The anticoagulation choices of internal medicine residents for stroke prevention in non-valvular atrial fibrillation

Moulson, Nathaniel; McIntyre, William F.; Oqab, Zardasht; Yazdan‐Ashoori, Payam; Quinn, Kieran L.; Oosten, Erik van; Hopman, Wilma M.; Baranchuk, Adrián

doi:10.1136/postgradmedj-2016-134159

Cited by 8 publications

(8 citation statements)

References 31 publications

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“…There existed no antidote for rivaroxaban or apixaban until the introduction of andexanet alfa in 2018-and still, no antidote has been recommended by a NICE technology appraisal. This is all in addition to potential inertia derived from prescriber preference and experience level [10]. Finally, a bevy of local factors such as pharmaceutical rebates, local incentives and policies, and patient demographics influence prescribing choices.…”

Section: Introductionmentioning

confidence: 99%

Trends in anticoagulant prescribing: a review of local policies in English primary care

Hove

Leng

2020

BMC Health Serv Res

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Background: Oral anticoagulants are prescribed for stroke prophylaxis in patients with atrial fibrillation, which is the most common heart arrhythmia worldwide. The vitamin K antagonist (VKA) warfarin is a long-established anticoagulant. However, newer direct oral anticoagulants (DOACs) have been recently introduced as an alternative. Given the prevalence of atrial fibrillation, anticoagulant choice has substantial clinical and financial implications for healthcare systems. In this study, we explore trends and geographic variation in anticoagulant prescribing in English primary care. Because national guidelines in England do not specify a first-line anticoagulant, we investigate the association between local policies and prescribing data. Methods: Primary care prescribing data of anticoagulants for all NHS practices from 2014 to 2019 in England was obtained from the ePACT2 database. Public formularies were accessed online to obtain local anticoagulation prescribing policies for 89.5% of clinical commissioning groups (CCGs). These were categorized according to their recommendations: no local policies, warfarin as first-line, or identification of a preferred DOAC (but not a preferred anticoagulant). Local policies were cross-tabulated with pooled prescribing data to measure the strength of association with Cramér's V. Results: Nationally, prescribing of DOACs increased from 9% of all anticoagulants in 2014 to 74% in 2019, while that of warfarin declined accordingly. Still, there was significant local variation. Across geographical regions, DOACs ranged from 53 to 99% of all anticoagulants. Most CCGs (73%) did not specify a first-line choice, and 16% recommended warfarin first line. Only 11% designated a preferred DOAC. Policies with a preferred DOAC indeed correlated with increased prescribing of that DOAC (Cramér's V = 0.25, 0.27, 0.38 for rivaroxaban, apixaban, edoxaban respectively). However, local policies showed a negligible relationship with the classes of anticoagulants prescribed-DOAC or VKA (Cramér's V = 0.01). Conclusions: Nationally, the use of DOACs to treat atrial fibrillation has increased rapidly. Despite this, significant geographical variation in uptake remains. This study provides insights on how local policies relate to this variation. Our findings suggest that, in the absence of a nationally recommended first-line anticoagulant, local prescribing policies may aid in deciding between individual DOACs, but not in adjudicating between DOACs and vitamin K antagonists (i.e. warfarin) as general classes.

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Section: Introductionmentioning

confidence: 99%

Trends in anticoagulant prescribing: a review of local policies in English primary care

Hove

Leng

2020

BMC Health Serv Res

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“…Similar results about the importance of the patient's role have been reported also from other countries. In a Canadian survey for internal medicine residents, patient convenience was the second most important factor when choosing an OAC for patients with AF after adverse events . In Italy, 70% of internal medicine centres participating in a survey on DOACs regarded the patient's preference to be highly relevant when prescribing DOAC therapy in AF .…”

Section: Discussionmentioning

confidence: 99%

“…Shared decision‐making is considered appropriate for stroke prevention in AF because of the availability of several treatment options with different risk‐benefit profiles. Recent physician surveys and interviews suggest that physicians consider patient participation in decision‐making on the use of oral anticoagulants (OACs) in AF important . Physicians also report clinical characteristics of the patient, risk of adverse events, their own knowledge, experience and preferences to be important in decision‐making.…”

Section: Introductionmentioning

confidence: 99%

“…Recent physician surveys and interviews suggest that physicians consider patient participation in decision‐making on the use of oral anticoagulants (OACs) in AF important . Physicians also report clinical characteristics of the patient, risk of adverse events, their own knowledge, experience and preferences to be important in decision‐making. Database studies have identified mainly clinical factors, such as estimated stroke risk, age and other cardiovascular diseases as factors affecting the choice of an OAC.…”

