Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
The University of Hong Kong Shenzhen Institute of Research and Innovation, Shenzhen, China.
PLoS Med. 2021 Aug 26;18(8):e1003730. doi: 10.1371/journal.pmed.1003730. eCollection 2021 Aug.
Adherence to oral anticoagulant therapy in patients with atrial fibrillation (AF) in China is low. Patient preference, one of the main reasons for discontinuation of oral anticoagulant therapy, is an unfamiliar concept in China.
A discrete choice experiment (DCE) was conducted to quantify patient preference on 7 attributes of oral anticoagulant therapy: antidote (yes/no), food-drug interaction (yes/no), frequency of blood monitoring (no need, every 6/3/1 month[s]), risk of nonfatal major bleeding (0.7/3.1/5.5/7.8[%]), risk of nonfatal stroke (ischemic/hemorrhagic) or systemic embolism (0.6/3.2/5.8/8.4[%]), risk of nonfatal acute myocardial infarction (AMI) (0.2/1.0/1.8/2.5[%]), and monthly out-of-pocket cost (0/120/240/360 RMB) (0 to 56 USD). A total of 16 scenarios were generated by using D-Efficient design and were randomly divided into 2 blocks. Eligible patients were recruited and interviewed from outpatient and inpatient settings of 2 public hospitals in Beijing and Shenzhen, respectively. Patients were presented with 8 scenarios and asked to select 1 of 3 options: 2 unlabeled hypothetical treatments and 1 opt-out option. Mixed logit regression model was used for estimating patients' preferences of attributes of oral anticoagulants and willingness to pay (WTP) with adjustments for age, sex, education level, income level, city, self-evaluated health score, histories of cardiovascular disease/other vascular disease/any stroke/any bleeding, and use of anticoagulant/antiplatelet therapy. A total of 506 patients were recruited between May 2018 and December 2019 (mean age 70.3 years, 42.1% women). Patients were mainly concerned about the risks of AMI (β: -1.03; 95% CI: -1.31, -0.75; p < 0.001), stroke or systemic embolism (β: -0.81; 95% CI: -0.90, -0.73; p < 0.001), and major bleeding (β: -0.69; 95% CI: -0.78, -0.60; p < 0.001) and were willing to pay more, from up to 798 RMB to 536 RMB (124 to 83 USD) monthly. The least concerning attribute was frequency of blood monitoring (β: -0.31; 95% CI: -0.39, -0.24; p < 0.001). Patients had more concerns about food-drug interactions even exceeding preferences on the 3 risks, if they had a history of stroke or bleeding (β: -2.47; 95% CI: -3.92, -1.02; p < 0.001), recruited from Beijing (β: -1.82; 95% CI: -2.56, -1.07; p < 0.001), or men (β: -0.96; 95% CI: -1.36, -0.56; p < 0.001). Patients with lower educational attainment or lower income weighted all attributes lower, and their WTP for incremental efficacy and safety was minimal. Since the patients were recruited from 2 major hospitals from developed cities in China, further studies with better representative samples would be needed.
Patients with AF in China were mainly concerned about the safety and effectiveness of oral anticoagulant therapy. The preference weighting on food-drug interaction varied widely. Patients with lower educational attainment or income levels and less experience of bleeding or stroke had more reservations about paying for oral anticoagulant therapies with superior efficacy, safety, and convenience of use.
在中国，房颤患者口服抗凝治疗的依从性较低。患者偏好是导致口服抗凝治疗中断的主要原因之一，但在中国，这一概念还不为人所知。
采用离散选择实验（DCE）对口服抗凝治疗的 7 个属性进行量化：解毒剂（有/无）、药物与食物相互作用（有/无）、血液监测频率（无需、每 6/3/1 个月）、非致命性大出血风险（0.7/3.1/5.5/7.8%）、非致命性卒中或全身性栓塞风险（缺血性/出血性）（0.6/3.2/5.8/8.4%）、非致命性急性心肌梗死风险（0.2/1.0/1.8/2.5%）和每月自付费用（0/120/240/360 人民币）（0 至 56 美元）。通过 D-Efficient 设计共生成 16 个场景，随机分为 2 个块。分别从北京和深圳的 2 家公立医院的门诊和住院部招募符合条件的患者进行访谈。向患者呈现 8 个场景，并要求他们从 3 个选项中选择 1 个：2 个未标记的假设治疗方案和 1 个弃权选项。采用混合 Logit 回归模型估计患者对口服抗凝药物属性的偏好和支付意愿（WTP），并对年龄、性别、教育程度、收入水平、城市、自我评估健康评分、心血管疾病/其他血管疾病/任何卒中/任何出血史以及抗凝/抗血小板治疗的使用情况进行调整。2018 年 5 月至 2019 年 12 月期间共招募了 506 名患者（平均年龄 70.3 岁，42.1%为女性）。患者主要关注的是心肌梗死（AMI）（β：-1.03；95%CI：-1.31，-0.75；p<0.001）、卒中和全身性栓塞（β：-0.81；95%CI：-0.90，-0.73；p<0.001）和大出血（β：-0.69；95%CI：-0.78，-0.60；p<0.001）的风险，愿意支付更多的费用，每月最高可达 798 元至 536 元（124 至 83 美元）。最不关注的属性是血液监测频率（β：-0.31；95%CI：-0.39，-0.24；p<0.001）。如果患者有卒中或出血史（β：-2.47；95%CI：-3.92，-1.02；p<0.001）、来自北京（β：-1.82；95%CI：-2.56，-1.07；p<0.001）或男性（β：-0.96；95%CI：-1.36，-0.56；p<0.001），即使考虑到 3 种风险，患者对药物-食物相互作用的担忧也会超过对这 3 种风险的关注。受教育程度较低或收入较低的患者对所有属性的权重都较低，他们对增加疗效和安全性的支付意愿也最低。由于患者是从中国发达城市的 2 家大医院招募的，因此需要进一步研究以获得更好的代表性样本。
中国的房颤患者主要关注口服抗凝治疗的安全性和有效性。药物-食物相互作用的偏好权重差异很大。受教育程度或收入较低、出血或卒中经验较少的患者，对具有更好疗效、安全性和使用便利性的口服抗凝治疗药物持更多保留意见。
