Research

Pharmacist-led interventions in optimising the use of oral anticoagulants in patients with atrial fibrillation in general practice in England: a retrospective observational study

Raman Sharma, Syed Shahzad Hasan, Ishtiaq A Gilkar, Waheed F Hussain, Barbara R Conway and Muhammad Usman Ghori
BJGP Open 2024; 8 (2): BJGPO.2023.0113. DOI: https://doi.org/10.3399/BJGPO.2023.0113

Abstract

Background Oral anticoagulation (OAC) is the mainstay of treatment for the prevention of strokes in patients with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) account for increasing OAC in patients with AF. However, prescribing DOACs for patients with established AF poses various challenges and general practice pharmacists may have an important role in supporting their management.

Aim To investigate the effectiveness of pharmacist-led interventions in general practice in optimising the use of OAC therapies in AF.

Design & setting A retrospective observational study in general practices in Bradford.

Method The data were collected retrospectively from 1 November 2018–31 December 2019 using electronic health record data. The data were analysed: 1) to identify patients with AF not on OAC; 2) to describe inappropriate DOAC prescriptions; and 3) to calculate HAS-BLED scores.

Results Overall, 76.3% (n = 470) of patients with AF received OAC therapy, and of these, 63.4% received DOACs. Pharmacist-led interventions increased DOAC prescribing by 6.0% (P = 0.03). Inappropriate DOAC use was identified in 24.5% of patients with AF, with underdosed and overdosed identified in 9.7% and 14.8%, respectively. Post-intervention, inappropriate prescribing was reduced to 1.7%. The mean HAS-BLED score decreased from 3.00 to 2.22 (P<0.01). Successful transition from vitamin K antagonist (VKA) therapy to DOACs was achieved in 25.7% of patients.

Conclusion Pharmacist-led interventions have successfully improved the use of OAC therapies in patients with AF, and effectively managed the bleeding risks and transition from VKA to DOAC therapy, in line with guidelines.

How this fits in

Given the relatively recent implementation of pharmacists in patient-facing roles within general practice, there is a scarcity of published research in this domain, particularly concerning the assessment of pharmacist-led interventions in chronic conditions such as atrial fibrillation (AF). This research aids in assessing the role of GP pharmacist-led interventions in optimising oral anticoagulants in patients with AF in general practices in England. The findings of this research will enhance the understanding of anticoagulant optimisation within primary care, providing valuable insights for healthcare professionals.

Introduction

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults worldwide, with an increased risk of stroke.1 AF prevalence in adults is estimated to be between 2% and 4%, with a two-to-three-fold increase expected in the general population over the next decade.2,3 UK prevalence of AF has increased in all age categories and sexes, with higher prevalence in males and the most significant increase in patients aged >85 years.4 Public Health England estimates a prevalence of 2.5% in the population.5

Oral anticoagulation (OAC) remains the mainstay of treatment for stroke prevention, recommended by the National Institute for Health and Care Excellence (NICE).6 Current guidelines recommend OAC for all patients with AF and CHA2DS2VASc score of ≥2, and in males with a CHA2DS2VASc score of 1, taking bleeding risk into consideration.1,7 OAC options include the vitamin K antagonist (VKA), warfarin, and direct oral anticoagulants (DOACs), which include apixaban, dabigatran, edoxaban, and rivaroxaban. The prescribing trend for DOACs has shown an overall increase, accounting for 62% of all OACs in 2019 compared with 16% in 2015.8 Randomised controlled trials (RCTs) have demonstrated that DOACs are comparable with warfarin in stroke prevention.9–12 Owing to their efficacy in clinical practice,13,14 DOACs are now considered the first-line treatment.1,7 Significant variations remain within geographical regions in England regarding DOAC uptake, with rates of 130 per 1000 patient population in Greater London and 232 per 1000 patient population in Yorkshire and Humber in 2019.8 It has been shown that local clinical guidance increases DOAC usage when listed as first-line treatments,15 with edoxaban recently identified as the preferred DOAC.16 At the time of writing, the effect of this on DOAC usage in England is yet to be quantified.

