Aspirin desensitization in patients undergoing percutaneous coronary intervention: A survey of current practice

Background: Aspirin remains the mainstay of anti-platelet therapy in cardiac patients.However, if a patient is allergic to aspirin and dual anti-platelet therapy is indicated — suchas with percutaneous coronary intervention (PCI), then there is no clear guidance. Onepossibility is aspirin desensitization. A variety of protocols exist for the rapid desensitization ofpatients with aspirin allergy. The aim of this survey was to assess current knowledge andpractice regarding aspirin desensitization in the UK.Methods and results: We conducted a UK wide survey of all UK 116 PCI centers andobtained complete responses from 40 (35.4%) centers. Of these, just 7 (17.5%) centers hadpreviously desensitised patients; 29 (87.9%) centers suggested a lack of a local protocolprevented them from desensitizing, with 10 (30.3%) unsure of how to conduct desensitization.Only 5 (12.5%) centers had a local policy for aspirin desensitization although 25 (64.1%)units had a clinical strategy for dealing with aspirin allergy; the majority (72%) giving higherdoses of thienopyridine class drugs.Conclusions: In the UK, there appears to be no consistent approach to patients with aspirinallergy. Patients undergoing PCI benefit from dual anti-platelet therapy (including aspirin),and aspirin desensitization in those with known allergy may facilitate this. Sustained effortshould be placed on encouraging UK centers to use desensitization as a treatment modalityprior to PCI rather than avoiding aspirin altogether

General practitioner views of an electronic high-risk medicine proforma to facilitate information transfer.

Background The potential of warfarin related harm is increased if clinicians lack the full patient specific information to make informed decisions—an e-proforma has been developed to communicate this information on hospital discharge. Objective To determine the views of general practitioners (GPs) on a warfarin discharge e-proforma. Method A cross-sectional survey of all GPs (n=272) within the Raigmore Hospital catchment area of NHS Highland, Scotland. Results The response rate was 39.3% (107/272). 84 (78.5%) noticed recent changes to information supplied on discharge for warfarin patients. 64 (59.8%) respondents thought this would result in more informed prescribing with regards to dosing, while 65 (60.7%) felt this would improve safety. Accurate completion, timely receipt of the e-proforma and a realistic date for subsequent INR tests were considered important by GPs. Conclusion This study suggests the use of an e-proforma to communicate information about a high-risk medication, warfarin, to GPs on discharge optimises safe, informed prescribing and monitoring in primary care. The development of a discharge e-proforma for other high-risk medication as a patient safety improvement measure should be explored

Urban vs rural STEMI patients; is there a difference?

Background: Timely access to reperfusion therapy for ST elevation myocardial infarction (STEMI) is vital. Every minute of delay costs 10 days of patient's life. Patients living in the rural Scottish highlands face a lot of challenges to optimum reperfusion therapy (ORT), due to geographical and environmental barriers that influence receiving pharmacological or interventional therapy timeously. Aims: looking at ORT comparing remote vs urban patients. Methods: Patients admitted, between March 2014 and April 2015, were selected from Raigmore hospital STEMI electronic database. A data collection form was developed by the research team and piloted. Clinical details were collected retrospectively from patient's discharge letters. 132 patients who suffered STEMI were included. Data collected included; patients' treatment location, date of admission, distance to the nearest cardiac-unit (CU), MI location, route of access to health, LV function and reperfusion therapy received. Results: 132 patients were identified, 73% received percutaneous coronary intervention, 31.7% received pre-hospital thrombolysis, 24.8% received in-hospital thrombolysis while 13% didn't receive any treatment. From this cohort 51% lived more than 50 miles from the nearest CU. Further analysis is ongoing to identify who received ORT and in the remaining cases what barriers limited ORT. These barriers will be divided into modifiable and non-modifiable. Conclusion: From initial analysis of the results it seems that there is a differential in patients' care, with more rural patients potentially receiving sub-optimal reperfusion therapy. This is likely to have an adverse mortality outcome. More research required to determine if addressing barriers to ORT is achievable and cost effective

Prescribers’ perceptions of benefits and limitations of direct acting oral anticoagulants in non-valvular atrial fibrillation.

Background: There is an acknowledged lack of robust and rigorous research focusing on the perspectives of those prescribing direct acting oral anticoagulants (DOACs) for non-valvular atrial fibrillation (AF). Objective: The objective was to describe prescribers’ experiences of using DOACs in the management of non-valvular AF, including perceptions of benefits and limitations. Methods: A cross-sectional survey of prescribers in a remote and rural area of Scotland. Among other items, the questionnaire invited free-text description of positive and negative experiences of DOACs, and benefits and limitations. Responses were independently analysed by two researchers using a summative content analysis approach. This involved counting and comparison, via keywords and content, followed by interpretation and coding of the underlying context into themes. Results: One hundred and fifty-four responses were received, 120 (77.9%) from physicians, 18 (11.7%) from nurse prescribers and 10 (6.4%) from pharmacist prescribers (6 unidentified professions). Not having to monitor INR was the most cited benefit, particularly for prescribers and patients in remote and rural settings, followed by potentially improved patient adherence. These benefits were reflected in respondents’ descriptions of positive experiences and patient feedback. The main limitations were the lack of reversal agents, cost and inability to monitor anticoagulation status. Many described their experiences of adverse effects of DOACs including fatal and non-fatal bleeding, and upper gastrointestinal disturbances. Conclusions: While prescribers have positive experiences and perceive benefits of DOACs, issues such as adverse effects and inability to monitor anticoagulation status merit further monitoring and investigation. These issues are particularly relevant given the trajectory of increased prescribing of DOACs

