Investigating prescribers' experiences of direct-acting oral anticoagulants for the management of nonvalvular atrial fibrillation.

Generalova, Daria

Abstract

Direct-acting oral anticoagulants (DOACs) have relatively recently been licensed for stroke and systemic embolism prevention in patients with non-valvular atrial fibrillation (AF) and have replaced warfarin as the first line agent of choice. The aim of this research was to determine prescribers' views and experiences of the use of DOACs for the management of non-valvular AF. The first phase was a PROSPERO-registered systematic review of clinicians' views and experiences of DOACs for the management of non-valvular atrial fibrillation. Ten studies were identified. In those studies reporting clinician preference, DOACs were first choice over warfarin in naïve patients, based on perceptions of evidence that DOACs had effectiveness equivalent or superior to warfarin and were also superior in safety. Other advantageous factors were in those with an unstable International Normalized Ratio and who were likely to miss appointments. There were, however, concerns relating to management of over-anticoagulation and experiences of observed bleeding rates. In addition to the lack of studies, none of the studies had used theory in the development of the data collection tools or analysis, indicating a gap in the literature. The second phase was a cross-sectional survey of prescriber's views, behaviours and experiences related to prescribing DOACs for the management of non-valvular AF. The survey was conducted in NHS Highland, inviting all medical and non-medical prescribers to participate. Items on potential influences on DOAC prescribing were based on the Theoretical Domains Framework (TDF). Principal component analysis (PCA) of the TDF items gave four components. Component scores were positive for (i) role of professionals, their knowledge and skills and (ii) influences on prescribing. There did, however, appear to be issues in switching from warfarin to DOACs or from one DOAC to another. Scores were more neutral for (iii) consequences of prescribing and (iv) monitoring for safety and effectiveness. There were low levels of agreement for statements relating to DOACs being more effective, safer and cost-effective than warfarin. There were similar responses around the complexity of bleeding management and detection of over and under-anticoagulation. Less experienced prescribers were statistically significantly more positive than more experienced prescribers in terms of the consequences of prescribing (p < 0.05). Content analysis of the responses to the open questions identified that the overwhelming perceived benefit was the absence of need for INR monitoring, with the main limitations being the lack of a suitable reversal agent and ability to monitor anticoagulation status.Given the updated recommendations of Healthcare Improvement Scotland (HIS) to use edoxaban first line, the final phase was a cross-sectional survey of prescriber's views, behaviours and experiences related to prescribing edoxaban for the management of non-valvular AF. Responses were received from 103 prescribers in NHS Highland. While almost all respondents had been encouraged to implement this recommendation of prescribing edoxaban, less than one third had either switched patients from warfarin or other DOACs to edoxaban. The following three PCA components identified in the previous survey were applied to the TDF determinants: the role of professionals, their knowledge and skills; influences on prescribing; and consequences of prescribing. While component scores for the first two components were positive, the scores for consequences of prescribing were more neutral. Although a number of respondents described edoxaban (and other DOAC) related adverse drug reactions (ADRs), very few had submitted a Yellow Card report to the Medicines and Healthcare products Regulatory Agency (MHRA). Content analysis of the responses to the open questions identified benefits and limitations similar to the previous survey. This doctoral research has generated original findings in terms of DOACs views, experiences and behaviours related to management of non-valvular AF. There is merit in reviewing the local and national guidelines, particularly in relation to switching and awareness of the evidence base. Attention should be paid to the literature on guideline implementation.

Citation

GENERALOVA, D. 2020. Investigating prescribers' experiences of direct-acting oral anticoagulants for the management of nonvalvular atrial fibrillation. Robert Gordon University, PhD thesis. Hosted on OpenAIR [online]. Available from: https://doi.org/10.48526/rgu-wt-1447131

• Thesis Type: Thesis
• Deposit Date: Sep 7, 2021
• Publicly Available Date: Sep 7, 2021
• Keywords: Non-valvular atrial fibrillation; Warfarin; Edoxaban; Direct-acting oral anticoagulants (DOACs); Prescriptions; Prescribing; Blood; Bleeding
• Public URL: https://rgu-repository.worktribe.com/output/1447131
• Publisher URL: https://doi.org/10.48526/rgu-wt-1447131
• Award Date: Jun 30, 2020