Optimization of DOAC management services in a centralized anticoagulation clinic

“…In the first few months after initiation of anticoagulation, patients are at the highest risk of adverse events and medication access barriers (eg, high copays, prior authorizations, or insurance formulary requirements); additionally, more contact with the patient early in management allows providers to establish relationships with the patients. 20 , 21 After the first 6 months, patients are stratified into either active surveillance or maintenance phase of care depending on the likelihood of requiring a dose adjustment within the next 12 months based on the DOAC specific manufacturer recommendations (Table 2 ). Patients with a moderate or high risk of needing a dose adjustment are transitioned to active surveillance after 6 months of active management.…”

“…For the first 6 months, patients are enrolled in the AMS; they remain in active management and have follow‐ups scheduled on the basis of our previous DOAC management plan. In the first few months after initiation of anticoagulation, patients are at the highest risk of adverse events and medication access barriers (eg, high copays, prior authorizations, or insurance formulary requirements); additionally, more contact with the patient early in management allows providers to establish relationships with the patients 20,21 . After the first 6 months, patients are stratified into either active surveillance or maintenance phase of care depending on the likelihood of requiring a dose adjustment within the next 12 months based on the DOAC specific manufacturer recommendations (Table 2).…”

Social and psychological risk factors for decreased adherence among patients with atrial fibrillation

“…В то же время некоторые исследователи сообщают об отсутствии значимой связи между женским полом и риском снижения приверженности терапии среди пациентов с ФП. Так, в некоторых работах не выявляются гендерные различия в отношении приверженности АКТ ФП [17]. R. Bartolazzi и соавт.…”