1. Overall, 72% of Veteran’s Affairs patients with atrial fibrillation in this study were adherent to their dabigatran for prevention of thromboembolic disease.
2. Veteran’s Health Administration sites that performed appropriateness screening of patients and provided monitoring on dabigatran had higher rates of adherence in this study.
Evidence Rating Level: 3 (Average)
Study Rundown: Anticoagulant therapy is a widely used means of preventing stroke in patients with atrial fibrillation, the most common cardiac arrhythmia. Warfarin was the only medication available for anticoagulation therapy in this population until a new class of oral anticogulants, including dabigatran, was introduced. Warfarin required regular blood testing to be sure that the patient was on an appropriate dose of the medication. The new oral anticoagulants do not require regular blood testing and the optimal way to track adherence and plan follow-up on these medications is still being determined.
This study included sites in the Veteran’s Health Administration (VHA) system and performed telephone surveys about practices regarding dabigatran management and compared adherence rates to dabigatran therapy between October 1, 2010 and September 30, 2012. 72.2% of the 5,376 patients from 125 VHA sites were adherent (took dabigatran at least 80% of the time). There was a large degree of variation in adherence between sites, with a range from 42% to 93% among 67 of the sites. Veteran’s Health Administration sites that performed appropriateness screening of patients and provided monitoring on dabigatran had higher rates of adherence in this study. This study has several strengths including the inclusion of a large number of sites, the completeness of data available within the VHA system, and the two-year study period. Weaknesses of the study include the use of telephone interviews with one representative for information about sites, the fact that most participants were White males, and the need to use dispensing of medication as a proxy for adherence. This study suggests several interventions that may be employed to improve dabigatran adherence and a larger study should be done to substantiate these strategies in more varied practice settings with a more diverse patient population.
In-Depth [survey]: This study examined dabigatran adherence and practice patterns regarding dabigatran monitoring in VHA sites between 2010 and 2012. Overall, 72% of patients were adherent to dabigatran (SD 12%, median 74%, IQR 66%-80%). High-performing sites (with adherence above the median) were more likely to be in the Midwest, have a higher proportion of White patients, and have a lower proportion of patients with chronic kidney disease than low-performing sites. Sites that had higher rates of adherence were more likely to perform appropriate patient selection (75% vs 69%), provide patient education (76% vs 66%), and maintain monitoring (77% vs 65%). In multivariate analysis, pharmacist-led education prior to initiation of therapy was not associated with increased adherence, but appropriate selection of patients and monitoring were both associated with increased adherence. Additionally, adherence increased with longer length of monitoring, involvement of physicians in managing non-adherent patients, tailoring the monitoring process, and providing pharmacist-led adverse event and adherence monitoring. Involvement of an anticoagulation clinic did not increase adherence in a multivariate model and there were no differences in adherence between various modes of contacting patients.
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