PDF(Pubmed)
Abstract：
UNASSIGNED: Direct oral anticoagulants (DOACs) are recommended for patients with atrial fibrillation (AF) given their improved safety profile. Suboptimal adherence to DOACs remains a significant concern among individuals with AF. However, the extent of adherence to DOACs following a cardiovascular or bleeding event has not been fully evaluated.
UNASSIGNED: To evaluate the pattern of adherence trajectories of DOACs after a cardiovascular or bleeding event and to investigate the sociodemographic and clinical predictors associated with each adherence trajectory by using claims-based data.
UNASSIGNED: This retrospective study was conducted among patients with AF prescribed with DOACs (dabigatran/apixaban/rivaroxaban) between July 2016 and December 2017 and who were continuously enrolled in the Texas-based Medicare Advantage Plan. Patients who experienced a cardiovascular or bleeding event while using the DOACs were further included in the analysis. The sample was limited to patients who experienced a clinical event such as a cardiovascular or bleeding event while using the DOACs. The clinical events considered in this study were cardiovascular (stroke, congestive heart failure, myocardial infarction, systemic embolism) and bleeding events. To assess adherence patterns, each patient with a DOAC prescription was followed up for a year after experiencing a clinical event. The monthly adherence to DOACs after these events was evaluated using the proportion of days covered (PDC). A group-based trajectory model incorporated the monthly PDC to classify groups of patients based on their distinct patterns of adherence. Predictors associated with each trajectory were assessed using a multinomial logistic regression model, with the adherent trajectory serving as the reference group in the outcome variable.
UNASSIGNED: Among the 694 patients with AF who experienced clinical events after the initiation of DOACs, 3 distinct adherence trajectories were identified: intermediate nonadherent (30.50%), adherent (37.7%), and low adherent (31.8%); the mean PDC was 0.47 for the intermediate nonadherent trajectory, 0.93 for the adherent trajectory, and 0.01 for low adherent trajectory. The low-income subsidy was significantly associated with lower adherence trajectories (odds ratio [OR] = 4.81; 95% CI = 3.07-7.51) and with intermediate nonadherent trajectories (OR = 1.57; 95% CI = 1.06-2.34). Also, nonsteroidal anti-inflammatory drug use was significantly associated with lower adherence trajectories (OR = 5.10; 95% CI = 1.95-13.36) and intermediate nonadherent trajectories (OR = 3.17; 95% CI = 1.26-7.93). Other predictors significantly associated with both nonadherent trajectories are type of DOACs (OR = 0.53; 95% CI = 0.35-0.79), presence of coronary artery disease (OR = 1.89; 95% CI = 1.01-3.55), and having 2 or more clinical events (OR = 1.65; 95% CI = 1.09-2.50).
UNASSIGNED: Predictors identified provide valuable insights into the suboptimal adherence of DOACs among Medicare Advantage Plan enrollees with AF, which can guide the development of targeted interventions to enhance adherence in this high-risk patient population.
UNASSIGNED: To evaluate the pattern of adherence trajectories of DOACs after a cardiovascular or bleeding event and to investigate the sociodemographic and clinical predictors associated with each adherence trajectory by using claims-based data.
UNASSIGNED: This retrospective study was conducted among patients with AF prescribed with DOACs (dabigatran/apixaban/rivaroxaban) between July 2016 and December 2017 and who were continuously enrolled in the Texas-based Medicare Advantage Plan. Patients who experienced a cardiovascular or bleeding event while using the DOACs were further included in the analysis. The sample was limited to patients who experienced a clinical event such as a cardiovascular or bleeding event while using the DOACs. The clinical events considered in this study were cardiovascular (stroke, congestive heart failure, myocardial infarction, systemic embolism) and bleeding events. To assess adherence patterns, each patient with a DOAC prescription was followed up for a year after experiencing a clinical event. The monthly adherence to DOACs after these events was evaluated using the proportion of days covered (PDC). A group-based trajectory model incorporated the monthly PDC to classify groups of patients based on their distinct patterns of adherence. Predictors associated with each trajectory were assessed using a multinomial logistic regression model, with the adherent trajectory serving as the reference group in the outcome variable.
UNASSIGNED: Among the 694 patients with AF who experienced clinical events after the initiation of DOACs, 3 distinct adherence trajectories were identified: intermediate nonadherent (30.50%), adherent (37.7%), and low adherent (31.8%); the mean PDC was 0.47 for the intermediate nonadherent trajectory, 0.93 for the adherent trajectory, and 0.01 for low adherent trajectory. The low-income subsidy was significantly associated with lower adherence trajectories (odds ratio [OR] = 4.81; 95% CI = 3.07-7.51) and with intermediate nonadherent trajectories (OR = 1.57; 95% CI = 1.06-2.34). Also, nonsteroidal anti-inflammatory drug use was significantly associated with lower adherence trajectories (OR = 5.10; 95% CI = 1.95-13.36) and intermediate nonadherent trajectories (OR = 3.17; 95% CI = 1.26-7.93). Other predictors significantly associated with both nonadherent trajectories are type of DOACs (OR = 0.53; 95% CI = 0.35-0.79), presence of coronary artery disease (OR = 1.89; 95% CI = 1.01-3.55), and having 2 or more clinical events (OR = 1.65; 95% CI = 1.09-2.50).