Major bleeding risks persist with OAC use but DOACs show a favourable net clinical benefit compared with warfarin.17 Annual rates of major bleeding with VKA therapy in AF range from 1.4%–3.4%,18 with severe bleeds, such as intracranial haemorrhage (ICH), occurring in 0.1%–2.5% of patients.19 The different classification of bleeds with OAC are described in Supplementary Table S1. DOACs exhibit lower incidence of major bleeds (–14%) and ICH (–52%) compared with VKA.13,18 Bleeding risk factors, influenced by age, comorbidities, and concurrent medications, should be periodically addressed.20 The HAS-BLED score was developed, validated, and recommended for bleed risk assessment by NICE,6 but it was superseded by ORBIT in 2021,7 with the scoring criteria for each described in Supplementary Table S2.

Inadequate stroke prevention treatment for AF has been widely reported, burdening patients, carers, and healthcare systems.21–23 Moreover, the number of GPs in England declined by 5% between 2015 and 2021 despite a 4% population increase and more complex health requirements posing a further challenge to the adequate treatment options for patients with stroke.24 National efforts have prioritised AF detection, OAC initiation, and optimisation,25–28 but OACs remain underutilised in about one-third of eligible patients.29–31 Furthermore, clinicians' individual perceptions pose barriers to prescribing, including medication safety concerns, polypharmacy issues, limited understanding and experience in AF management, and perceived risks of falls and bleeding.32 Clinical decision making appears to be based on individual preference rather than a systematic approach by different clinicians.33 Despite these data, efforts to improve AF management in general practice are not extensively documented. Pharmacist-led care has been shown to improve screening rates in general practice,34–36 and improve patient understanding of and outcomes associated with OAC therapy in AF management. A secondary care-based specialist pharmacist supported the practice-based pharmacist (PBP) workforce with AF management, reduced bleed risk by deprescribing antiplatelet therapy, and guideline adherence.37–39

The current study aimed to investigate the effectiveness of pharmacist-led interventions in optimising the use of OAC therapies in patients with AF in general practice settings in England.

Method

Study design and setting

A multi-centre retrospective observational (pre-post) study was undertaken across general practices in the City Health Bradford GP Federation from 1 November 2018–31 December 2019. It compared the prescribing practices for OAC treatment (pre-intervention) to outcomes for patients managed by pharmacist-led medicines optimisation interventions in AF (post-intervention).

Study population

The study population consisted of patients aged ≥18 years with a confirmed AF diagnosis and on the Quality and Outcomes Framework (QOF) AF register.40 Patients registered at one of the City Health Bradford GP Federation member general practices with a confirmed diagnosis of AF were included with no limitations placed on sex and ethnic group. However, patients with a confirmed diagnosis of valvular AF were excluded from the study, owing to their OAC treatment modalities varying from those patients diagnosed with non-valvular AF.

Outcome measure

The primary objective was to determine OAC prescribing pre- and post-intervention by pharmacists. A summary of intervention details related to different phases of the current project has been tabulated in Supplementary Table S3. Secondary outcomes included determining the proportion and classification of inappropriately prescribed OAC treatments and bleed risk, and consequent intervention analyses related to these parameters.

Risk stratification and OAC treatment

Baseline characteristics, including age, sex, previous stroke history, and any hospital admissions in relation to thrombolytic events, were collected via the medical record. Blood biochemical measurements of estimated creatinine clearance (CrCl) were calculated using the Cockcroft–Gault calculator in the clinical system, SystmOne, using actual body weight as recommended for DOAC dosing.41

The CHA2DS2VASc score was used to evaluate the risk of stroke in patients with AF.42 HAS-BLED score is a composite of modifiable and non-modifiable bleeding risk factors.42 The score can be stratified as low (0 points), intermediate (1–2 points), and high risk (≥3 points).43 Where data for time in therapeutic range (TTR) were not available for patients on VKA therapy, 0 points were allocated when undertaking bleed risk assessment.