Section: Introductionmentioning

confidence: 99%

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Physicians’ views on patient participation in choice of oral anticoagulants in atrial fibrillation—a qualitative study

Aarnio

Huupponen

Hämeen‐Anttila

et al. 2018

Basic Clin Pharma Tox

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Direct oral anticoagulants provide an alternative to vitamin K antagonists for the anticoagulation therapy in atrial fibrillation (AF). The availability of several treatment options with different attributes makes shared decision-making appropriate for the choice of anticoagulation therapy. The aim of this study was to understand how physicians choose an oral anticoagulant (OAC) for patients with AF and how physicians view patients' participation in this decision. Semi-structured interviews with 17 Finnish physicians (eight general practitioners and nine specialists) working in the public sector were conducted. An interview guide on experience, prescribing and opinions about oral anticoagulants was developed based on previous literature. The data were thematically analysed using deductive and inductive approaches. Based on the interviews, patient's opinion was the most influential factor in decision-making when there were no clinical factors limiting the choice between OACs. Of patient's preferences, the most important was the attitude towards co-payments of OACs. Patients' opinions on monitoring of treatment, dosing and antidote availability were also mentioned by the interviewees. The choice of an OAC in AF was patient-centred as all interviewees expressed that patient's opinion affects the choice. K E Y W O R D Satrial fibrillation, direct oral anticoagulants, interview, prescription of drugs, warfarin

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“…Multiple studies have demonstrated anticoagulation knowledge gaps in resident physicians. 11,12 One curriculum coauthor Irsk Anderson serves as the medical director for the Anticoagulant Management Service (AMS), an outpatient-based clinic that longitudinally follows and monitors patients on oral anticoagulation. Irsk Anderson, while serving as the AMS medical director as well as precepting the internal medicine residents in continuity clinic and on the inpatient wards, noted significant and concerning knowledge gaps within the residency program.…”

Section: Introductionmentioning

confidence: 99%

Direct-Acting Oral Anticoagulants: A Resident-Based Workshop to Improve Knowledge and Confidence

Anderson

Arora

2020

MedEdPORTAL

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Introduction: Direct-acting oral anticoagulant (DOAC) prescriptions have increased steadily since the first, dabigatran, was Food and Drug Administration-approved in 2010. They have multiple advantages over vitamin K antagonists including fixed dosing without coagulation lab monitoring, rapid onset and offset of action, and fewer drug and food interactions. Patient-specific dosing, administration education, adherence, and monitoring are critically important. Many providers are unfamiliar with these concepts and too often use DOACs for off-label indications or at off-label dosing. A DOAC workshop was created to address knowledge gaps and improve internal medicine resident prescribing confidence. Methods: One author (Irsk Anderson) conducted four 1-hour DOAC workshops with 49 total internal medicine residents rotating on their outpatient clinical rotation between October 2018 and November 2019. Residents performed small-group learning around four DOAC-specific cases, followed by a large-group report-out session. The residents completed pre-and postworkshop multiple-choice questions (MCQs) to assess knowledge as well as a postworkshop DOAC confidence self-assessment. Results: Resident knowledge, assessed by percentage of residents answering correctly, improved significantly for all four MCQs after completing the workshop (all p <.003). Resident confidence, assessed on a 5-point Likert scale, improved significantly for all five themes (p <.001). Overall resident satisfaction was high (M = 4.2 on a 5-point Likert scale) and 85% desired further DOAC training. Discussion: A 1-hour DOAC workshop was feasible and improved internal medicine resident knowledge and self-confidence. Future work should assess behavior change and patient clinical outcomes.

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The anticoagulation choices of internal medicine residents for stroke prevention in non-valvular atrial fibrillation

Abstract: Canadian internal medicine residents favoured warfarin over NOACs for patients with NVAF, which is in discordance with the evidence-based CCS guidelines. This finding persisted throughout the 3 years of core internal medicine training.

Cited by 8 publications

References 31 publications

Trends in anticoagulant prescribing: a review of local policies in English primary care

Trends in anticoagulant prescribing: a review of local policies in English primary care

Physicians’ views on patient participation in choice of oral anticoagulants in atrial fibrillation—a qualitative study

Direct-Acting Oral Anticoagulants: A Resident-Based Workshop to Improve Knowledge and Confidence

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