Long-term adherence to direct acting oral anticoagulants and the influence of health beliefs after switching from vitamin-K antagonists: Findings from the Switching Study.

AIMS: Switching non-adherent patients prescribed anticoagulant treatment to a regime with less monitoring could lead to significant non-adherence. Health beliefs are known to influence medication adherence; however, the extent of this influence is unknown in patients switched from vitamin-K antagonists (VKAs) to direct oral anticoagulants (DOACs). This study aimed to determine adherence to long-term therapy in patients switched from VKAs to DOAC due to low time in therapeutic range (TTR) and if adherence is associated with health beliefs. METHODS: The Switching Study is a longitudinal observational cohort study following patients for at least 1-year. 254 patients anticoagulated with VKAs for stroke prevention in atrial fibrillation (AF) or secondary prevention of venous thromboembolism (VTE) and TTR < 50% were recruited from anticoagulation clinics at King's College Hospital, London, UK. All participants were switched to DOAC and had health beliefs measured at baseline with VKA, 1-month and 12-months after switching. RESULTS: Of the 220 patients who completed 12-month follow-up 39% had sub-optimal adherence measured by self-report. 23% were non-adherent according to prescriptions issued. Increasing concerns about anticoagulation over time relative to beliefs about necessity was associated with lower self-reported adherence (OR = 0.902 95%C.I: 0.836, 0.974; p = 0.008). At baseline, believing that medications in general were overused in healthcare was negatively associated with adherence to DOAC (ß = -1.5, 95%C.I: -2.7, -0.3; p = 0.013). CONCLUSIONS: Although many patients who switched were adherent to therapy long-term, between 23 and 39% of patients exhibited sub-optimal adherence: these patients can be identified through their modifiable health beliefs at the time of switching.

The transition from hospital to home following acute coronary syndrome: an exploratory qualitative study of patient perceptions and early experiences in two countries.

OBJECTIVES: Following acute coronary syndrome (ACS), it is standard practice for stable patients to be discharged as quickly as possible from hospital. If patients are not adequately supported at this time, issues such as readmission can occur. We report findings from an exploratory qualitative study investigating the perceptions and early experiences of patients transitioning from hospitals in the UK and USA to home following ACS. METHODS: Within 1 month of discharge, we conducted semi-structured telephone interviews with patients hospitalised for ACS (UK: n = 8; USA: n = 9). Data were analysed using the Framework Method. KEY FINDINGS: We identified four superordinate themes. Coping, adjustment and management: Patients were still adjusting to the physical limitations caused by their event but most had begun to implement positive lifestyle changes. Gaps in care transition: Poor communication and organisation postdischarge resulted in delayed follow-up for some patients causing considerable frustration. Quality of care from hospital to home: Patients experienced varied inpatient care quality but had largely positive interactions in primary/community care. Pharmacy input during care transition was viewed favourably in both countries. Medication-taking beliefs and behaviour: Patients reported good initial adherence to treatment but side effects were a concern. CONCLUSIONS: ACS patients experienced gaps in care early in the transition from hospital to home. Poor communication and uncoordinated support postdischarge negatively impacted patient experience. Further research is needed to determine how patients' early experiences following ACS can affect longer-term outcomes including healthcare engagement and treatment maintenance.

Associations between illness beliefs, medication beliefs, anticoagulation-related quality of life, and INR control: Insights from the Switching Study.

BACKGROUND: Anticoagulation control with vitamin-K antagonists (VKAs) in patients with atrial fibrillation (AF) or venous thromboembolism (VTE) can be measured using time in therapeutic range (TTR), where TTR >65% is considered good and low TTR may be associated with low adherence. METHODS: This cross-sectional observational study compared illness beliefs, treatment beliefs, and treatment satisfaction of patients with TTR >75% and TTR <50% using validated tools to determine their association with TTR. Adults requiring chronic VKA therapy were recruited from 2 hospital anticoagulation clinics in London, UK. RESULTS: 311 patients with TTR >75% and 214 with TTR <50% were recruited. TTR >75% patients had been taking warfarin on average over 2 years longer than TTR <50% patients (P < .001). Statistically significant differences in beliefs were found in all subscales other than in treatment control, general harm, and general overuse. Cluster analysis determined there were 4 distinct clusters of beliefs among patients. Multivariate binary logistic regression found VTE patients were least likely to have poor TTR (OR = 0.49; 95% CI 0.29, 0.77). Patients in the "cautious of therapy and fearful of illness" cluster were most likely to have low TTR (OR = 4.75; 95% CI 2.75, 8.77). CONCLUSION: Illness perceptions, medication beliefs and treatment satisfaction were associated with INR control. VTE patients and those who were accepting of both illness and treatment were most likely to have optimal INR control.

Exploration of adherence and patient experiences with DOACs one year after switching from vitamin-K antagonists- insights from the switching study.

BACKGROUND: Current UK and European guidelines recommend anticoagulated patients prescribed warfarin with time in therapeutic range (TTR) <65% be considered for DOAC therapy. There has been considerable concern that adherence with DOACs may be poor compared with warfarin. Little is known about the patient experience of switching from warfarin to DOAC and how patients manage their DOAC long term. Our aim was to conduct focus groups exploring patient's previous experiences with warfarin, their current experience with DOACs, their adherence to DOACs and the long-term service provision they envisage. METHODS: Patients enrolled on the Switching Study who had been switched from warfarin to a DOAC >1year previously were invited to participate in focus groups. Two focus groups for atrial fibrillation (AF) and two for secondary prevention of venous thromboembolism (VTE) patients were held at anticoagulation clinics in South London, UK. Data was analysed using framework analysis to extract dominant themes. RESULTS: Five VTE patients and 15 AF patients attended the focus groups. Dominant themes that emerged were: indication specific anticoagulation prioritisation, warfarin as a necessary inconvenience, DOACs as the anticoagulant of choice, concerns regarding DOAC monitoring, high adherence to DOACs and desire for long-term access to specialist anticoagulation services. DISCUSSION: VTE patients prioritised anticoagulation over other therapies whereas AF patients did not. All participants reported high levels of adherence to DOACs. Patients derived confidence from long-term management in specialist anticoagulation clinics stating a preference to be managed in such a service.