The summary of medicines characteristics44–49 and Figure 1 list standard dose parameters for UK-licensed OACs. The appropriateness of DOAC administration was assessed by the primary author and oversight provided by the GP clinical lead. The number, type, and acceptance of pharmacist-led interventions were collated during the post-intervention study period. Pharmacists undertaking reviews were qualified as independent prescribers and received an educational update on AF management, before interventions were undertaken in October 2018, via a presentation, including key differences between OAC choices, key differences on efficacy, and safety points.

Figure 1.
Figure 1. Direct oral anticoagulants dosing algorithms.44–49 BID = twice daily. CrCl = creatinine clearance. DOAC = direct oral anticoagulant. NVAF = non-valvular atrial fibrillation. OD = once daily. P-gp = glycoprotein.

Data analysis

Data collection parameters were decided on with consultation and agreement between the researchers, GP clinical teams, and the ethical committee at the University of Huddersfield. Data were initially entered into a spreadsheet using Microsoft Excel 2019 and all analyses were performed using R (version 4.1.3). Results from descriptive analyses were reported as means or percentages. The Shapiro–Wilk test was used to test for normality of the dataset. Differences between patient groups were tested using the t-test or the Wilcoxon signed-rank test as appropriate for the continuous variables, expressed as percentages; a χ2 test was used for categorical variables, expressed as mean ± standard deviation (SD). A P-value <0.05 was considered statistically significant.

Results

The combined population of the practices as of April 2019 was 139 236. In total, 616 patients were on the AF register representing a prevalence of 0.4%, with 76.3% (n = 470) of these on established OAC treatment. Baseline characteristics are outlined in Table 1.

View this table:
Table 1. Baseline characteristics of DOAC and warfarin users (N = 470)

DOAC initiation

The most prescribed OAC at baseline across the study population was rivaroxaban (43.8%) followed by warfarin (36.3%). DOAC prescribing increased from 48.4% in the pre-intervention group to 54.4% in the post-intervention group (P = 0.03) (Table 2). The largest increases were for edoxaban 60 mg tablets and apixaban 5 mg tablets.

View this table:
Table 2. Change in DOAC prescribing pre- and post-intervention

Inappropriate DOAC prescribing

Inappropriate DOAC prescribing was present in 24.5% at pre-intervention. Pre-intervention compared with the post-intervention was related to underdosing (9.7% versus 1.0%, P = 0.09) or overdosing (14.8% versus 0.7%, P = 0.01), with inappropriate DOAC prescribing reducing to 1.7% post-intervention. The most common DOAC that was inappropriately prescribed was rivaroxaban (underdose and overdose) followed by apixaban (underdose) (Table 3).

View this table:
Table 3. Number of patients with inappropriate DOAC prescribing by criterion

Bleed risk factors

Mean HAS-BLED scores were calculated and there was a reduction from 3.00±0.65 versus 2.22±0.79 (P<0.01), pre- intervention to post-intervention. Modifiable bleed risk interventions resulted in 73.0% (n = 54) of patients having a reduction in their HAS-BLED score by at least one point, with one patient reducing by two points. Overall, 47 (63.5%) patients had a reduction in their HAS-BLED risk category from a higher bleed risk to a lower one (Table 4).

View this table:
Table 4. HAS-BLED intervention outcomes (N = 74)

In 27.0% (n = 20) of patients who received an intervention to modify the bleed risk, the HAS-BLED score did not decrease despite an intervention being applied. Specifically, the deprescribing of NSAIDs was not achieved in eight (40.0%) patients owing to patient preference, systolic blood pressure (SBP) remaining >160 mmHg after intensification in antihypertensive treatments in six (30.0%) patients, and patient-reported alcohol intake remaining >8 units per week after counselling and signposting to available community-based services in six (30.0%) patients (Table 5).

