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Guideline Adherence As An Indicator of the Extent of Antithrombotic Overuse and Underuse: A Systematic Review Cover

Guideline Adherence As An Indicator of the Extent of Antithrombotic Overuse and Underuse: A Systematic Review

Global Heart
Volume 17 (2022): Issue 1
By: Magnolia Cardona,  Louise Craig,  Mark Jones,  Oyungerel Byambasuren,  Mila Obucina,  Laetitia Hattingh,  Justin Clark,  Paul Glasziou and  Tammy Hoffmann  
Open Access
|Aug 2022
Figures & tables

Figures & Tables

Figure 1

PRISMA diagram for selection of eligible studies.

Table 1

Overuse and underuse study characteristics by study design and setting (N = 21).

AUTHORS AND PUBLICATION YEARCOUNTRYSAMPLE SIZESTUDY DESIGNSETTINGTARGET CONDITIONS/CLINICAL ACTIVITYTARGET TOPIC
RETROSP REVIEWCOHORT/C-CHOSPITALISEDPRIMARY CARECOMM/OUTPATOVERUSEUNDERUSE
Overuse
Moesker et al., 2019 [21]NL256✓HReviewing the bridging anticoagulation policy for acute or elective surgical procedures✓✓
Wong et al, 2015 [24]Australia19,613✓HAnticoagulation for non-valvular AF in high and low-risk patients✓✓
Admassie et al, 2017 [20]Australia625✓HAnticoagulants in patients at risk of stroke from non-valvular AF✓✓
Wertheimer et al., 2019 [23]Australia200✓HAnticoagulants for valvular and non-valvular AF✓✓
Vesa et al., 2020 [22]Romania784✓HAntithrombotics in non-valvular AF✓✓
Gorczyca et al., 2020 [25]Poland1,236✓HProphylactic antithrombotic therapy among patients with AF✓✓
Steib et al, 2014 [29]France394✓HPerioperative Vit K antagonists✓✓
Manoucheri et al., Fallahi, 2015 [27]Iran472✓HAntithrombotic agents for prophylaxis and treatment of VTE✓✓
Khatib et al., 2020 [26]USA13,677✓HPost-discharge home-based antithrombotic therapy for VTE✓
Rosignol et al, 2019 [28]France145✓HManagement of traumatic bleeding in patients with injury severity score of >16✓
Waechter et al., 2020 [30]Germany373✓HAnticoagulants for persistent AF and mitral valve repair patients undergoing TMVR✓
Boivin-Proulx et al., 2020 [34]Canada459CohHAntithrombotics for AF on patients undergoing percutaneous coronary intervention with coronary stenting✓
Giustozzi, M 2020 [36]Italy155CohHAntithrombotics for stroke/Transient Ischaemic attack in patients known to have AF before admission✓
Jortveit et al., 2019 [37]Norway47,204CohHAnticoagulants for AF in patients with myocardial infarction who were in the registry✓
Uzieblo-Zyczowska et al., 2021 [39]Poland359CohHAntithrombotics for AF on patients undergoing percutaneous coronary intervention✓✓
Moerlie et al., 2020 [38]NL411CohHDual Antithrombotics for multiple conditions in hospital inpatients✓
Devine et al, 2009 [35]USA417CohHOManagement of excess warfarin anticoagulation✓✓
Laughenburger et al, 2015 [31]USA70,498✓HCAnticoagulants first prescription for patients diagnosed with AF✓
Miyazawa et al., 2019 [33]Japan & UK4,239
2,259		✓
✓		PCAntithrombotics for stroke prevention in AF using 2 registries✓✓
Le Blanc et al., 2020 [32]Canada1,681✓PAnticoagulants for permanent, paroxysmal or persistent non-valvular AF✓
Vanbeseleare et al, 2016 [40]Belgium1,830C-CPAnticoagulants for treatment of AF within 6 months of diagnosis✓✓

[i] C = Community setting; O = Outpatients; CC = Case-Control; Coh = Cohort; NL = The Netherlands.

Figure 2

Risk of bias across the included studies (N = 21).

