Anticoagulants' Safety and Effectiveness in General Practice: A Nationwide Prospective Cohort Study.

PURPOSE: Most real-world studies on anticoagulants have been based on health insurance databases or performed in secondary care. The aim of this study was to compare safety and effectiveness between patients treated with vitamin K antagonists (VKAs) and patients treated with direct oral anticoagulants (DOACs) in a general practice setting. METHODS: The CACAO study (Comparison of Accidents and their Circumstances with Oral Anticoagulants) is a multicenter prospective cohort study conducted among ambulatory patients taking an oral anticoagulant. Participants were patients from the study's cross-sectional phase receiving oral anticoagulants because of nonvalvular atrial fibrillation, for secondary prevention of venous thromboembolism, or both. They were followed as usual for 1 year by their general practitioners, who collected data on changes in therapy, thromboembolic events, bleeding, and deaths. All events were adjudicated by an independent committee. We used a propensity score and a Cox regression model to derive hazard ratios. RESULTS: Between April and December 2014, a total of 3,082 patients were included. At 1 year, 42 patients (1.7%) had experienced an arterial or venous event; 151 (6.1%) had experienced bleeding, including 47 (1.9%) who experienced major bleeding; and 105 (4.1%) had died. There was no significant difference between the VKA and DOAC groups regarding arterial or venous events, or major bleeding. The VKA group had a lower risk of overall bleeding (hazard ratio = 0.65; 95% CI, 0.43-0.98) but twice the risk of death (hazard ratio = 1.98; 95% CI, 1.15-3.42). CONCLUSIONS: VKAs and DOACs had fairly similar safety and effectiveness in general practice. The substantially higher incidence of deaths with VKAs is consistent with known data from health insurance databases and calls for further research to understand its cause.

[How do general practitioners limit their prescriptions? A qualitative study based on a focus group]. / Comment les médecins généralistes limitent-ils leurs prescriptions? Etude qualitative par entretiens collectifs.

AIM: There is no consensus on prescription of medicines in many situations in general medicine. The aim of this study was to identify the strategies used by general practitioners to limit prescriptions in order to make their prescriptions more effective. METHODS: A mixed sample of general practitioners in terms of age and types of practice were interviewed using the focus group method until a sufficient number of data were obtained. RESULTS: Fourteen women and ten men aged between 32 and 64 years were interviewed by means of three group interviews. Various strategies were identified: the practitioner's attitude (rapid identification of the patient's needs, listening and evaluation of symptoms, support by physical examination) and the use of resources (reference tools and news) during the consultation; the importance of the conclusion of the consultation (written advice or visit report, review of the previous prescription) and explanation (reasons for limitation, reassurance, arguments, proposal of a follow-up visit). Limitation of prescriptions also depends on the practitioner's own reasons (initial and continued training, motivation and personal objectives, part of a peer group) but equally on the health care system (institutional, specialist support). CONCLUSION: The study highlights numerous approach to facilitate limitation of prescriptions: training and informing practitioners and patients, consultation management, promote communication at the heart of the health care system and policy-makers. Training organizations and health authorities could facilitate these strategies for the benefit of patients.

[New oral anticoagulants in primary care: The general practitioner's point of view]. / Nouveaux anticoagulants oraux en soins primaires : point de vue du médecin généraliste.

The assessment of new anticoagulants benefits is based on the assessment of thromboembolism and bleeding risks, referring when possible to CHA2DS2-VASc and HAS-BLED scores. The management of patients treated with new anticoagulants includes a clinical assessment and the annual measure of the creatinine clearance (three times per year in some particular cases). New anticoagulants make hemostasis tests not reliable. The general practitioner has a role in preventing interactions and reporting potential adverse drug reactions. The context of uncertainty about the risk/benefit ratio of new anticoagulants emphasizes the need to integrate the values of the patient in treatment decisions.