Prescribers' views and experiences of using direct acting oral anticoagulants in the management of nonvalvular atrial fibrillation: a survey in remote and rural Scotland.

A recent systematic review highlighted the lack of robust studies on prescribers' perspectives of direct-acting oral anticoagulants (DOACs) for non-valvular atrial fibrillation (AF). The aim was to determine prescribers' views and experiences of prescribing DOACs. A cross-sectional survey of prescribers in a remote and rural area of Scotland. Survey items were: demographics; prescribing of DOACs; views of potential influences on DOAC prescribing; knowledge of prescribing guidelines; and experiences. Items on potential influences were based on the Theoretical Domains Framework (TDF). Data were analysed using descriptive and inferential statistics, and content analysis of responses to open questions. Principal component analysis (PCA) was performed on the items of potential influences. One hundred and fifty-four responses were received, 120 (77.9%) from doctors, 18 (11.7%) from nurse prescribers and 10 (6.4%) from pharmacist prescribers (6 missing). PCA of the TDF items of potential influences gave four components. Component scores for (i) role of professionals, their knowledge and skills and (ii) influences on prescribing were positive. Those for (iii) consequences of prescribing and (iv) monitoring for safety and effectiveness were more neutral. 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. This study has identified several key issues of DOAC prescribing (e.g. bleeding management) hence further emphasis is required in continuing professional development and during guideline implementation and evaluation

Longitudinal study of the relationship between patients' medication adherence and quality of life outcomes and illness perceptions and beliefs about cardiac rehabilitation

Background Adherence to medication regimens is essential for preventing and reducing adverse outcomes among patients with coronary artery disease (CAD). Greater understanding of the relation between negative illness perceptions, beliefs about cardiac rehabilitation (CR) and medication adherence may help inform future approaches to improving medication adherence and quality of life (QoL) outcomes. The aims of the study are: 1) to compare changes in illness perceptions, beliefs about CR, medication adherence and QoL on entry to a CR programme and 6 months later; 2) to examine associations between patients’ illness perceptions and beliefs about CR at baseline and medication adherence and QoL at 6 months. Methods A longitudinal study of 40 patients with CAD recruited from one CR service in Scotland. Patients completed the Medication Adherence Report Scale, Brief Illness Perception Questionnaire, Beliefs about CR questionnaire and the Short-Form 12 Health Survey. Data were analysed using the Wilcoxon Signed Ranks test, Pearson Product Moment correlation and Bayesian multiple logistic regression. Results Most patients were men (70%), aged 62.3 mean (SD 7.84) years. Small improvements in ‘perceived suitability’ of CR at baseline increased the odds of being fully adherent to medication by approximately 60% at 6 months. Being fully adherent at baseline increased the odds of staying so at 6 months by 13.5 times. ‘Perceived necessity, concerns for exercise and practical barriers’ were negatively associated with reductions in the probability of full medication adherence of 50, 10, and 50%. Small increases in concerns about exercise decreased the odds of better physical health at 6 months by about 50%; and increases in practical barriers decreased the odds of better physical health by about 60%. Patients perceived fewer consequences of their cardiac disease at 6 months. Conclusions Patients’ beliefs on entry to a CR programme are especially important to medication adherence at 6 months. Negative beliefs about CR should be identified early in CR to counteract any negative effects on QoL. Interventions to improve medication adherence and QoL outcomes should focus on improving patients’ negative beliefs about CR and increasing understanding of the role of medication adherence in preventing a future cardiac event

Longitudinal evaluation of the effects of illness perceptions and beliefs about cardiac rehabilitation on quality of life of patients with coronary artery disease and their caregivers