Figure 3

Estimates of overuse of antithrombotic interventions across clinical settings (N = 17 studies).

Figure 4

Estimates of underuse of antithrombotic interventions across clinical settings (N = 17 studies).

Table 2

Clinician, patient and system determinants of overuse and underuse.

REASON FOR OVERUSE [REFERENCE #]REASON FOR UNDERUSE [REFERENCE #]
P

  • Low-risk patients with genuine indication for anticoagulants for other non-AF conditions [40]

C

  • Fear of patient bleeding complication; overestimation of risk over benefits [20, 22, 24, 32, 36]

P

  • Low-risk patient preference to minimize risk of stroke [23]

C

  • CHA2DS2-VASc risk scores not documented or incorrect [23]

C

  • Clinician lack of knowledge of the disease [27] Clinician’s lack of awareness of stroke risk from non-use of the combined CHA2DS2-VASc score and bleeding (HAS-BLED) score [22]

S

  • Update in guidelines in some countries no longer recommending antiplatelet agents in AF make others appear overprescribing [20, 33]

C

  • GP perceived risk of bleeding if history of peptic ulcer or tumour [40]

S

  • Absence of a national guideline [20]

C

  • Doctor perceived lower thromboembolic risk in women than in men [20, 40]

S

  • Evolution in risk prediction and wide availability of direct OA [24]

C

  • Older age a barrier to start OA [25, 32] due to clinician’s perceived risk of bleeding [20, 40]

S

  • Patient comorbidities, lack of social support or insurance status as incentive for in-hospital management [26]

C

  • Falls risk reduces clinician inclination to prescribe [20, 23, 40]

S

  • Aggressive promotion by pharmaceutical companies [20]

C

  • Lower inclination to prescribe in dementia, frailty syndrome [25], known poor patient compliance [40]

S

  • Lack of registry information on discontinuation at subsequent time points [33]

P

  • Patients’ unwillingness to receive prescription and non-adherence after prescription [24, 33]

C

  • Low clinician familiarity with or adoption of risk stratification methods [20, 26] or guidelines [24, 27]

P

  • Documented contraindication: scheduled surgical procedure, active bleeding, reduce glomerular filtration, alcoholism [23, 25, 32, 36]

[i] AF = atrial fibrillation; OA = oral anticoagulants; C = clinician reason, P = patient reason; S = system determinant.

Table 3

Proposed solutions for overuse and underuse from included studies and other literature.

To reduce overuse

  • Integration of pharmacists in post-discharge follow-up to cease time-limited medication when no longer indicated [38]

  • Training of and alerts for high-volume prescribers [44]

  • Decision support tools [45]

  • Public awareness campaigns [4]

  • Health literacy programs on overdiagnosis to reduce healthcare expectations [46]

To reduce underuse

  • Patient education on long-term benefits of anticoagulation and on enhancing self-care [22]

  • Clinician education on calculating/interpreting stroke risk and bleeding risk [22]

  • Clinician education on old age, comorbidities and dementia not being contraindications for anticoagulants [47]

To reduce practice variations

  • Development of national guidelines, and clinician education on customizing treatments to different risk levels[20] including reversal of overtreatment [48]

  • Wider availability of direct-acting oral anticoagulants to replace vitamin K antagonists which are more prone to mis-prescribing [20]

  • Quality improvement initiatives with group or individual feedback [49]

  • Policies mandating the use of protocols for healthcare delivery [50]

  • Practice incentives to fast-track evidence uptake [51]

DOI: https://doi.org/10.5334/gh.1142 | Journal eISSN: 2211-8179
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Language: English
Submitted on: Mar 16, 2022
Accepted on: Jun 30, 2022
Published on: Aug 12, 2022
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services
Publication frequency: 1 issue per year
Keywords:
adherence,
guidelines,
review

© 2022 Magnolia Cardona, Louise Craig, Mark Jones, Oyungerel Byambasuren, Mila Obucina, Laetitia Hattingh, Justin Clark, Paul Glasziou, Tammy Hoffmann, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.

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