UNASSIGNED: Predictors identified provide valuable insights into the suboptimal adherence of DOACs among Medicare Advantage Plan enrollees with AF, which can guide the development of targeted interventions to enhance adherence in this high-risk patient population.
摘要：
■考虑到房颤（AF）患者的安全性改善，推荐直接口服抗凝剂（DOAC）。对DOAC的次优依从性仍然是房颤个体中的一个重要问题。然而,心血管事件或出血事件后DOAC的依从性程度尚未得到充分评估.
■评估心血管或出血事件后DOAC的依从性轨迹模式，并通过使用基于索赔的数据调查与每个依从性轨迹相关的社会人口统计学和临床预测因素。
这项回顾性研究是在2016年7月至2017年12月期间服用DOAC(达比加群/阿哌沙班/利伐沙班)并连续参加德克萨斯州MedicareAdvantage计划的房颤患者中进行的。在使用DOAC时经历心血管或出血事件的患者进一步包括在分析中。样本限于在使用DOAC时经历临床事件如心血管或出血事件的患者。本研究中考虑的临床事件是心血管事件（中风，充血性心力衰竭,心肌梗塞,全身性栓塞）和出血事件。为了评估依从性模式，每位服用DOAC处方的患者在经历临床事件后随访一年.使用覆盖天数比例(PDC)评估这些事件后对DOAC的每月依从性。基于组的轨迹模型结合了每月PDC，以根据患者的不同依从性模式对患者组进行分类。使用多项逻辑回归模型评估与每个轨迹相关的预测因子，将粘附轨迹作为结果变量中的参考组。
■在开始DOAC后出现临床事件的694例房颤患者中，确定了3种不同的粘附轨迹：中间非粘附(30.50%)，粘附（37.7%），和低粘附性（31.8％）；中间非粘附轨迹的平均PDC为0.47，0.93的粘附轨迹，低粘附轨迹为0.01。低收入补贴与较低的依从性轨迹（比值比[OR]=4.81；95％CI=3.07-7.51）和中等非依从性轨迹（OR=1.57；95％CI=1.06-2.34）显着相关。此外，非甾体类抗炎药的使用与较低的依从性轨迹(OR=5.10;95%CI=1.95~13.36)和中等非粘附轨迹(OR=3.17;95%CI=1.26~7.93)显著相关.与两个非粘附轨迹显着相关的其他预测因素是DOAC类型（OR=0.53；95％CI=0.35-0.79），存在冠状动脉疾病（OR=1.89；95%CI=1.01-3.55），并有2个或更多临床事件（OR=1.65；95%CI=1.09-2.50）。
■所确定的预测因子提供了对患有AF的MedicareAdvantage计划参与者中DOAC的次优依从性的有价值的见解，这可以指导制定有针对性的干预措施，以提高这一高危患者人群的依从性。
■评估心血管或出血事件后DOAC的依从性轨迹模式，并通过使用基于索赔的数据调查与每个依从性轨迹相关的社会人口统计学和临床预测因素。
这项回顾性研究是在2016年7月至2017年12月期间服用DOAC(达比加群/阿哌沙班/利伐沙班)并连续参加德克萨斯州MedicareAdvantage计划的房颤患者中进行的。在使用DOAC时经历心血管或出血事件的患者进一步包括在分析中。样本限于在使用DOAC时经历临床事件如心血管或出血事件的患者。本研究中考虑的临床事件是心血管事件（中风，充血性心力衰竭,心肌梗塞,全身性栓塞）和出血事件。为了评估依从性模式，每位服用DOAC处方的患者在经历临床事件后随访一年.使用覆盖天数比例(PDC)评估这些事件后对DOAC的每月依从性。基于组的轨迹模型结合了每月PDC，以根据患者的不同依从性模式对患者组进行分类。使用多项逻辑回归模型评估与每个轨迹相关的预测因子，将粘附轨迹作为结果变量中的参考组。
■在开始DOAC后出现临床事件的694例房颤患者中，确定了3种不同的粘附轨迹：中间非粘附(30.50%)，粘附（37.7%），和低粘附性（31.8％）；中间非粘附轨迹的平均PDC为0.47，0.93的粘附轨迹，低粘附轨迹为0.01。低收入补贴与较低的依从性轨迹（比值比[OR]=4.81；95％CI=3.07-7.51）和中等非依从性轨迹（OR=1.57；95％CI=1.06-2.34）显着相关。此外，非甾体类抗炎药的使用与较低的依从性轨迹(OR=5.10;95%CI=1.95~13.36)和中等非粘附轨迹(OR=3.17;95%CI=1.26~7.93)显著相关.与两个非粘附轨迹显着相关的其他预测因素是DOAC类型（OR=0.53；95％CI=0.35-0.79），存在冠状动脉疾病（OR=1.89；95%CI=1.01-3.55），并有2个或更多临床事件（OR=1.65；95%CI=1.09-2.50）。
■所确定的预测因子提供了对患有AF的MedicareAdvantage计划参与者中DOAC的次优依从性的有价值的见解，这可以指导制定有针对性的干预措施，以提高这一高危患者人群的依从性。
