Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Pharmacotherapy. 2020 Oct;40(10):1022-1035. doi: 10.1002/phar.2457. Epub 2020 Sep 21.
Adherence to chronic medications remains poor in practice. There is limited evidence on how hospitalization affects post-discharge adherence to oral anticoagulants (OACs) in individuals with atrial fibrillation. The aim of this study was to examine the impact of hospitalization and medication switching on post-discharge adherence to OACs in the population with atrial fibrillation.
A quasi-experimental pre-post observational study was conducted using United States commercial insurance health care claims from the 2009 to 2016 Optum database. Adults with atrial fibrillation taking OACs who had a random hospitalization occurring after the first observed OAC prescription fill and no other admission in the preceding and following 6 months were identified. OAC adherence was estimated by the proportion of days covered within 6 and 12 months before and after hospitalization. Difference-in-difference analysis was employed to compare the pre-hospitalization and post-hospitalization proportion of days covered, stratified by reasons for hospitalization (i.e., bleeding vs non-bleeding-related reasons) and adjusting for imbalanced baseline characteristics between groups. Change in adherence when the OAC was switched at discharge was also examined.
The 22,429 individuals who met study criteria were predominantly male (52.4%), white (77.2%), and older age (median 74 years). A clinically significant hemorrhage was the reason for 1029 (4.5%) of qualifying hospitalizations. After covariate adjustment, there was a reduction in the proportion of days covered after discharge, regardless of admission diagnosis (p<0.0001). The 6-month difference-in-difference analyses revealed that adherence was incrementally reduced by 3.2% (p=0.0003) in the bleeding group compared with the nonbleeding group, whereas switching from warfarin to a direct oral anticoagulant after hospitalization was associated with a smaller reduction by 3.4% in adherence (p=0.0342) compared with other switchers, regardless of the reason for hospitalization. The 12-month difference-in-difference analyses revealed similar results.
Hospitalization is temporally associated with a reduction in adherence to OACs, regardless of reason for hospitalization. More effective strategies are needed to improve OAC adherence, particularly during transition of care.
在实践中，慢性病药物的依从性仍然很差。关于住院如何影响房颤患者出院后口服抗凝剂（OAC）的依从性，证据有限。本研究旨在探讨住院和药物转换对房颤人群出院后 OAC 依从性的影响。
使用来自 2009 年至 2016 年 Optum 数据库的美国商业保险健康保险索赔进行了一项准实验前后观察性研究。确定了服用 OAC 且在首次观察到 OAC 处方后随机住院且在之前和之后 6 个月内没有其他入院的房颤患者。通过在住院前和住院后 6 个月和 12 个月内覆盖的天数比例来估计 OAC 的依从性。采用差异-差异分析比较了因出血和非出血相关原因住院的患者的住院前和住院后覆盖天数的比例，并对组间不平衡的基线特征进行了调整。还检查了出院时 OAC 转换时依从性的变化。
符合研究标准的 22429 人主要为男性（52.4%）、白人（77.2%）和年龄较大（中位数为 74 岁）。1029 例（4.5%）符合条件的住院治疗是由于临床明显出血。在调整协变量后，无论入院诊断如何，出院后的覆盖天数比例均降低（p<0.0001）。6 个月的差异-差异分析显示，与非出血组相比，出血组的依从性逐渐降低 3.2%（p=0.0003），而与其他转换者相比，出院后从华法林转换为直接口服抗凝剂与依从性降低 3.4%相关（p=0.0342），无论住院原因如何。12 个月的差异-差异分析得出了类似的结果。
无论住院原因如何，住院与 OAC 依从性的降低有关。需要更有效的策略来提高 OAC 的依从性，特别是在护理过渡期间。