View this table:
Table 5. Pharmacist interventions not resulting in lower HAS-BLED risk score (N = 74)

VKA to DOAC transition

In total, 36.6% of all patients on OAC were on VKA therapy, warfarin (n = 168) and acenocoumarol (n = 4), with a median duration of treatment of 4.05 years. TTR was available for 16.9% (n = 29) of patients on VKAs (median 92.5%, range 69–100). Table 6 shows their eligibility for conversion to a DOAC, with 25.7% of patients transitioning from VKA therapy to a DOAC, and summarises the reasons patients were unsuitable for transition to DOACs.

View this table:
Table 6. Eligibility for transition from VKA therapy to a DOAC

Discussion

Summary

This study demonstrated that pharmacists in general practice could improve the management of AF. There are three main findings in this study: 1) the overall prescribing of OAC increased by 6.0% in those patients with AF where OAC is currently not initiated; 2) optimising medicines, and in particular optimising DOAC dosing, in line with guidance and individual patient parameters, is potentially a valuable role for pharmacists in general practice, particularly overdose, as there was a reduction in overall inappropriate prescribing of DOAC by 11.0%; and 3) proactive management of modifiable bleeding risk factors by pharmacists in general practice could reduce the risk of harm commonly associated with DOAC use.

Strengths and limitations

This study has successfully provided evidence that pharmacists in general practice can effectively improve the use of OAC therapies in patients with AF. Pharmacist-led interventions were successful in promoting higher prescription rates for DOACs in patients with AF. Furthermore, these interventions effectively optimised the dose of DOACs while considering bleeding risk. However, this study has some limitations and should be interpreted with caution. The study was conducted across 21 general practices, with varying processes, and differences in patient demographics, ethnic group, and deprivation were not considered. Therefore, the results may not be generalisable to other general practices in the UK. Furthermore, no economic analysis or evaluation was included, and patient follow-up was limited to the study period.

Comparison with existing literature

The study population represented the entire AF register across the 21 general practices, with a prevalence of 0.4%. Although this study did not measure the effects of screening and AF identification, the study prevalence remains below the estimates of 1.1% AF prevalence for this region.5 This may be explained by the findings of the Bradford AF study, which concluded that people from a South Asian ethnic group have a significantly lower prevalence of AF when compared with people from a White ethnic group despite having a higher frequency of risk factors for the development of AF.50

There is overwhelming evidence that increased OAC rates in patients with AF lead to marked reduction in stroke prevalence, and the benefits of anticoagulating outweighs the associated risks.51 DOAC modelling data suggest a lower number needed to treat than warfarin,52 although these medications still need to be managed carefully to avoid harm. The results of this study indicate an increase in DOAC prescribing in line with other published literature of approximately 6.0%,37–39 demonstrating the role a pharmacist may undertake in the long-term condition management of AF.

Previous studies have reported the inappropriate dosing of DOACs in the range from 7.7%53–32%,54 with underdosing being more frequently reported.53–55 In the present study, overdosing (14.8%) was more frequent than underdosing (9.7%) in those already prescribed DOACs. This might be explained by the differing study population characteristics and the length of time patients were already established on DOACs. A dosing issue may not have been present at the time of initiation but subsequent changes in clinical characteristics may have resulted in dosing being inappropriate, such as a decline in estimated CrCl.

These findings align with harm reduction strategies by reducing incorrect DOAC prescribing in hospitals,56 and in primary care studies where problematic polypharmacy and antiplatelet monotherapy for AF were reduced.38,39 To the authors’ knowledge, no other studies have reported on pharmacist-led interventions across the full range of modifiable aspects of bleed risk reduction in primary care, uncontrolled SBP management, concurrent medication use predisposing to bleeding, and addressing alcohol intake.