Background Patients’ negative illness perceptions and beliefs about cardiac rehabilitation (CR) can influence uptake and adherence to CR. Little is known about the interpartner influence of these antecedent variables on quality of life of patients with coronary artery disease (CAD) and their family caregivers. The aims of the study were: 1) to assess differences in illness perceptions, beliefs about CR and quality of life between patients with CAD and their family caregivers upon entry to a CR programme and at 6 months follow-up; and 2) to examine whether patients’ and caregivers’ perceptions of the patient’s illness and beliefs about CR at baseline predict their own and their partner’s quality of life at 6 months. Methods In this longitudinal study of 40 patient-caregiver dyads from one CR service, patients completed the Brief Illness Perception Questionnaire and Beliefs about Cardiac Rehabilitation Questionnaire at baseline and 6 months; and caregivers completed these questionnaires based on their views about the patient’s illness and CR. The Short-Form 12 Health Survey was used to assess patients’ and caregivers’ perceived health status. Dyadic data were analysed using the Actor–Partner Interdependence Model. Results Most patients (70%) were men, mean age 62.45 years; and most caregivers (70%) were women, mean age 59.55 years. Caregivers were more concerned about the patient’s illness than the patients themselves; although they had similar scores for beliefs about CR. Patients had poorer physical health than caregivers, but their level of mental health was similar. Caregivers’ poorer mental health at 6 months was predicted by the patient’s perceptions of timeline and illness concern (i.e. partner effects). Patient’s and caregiver’s illness perceptions and beliefs about CR were associated with their own physical and mental health at 6 months (i.e. actor effects). Conclusions Overall, the patients and caregivers had similar scores for illness perceptions and beliefs about CR. The actor and partner effect results indicate a need to focus on specific illness perceptions and beliefs about CR, targeting both the individual and the dyad, early in the rehabilitation process to help improve patients and caregivers physical and mental health (outcomes)

A cross-sectional survey of the access of older people in the Scottish Highlands to general medical practices, community pharmacies and prescription medicines.

Access to medicines and healthcare is more problematic in remote and rural areas. The purpose of this study was to quantify issues of access to general practitioners (GPs), community pharmacies and prescribed medicines in older people resident in the Scottish Highlands. Anonymized questionnaires were mailed to a random sample of 2000 older people (≥60 years) resident in the Scottish Highlands. Questionnaire items were: access and convenience to GP and pharmacy services (10 items); prescribed medicines (13 items); attitudinal statements based on the Theoretical Domains Framework (12 items); quality of life (SF8, 8 items); and demographics (12 items). Results were analysed using descriptive, inferential and spatial statistics, and principal component analysis (PCA) of attitudinal items. With a response rate of 54.2%, the majority reported convenient access to GPs (89.1%) and community pharmacies (84.3%). Older age respondents (p < 0.0001) were more likely to state that their access to GP services was not convenient and those in rural areas to community pharmacies (p < 0.01). For access to prescribed medicines, those in poorer health (p < 0.001) and taking five or more regular prescribed medicines (p = 0.002) were more likely to state access not convenient. PCA identified three components of beliefs of capabilities, emotions and memory. Those with poorer health had more negative scores for all (p < 0.001). Those reporting issues of access to prescribed medicines had more negative scores for beliefs of capabilities (p < 0.001) while those of older age, living alone, and taking five or more regular prescribed medicines (all p < 0.001) had more negative scores for emotions. In conclusion, while the majority of respondents have convenient access to their GP practice, pharmacy and prescribed medicines, there is a need for further review of the pharmaceutical care of those of older age with poorer health, living alone in the more remote and rural areas and taking five or more prescribed medicines

Patterns of initial and first-intensifying antidiabetic drug utilization among patients with type 2 diabetes mellitus in Scotland, 2010-2020: A retrospective population-based cohort study : a retrospective population-based cohort study

To evaluate the utilization and prescribing patterns of antidiabetic drugs (ADDs) for patients with type 2 diabetes mellitus (T2DM) at treatment initiation and first intensification. A retrospective cohort study was performed using linked routinely collected data of patients with T2DM who received ADDs between January 2010 and December 2020 in Scotland. The prescribing patterns were quantified using frequency/percentages, absolute/relative change, and trend tests. Overall, 145 909 new ADD users were identified, with approximately 91% (N = 132 382) of patients receiving a single ADD at first treatment initiation. Metformin was the most often prescribed monotherapy (N = 118 737, 89.69%). A total of 50 731 patients (39.40%) who were started on metformin (N = 46 730/118 737, 39.36%) or sulphonylurea (SU; N = 4001/10 029, 39.89%) monotherapy had their treatment intensified with one or more additional ADD. Most initial-metformin (45 963/46 730; 98.36%) and initial-SU users (3894/4001; 97.33%) who added further drugs were intensified with single ADDs. SUs (22 197/45 963; 48.29%) were the most common first-intensifying monotherapy after initial metformin use, but these were replaced by sodium-glucose cotransporter-2 (SGLT2) inhibitors in 2019 (SGLT2 inhibitors: 2039/6065, 33.62% vs. SUs: 1924/6065, 31.72%). Metformin was the most frequently added monotherapy to initial SU use (2924/3894, 75.09%). Although the majority of patients received a single ADD, the use of combination therapy significantly increased over time. Nevertheless, there was a significant increasing trend towards prescribing the newer ADD classes (SGLT2 inhibitors, dipeptidyl peptidase-4 inhibitors) as monotherapy or in combination compared with the older ones (SUs, insulin, thiazolidinediones) at both drug initiation and first intensification. An overall increasing trend in prescribing the newer ADD classes compared to older ADDs was observed. However, metformin remained the most commonly prescribed first-line ADD, while SGLT2 inhibitors replaced SUs as the most common add-on therapy to initial metformin use in 2019. [Abstract copyright: © 2024 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.