Exploring patient barriers to adherence with anticoagulation therapy for atrial fibrillation
Anticoagulation therapy is a key strategy for preventing stroke and other thromboembolic complications in patients with atrial fibrillation (AF). However, many patients with AF do not adhere to their prescribed anticoagulant regimen, which can increase their risk of adverse outcomes. This paper aims to explore the patient barriers to adherence with anticoagulation therapy for AF, and to provide some recommendations for improving adherence.
According to a systematic review and meta-analysis of observational studies, the pooled mean adherence scores of over half a million patients with AF 6 months and 1 year after therapy initiation were 77 and 74 out of 100, respectively (Salmasi et al., 2020). The adherence rates varied by the type of oral anticoagulant (OAC) used, with rivaroxaban and apixaban showing slightly higher adherence than dabigatran. However, there was no significant difference in adherence between novel OACs (NOACs) and warfarin.
Some of the factors that were associated with increased adherence included older age, higher stroke risk, once-daily regimen, history of hypertension, diabetes or stroke, concomitant cardiovascular medications, living in rural areas and being an experienced OAC user (Salmasi et al., 2020). On the other hand, some of the factors that were associated with decreased adherence included younger age, lower stroke risk, twice-daily regimen, history of bleeding or gastrointestinal disorders, polypharmacy, living in urban areas and being a new OAC user.
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Moreover, some of the psychosocial factors that influenced adherence were knowledge, satisfaction, perceived benefits, perceived barriers, symptom severity and self-efficacy. A cross-sectional study in Taiwan found that patients with greater self-efficacy and perceived fewer barriers showed better adherence to anticoagulation therapy (Chen et al., 2019). The most common barriers reported by patients were fear of bleeding, inconvenience of taking medication, lack of information and forgetfulness. The most common benefits reported by patients were prevention of stroke, improvement of quality of life and reduction of anxiety.
Therefore, to improve adherence to anticoagulation therapy for AF, it is important to address the patient barriers and enhance the patient benefits. Some of the strategies that can be implemented are:
– Providing education about the efficacy and safety of anticoagulation therapy, and the availability of reversal agents in case of bleeding (ACC.org, 2023).
– Engaging in shared decision making with patients about the choice of OAC, taking into account their preferences, values and clinical characteristics (Heart.bmj.com, 2021).
– Simplifying the medication regimen by using once-daily dosing or fixed-dose combinations when possible (Heart.bmj.com, 2017).
– Monitoring the adherence and persistence of patients using electronic devices or pharmacy records, and providing feedback and reminders when needed (Heart.bmj.com, 2017).
– Offering support and counselling to patients who have low self-efficacy or high perceived barriers, and addressing their concerns and misconceptions (Chen et al., 2019).
In conclusion, adherence to anticoagulation therapy for AF is a complex and multifaceted issue that requires a patient-centred approach. By exploring the patient barriers and enhancing the patient benefits, clinicians can help improve the quality of care and outcomes for patients with AF.
References
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Salmasi S., Loewen P.S., Tandun R., Andrade J.G., De Vera M.A. (2020). Adherence to oral anticoagulants among patients with atrial fibrillation: a systematic review and meta-analysis of observational studies. BMJ Open. 10(4):e034778. https://doi.org/10.1136/bmjopen-2019-034778
Chen P.T., Wang T.J., Hsieh M.H., Liu J.C., Liu C.Y., Wang K.Y., Laio W.C. (2019). Anticoagulation adherence and its associated factors in patients with atrial fibrillation: I need help writing my essay, a cross-sectional study. BMJ Open. 9(9):e029974. https://doi.org/10.1136/bmjopen-2019-029974
ACC.org (2023). Reasons for Nonadherence to Apixaban Among Patients With AF. https://www.acc.org/latest-in-cardiology/journal-scans/2023/01/27/18/11/reasons-for-nonadherence
Heart.bmj.com (2021). Adherence to anticoagulation therapy in patients with atrial fibrillation: a cross-sectional study. Heart. 106(22):1710-1715. https://doi.org/10.1136/heartjnl-2020-318577
Heart.bmj.com (2017). Ensuring adherence to therapy with anticoagulation in patients with atrial fibrillation. Heart. 103(17):1308-1310. https://doi.org/10.1136/heartjnl-2017-311581