Prescribing trend data have outlined the increase in the growth of DOACs in comparison with VKA therapy.8 This may be owing to an increase in guideline adherence1,7 and more recently the transition of VKA therapy to DOACs as part of the NHS England priority workstreams in response to COVID-19.57 Despite the higher acquisition cost of DOACs compared with VKAs, the decline in AF-related strokes has resulted in incremental savings at a national level.58 This study reported on the number of VKA to DOAC transitions and the reasons transitions were not implemented. The main reason identified was the GP with primary responsibility for the patient’s clinical care deemed the transition not suitable and could reflect therapeutic inertia, with GPs hesitant to modify the OAC initiation by another physician.

Implications for research and practice

This study has suggested there is a useful role for pharmacists in general practice in the overall management of AF. It has shown that pharmacists are able to increase DOAC prescribing rates for already established AF, optimise DOAC to the patient’s clinical characteristics, and proactively manage bleeding risk.

The bleeding risk identification and management reported as part of this study may be limited as the bleeding risk stratification tool recommended by NICE in its guideline update recommended the use of ORBIT,7 whereas HAS-BLED was the recommended tool for bleeding risk stratification during the study period.6 Pharmacists in general practice have shown benefits to chronic disease management and the quality use of medicines,59 and improved adherence to guidelines for OAC treatment for AF in primary care,60 which this study’s findings support.

DOAC initiation was guideline-led and patient-centred, and inappropriate DOAC use was reviewed retrospectively. This may support a recommendation for patients with AF and on OAC to remain high priority for targeted structured medication review. Further research around patient perceptions and experiences of a pharmacist-led service would serve to enhance the outputs of this study. The long-term sustainability of this type of intervention programme may rely on balancing fidelity with adaptability61 to aid generalisability of the results and requires further research.

Notes

Funding

The authors are grateful to Health Education England and City Health Bradford GP Federation for financial support (reference: 0093-102021).

Ethical approval

Ethical approval was obtained from the School Research Ethics and Integrity Committee, School of Applied Sciences, University of Huddersfield (reference: SAS-SRIEC 05.06.23-2).

Provenance

Freely submitted; externally peer reviewed.

Acknowledgements

The authors would like to thank the participating GP surgeries and pharmacists for their contributions to this study.

Competing interests

The authors declare that no competing interests exist.

  • Received July 10, 2023.
  • Revision received November 10, 2023.
  • Accepted November 24, 2023.

This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)

