background Despite simpler regimens than vitamin K antagonists (VKas) for stroke prevention in atrial fibrillation (aF), adherence (taking drugs as prescribed) and persistence (continuation of drugs) to direct oral anticoagulants are suboptimal, yet understudied in electronic health records (ehrs). Objective We investigated (1) time trends at individual and system levels, and (2) the risk factors for and associations between adherence and persistence. Methods in UK primary care ehr (The health information network 2011-2016), we investigated adherence and persistence at 1 year for oral anticoagulants (Oacs) in adults with incident aF. Baseline characteristics were analysed by Oac and adherence/persistence status. risk factors for nonadherence and non-persistence were assessed using cox and logistic regression. Patterns of adherence and persistence were analysed. results among 36 652 individuals with incident aF, cardiovascular comorbidities (median cha 2 Ds 2 Vasc[congestive heart failure, hypertension, age≥75 years, Diabetes mellitus, stroke, Vascular disease, age 65-74 years, sex category] 3) and polypharmacy (median number of drugs 6) were common. adherence was 55.2% (95% ci 54.6 to 55.7), 51.2% (95% ci 50.6 to 51.8), 66.5% (95% ci 63.7 to 69.2), 63.1% (95% ci 61.8 to 64.4) and 64.7% (95% ci 63.2 to 66.1) for all Oacs, VKa, dabigatran, rivaroxaban and apixaban.One-year persistence was 65.9% (95% ci 65.4 to 66.5), 63.4% (95% ci 62.8 to 64.0), 61.4% (95% ci 58.3 to 64.2), 72.3% (95% ci 70.9 to 73.7) and 78.7% (95% ci 77.1 to 80.1) for all Oacs, VKa, dabigatran, rivaroxaban and apixaban. risk of non-adherence and non-persistence increased over time at individual and system levels. increasing comorbidity was associated with reduced risk of non-adherence and non-persistence across all Oacs. Overall rates of 'primary non-adherence' (stopping after first prescription), 'non-adherent nonpersistence' and 'persistent adherence' were 3.5%, 26.5% and 40.2%, differing across Oacs. Conclusions adherence and persistence to Oacs are low at 1 year with heterogeneity across drugs and over time at individual and system levels. Better understanding of contributory factors will inform interventions to improve adherence and persistence across Oacs in individuals and populations.on July 10, 2020 by guest. Protected by copyright.
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This is a protocol for a Cochrane Review (Diagnostic test accuracy). The objectives are as follows:To determine the diagnostic accuracy of bedside screening tools for detecting dysphagia, which is a predictor of aspiration, in people with acute stroke.To assess the influence of the following potential sources of heterogeneity.• Patient demographics (e.g. age, gender, percentage of males in study, median age of study by gender).• The time post-stroke that the study was conducted (from admission to 48 hours) to ensure only hyperacute and acute stroke dysphagia screening tools are identified.• Any significant change in the participant's condition between the index and reference tests being performed.• The definition of dysphagia used by the study.• Level of training of nursing staff, both grade and training in the screening tool.• Low-quality studies identified from the methodological quality checklist.• Type of the index test and the threshold of the index test.• Type of the reference test.1 Screening for aspiration risk associated with dysphagia in acute stroke (Protocol)
Objective SLE is characterized by relapses and remissions. We aimed to describe the frequency, type and time to flare in a cohort of SLE patients. Methods SLE patients with one or more ‘A’ or ‘B’ BILAG-2004 systems meeting flare criteria (‘new’ or ‘worse’ items) and requiring an increase in immunosuppression were recruited from nine UK centres and assessed at baseline and monthly for 9 months. Subsequent flares were defined as: severe (any ‘A’ irrespective of number of ‘B’ flares), moderate (two or more ‘B’ without any ‘A’ flares) and mild (one ‘B’). Results Of the 100 patients, 94% were female, 61% White Caucasians, mean age (s.d.) was 40.7 years (12.7) and mean disease duration (s.d.) was 9.3 years (8.1). A total of 195 flares re-occurred in 76 patients over 781 monthly assessments (flare rate of 0.25/patient-month). There were 37 severe flares, 32 moderate flares and 126 mild flares. By 1 month, 22% had a mild/moderate/severe flare and 22% had a severe flare by 7 months. The median time to any ‘A’ or ‘B’ flare was 4 months. Severe/moderate flares tended to be in the system(s) affected at baseline, whereas mild flares could affect any system. Conclusion . In a population with active SLE we observed an ongoing rate of flares from early in the follow-up period with moderate–severe flares being due to an inability to fully control the disease. This real-world population study demonstrates the limitations of current treatments and provides a useful reference population from which to inform future clinical trial design.
BackgroundThe choice of oral anticoagulant(OAC) for stroke prevention in patients with atrial fibrillation(AF) is now between warfarin and four non-vitamin K anticoagulants(NOACs):dabigatran, rivaroxaban, apixaban and edoxaban. Although discontinuation rates were reported in clinical trials of the NOACs, real-world persistence, adherence and cross-over between therapies are unknown. MethodsPrescription data for OACs in adults with AF between April 2011 and December 2015 were analysed from a representative national primary care database in England(The Health Improvement Network, THIN). Edoxaban was approved for use in the UK in September 2015 and therefore insufficient numbers of prescriptions were available for analysis. Persistence(estimated by gap between prescriptions) and adherence(proportion of days covered, PDC) for OACs were assessed in individuals with AF newly treated with dabigatran, rivaroxaban, apixaban or warfarin with at least 365 days follow-up after the prescription date. For each NOAC, the proportion of cross-over to another OAC was analysed. ResultsAmong 4,354,740 individuals, 118,056 with AF were identified, of which 82,795 had available prescription data for OACs. Of these patients, 78,447 had at least 12 months data: warfarin (n=67781), dabigatran (n=2540), rivaroxaban (n=5666) and apixaban (n=2460). At 1 year, the crude persistence rates were 88.7% (95% CI 88.4-88.9) for warfarin, 59.1% (57.2-61.0) for dabigatran, 64.7% (63.4-65.9) for rivaroxaban and 67.0% (65.1-68.9) for apixaban. Persistence was significantly lower than in the clinical trials and was lower for NOACs than warfarin. The adherence rates (PDC>80%) were 87.5% (CI 87.3,87.6) for warfarin, 83.5% (CI 82.3,84.8) for dabigatran, 84.1% (CI 83.1,85.1) for rivaroxaban and 83.6% (CI 81.6,85.5) for apixaban. The proportion of NOAC users crossing over to another NOAC and to warfarin were 12.1% and 7.3% for dabigatran, 3.4% and 3.4% for rivaroxaban, and 1.9% and 1.5% for apixaban respectively. ConclusionsIn a large English population, NOACs exhibited lower persistence rates than in clinical trials, warranting further analyses of side effect profile and acceptability of OACs. Routinely collected data can be used to measure real-world persistence and adherence which are important in future studies of comparative effectiveness.
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