Article
New oral anticoagulants (NOACs) in family practice – Use and medication switches in the PICANT study
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Published: | November 23, 2016 |
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Background: The use of the new oral anticoagulants Dabigatran, Rivaroxaban and Apixaban as opposed to Vitamin K antagonists (VKAs) is hotly debated. The topic is especially important for family doctors, as they care for the majority of patients taking anticoagulants over the long term. The cluster-randomized PICANT study (Primary Care Management for Optimized Antithrombotic Treatment) [1] was performed in family practices. The aim of the study was to investigate whether a best practice model that applies major elements of case management and patient education can improve antithrombotic management in primary health care, independently of the type of OACs (VKAs or NOACs) patients are taking.
Problem: How often did switches in anticoagulants occur during the course of the PICANT study and what kind of reasons did the family doctors give for the changes?
Materials and Methods: Using a mixed-methods approach, a questionnaire was used to gather information quantitatively and using free-text fields on a switch in medication, and the reasons for a change, for each participating patient at three points in time (baseline, after 12 and after 24 months. The evaluation was conducted descriptively using SPSS. Qualitative, structured telephone interviews were conducted with some of the family doctors at the end of the study. The transcribed interviews were evaluated using structured content analysis according to Kuckartz and MAXQDA analysis software.
Results: 52 family practices and 736 patients participated in the PICANT study. During the two-year follow up study, the use of NOACs more than doubled from 5% to 11%. 114 (15.5%) of patients switched medication, with the change occurring in both directions (→VKAs and →NOACs). The reasons for changing medication were numerous and included difficulties calculating the dosage (20%), complications (20%), advices of a specialist (16%) and the practice management (8%).
23 doctors agreed to participate in an interview (10 doctors in the intervention and 13 in the control group). The interviews lasted Ø 21 minutes. The doctors mentioned high patient uncertainty and poor patient adherence as reasons for switching medication, both to and from NOACs. A change to NOACs was often initiated to reduce the burden on practice procedures. The doctors regarded a switch to NOACs following a consultation at a specialist or a hospital stay as problematic.
Conclusion: Our results were similar to those of a study of 12 family practices in Bonn/Germany [2], [3] which also found a high proportion of NOACs and similar reasons for switching. However, in our study, it is also noteworthy that the same reasons (patient uncertainty, patient adherence) were given for changing from NOACs to VKAs as from VKAs to NOACs.
References
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- Dinkel K, Weckbecker K, Blechwein M. Behandlung mit Neuen oralen Antikoagulanzien in der Hausarztpraxis. In: Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin. 49. Kongress für Allgemeinmedizin und Familienmedizin. Bozen, 17.-19.09.2015. Düsseldorf: German Medical Science GMS Publishing House; 2015. Doc15degam048. DOI: 10.3205/15degam048
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- Bleckwein M, Dinkel K, Weckbecker K, Mücke M. Einsatz der Neuen oralen Antikoagulanzein in Hausarztpraxen. Z Allg Med. 2016;92(1):28–32. DOI: 10.3238/zfa.2016.0028-0032