References

  1. 1.↵
    1. Li H,
    2. Song X,
    3. Liang Y,
    4. et al.
    (2022) Global, regional, and national burden of disease study of atrial fibrillation/flutter, 1990–2019: results from a global burden of disease study, 2019. BMC Public Health 22 (1), doi:10.1186/s12889-022-14403-2, pmid:32860505. 2015.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Chugh SS,
    2. Havmoeller R,
    3. Narayanan K,
    4. et al.
    (2014) Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation 129 (8):837–847, doi:10.1161/CIRCULATIONAHA.113.005119, pmid:24345399.
    OpenUrlAbstract/FREE Full Text
  3. 3.↵
    1. Benjamin EJ,
    2. Muntner P,
    3. Alonso A,
    4. et al.
    (2019) Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation 139 (10):e56–e528, doi:10.1161/CIR.0000000000000659, pmid:30700139.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Adderley NJ,
    2. Ryan R,
    3. Nirantharakumar K,
    4. Marshall T
    (2019) Prevalence and treatment of atrial fibrillation in UK general practice from 2000 to 2016. Heart 105 (1):27–33, doi:10.1136/heartjnl-2018-312977, pmid:29991504.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Public Health England
    (2020) Atrial fibrillation prevalence estimates for local populations. accessed. https://www.gov.uk/government/publications/atrial-fibrillation-prevalence-estimates-for-local-populations. 11 Mar 2024.
  6. 6.↵
    1. National Institute for Health and Care Excellence (NICE)
    (2006) Atrial fibrillation: the management of atrial fibrillation. CG36. accessed. https://www.nice.org.uk/guidance/cg36. 11 Mar 2024.
  7. 7.↵
    1. NICE
    (2021) Atrial fibrillation: diagnosis and mangement. NG196. accessed. https://www.nice.org.uk/guidance/ng196. 11 Mar 2024.
  8. 8.↵
    1. Afzal S,
    2. Zaidi STR,
    3. Merchant HA,
    4. et al.
    (2021) Prescribing trends of oral anticoagulants in England over the last decade: a focus on new and old drugs and adverse events reporting. J Thromb Thrombolysis 52 (2):646–653, doi:10.1007/s11239-021-02416-4, pmid:33666824.
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Connolly SJ,
    2. Ezekowitz MD,
    3. Yusuf S,
    4. et al.
    (2009) Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 361 (12):1139–1151, doi:10.1056/NEJMoa0905561, pmid:19717844.
    OpenUrlCrossRefPubMed
  10. 10.
    1. Patel MR,
    2. Mahaffey KW,
    3. Garg J,
    4. et al.
    (2011) Rivaroxaban versus warfarin in Nonvalvular atrial fibrillation. N Engl J Med 365 (10):883–891, doi:10.1056/NEJMoa1009638, pmid:21830957.
    OpenUrlCrossRefPubMed
  11. 11.
    1. Granger CB,
    2. Alexander JH,
    3. McMurray JJV,
    4. et al.
    (2011) Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 365 (11):981–992, doi:10.1056/NEJMoa1107039, pmid:21870978.
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. Giugliano RP,
    2. Ruff CT,
    3. Braunwald E,
    4. et al.
    (2013) Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 369 (22):2093–2104, doi:10.1056/NEJMoa1310907, pmid:24251359.
    OpenUrlCrossRefPubMed
  13. 13.↵
    1. López-López JA,
    2. Sterne JAC,
    3. Thom HHZ,
    4. et al.
    (2017) Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis. BMJ 359 doi:10.1136/bmj.j5058, pmid:29183961. j5058.
    OpenUrlAbstract/FREE Full Text
  14. 14.↵
    1. Vinogradova Y,
    2. Coupland C,
    3. Hill T,
    4. Hippisley-Cox J
    (2018) Risks and benefits of direct oral anticoagulants versus warfarin in a real world setting: cohort study in primary care. BMJ 362 doi:10.1136/bmj.k2505, pmid:29973392. k2505.
    OpenUrlAbstract/FREE Full Text
  15. 15.↵
    1. Ho KH,
    2. van Hove M,
    3. Leng G
    (2020) Trends in anticoagulant prescribing: a review of local policies in English primary care. BMC Health Serv Res 20 (1), doi:10.1186/s12913-020-5058-1, pmid:32245380. 279.
    OpenUrlCrossRefPubMed
  16. 16.↵
    1. NHS England
    Investment and Impact Fund. accessed. https://www.england.nhs.uk/primary-care/primary-care-networks/network-contract-des/iif. 11 Mar 2024.
  17. 17.↵
    1. Ruff CT,
    2. Giugliano RP,
    3. Braunwald E,
    4. et al.
    (2014) Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 383 (9921):955–962, doi:10.1016/S0140-6736(13)62343-0, pmid:24315724.
    OpenUrlCrossRefPubMed
  18. 18.↵
    1. Agarwal S,
    2. Hachamovitch R,
    3. Menon V
    (2012) Current trial-associated outcomes with warfarin in prevention of stroke in patients with nonvalvular atrial fibrillation: a meta-analysis. Arch Intern Med 172 (8):623–631, doi:10.1001/archinternmed.2012.121, pmid:22450212.
    OpenUrlCrossRefPubMed
  19. 19.↵
    1. Lip GYH,
    2. Andreotti F,
    3. Fauchier L,
    4. et al.
    (2011) Bleeding risk assessment and management in atrial fibrillation patients: a position document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis. Europace 13 (5):723–746, doi:10.1093/europace/eur126, pmid:21515596.
    OpenUrlCrossRefPubMed
  20. 20.↵
    1. Gorog DA,
    2. Gue YX,
    3. Chao T-F,
    4. et al.
    (2022) Assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: a position paper from the ESC Working Group on Thrombosis, in collaboration with the European Heart Rhythm Association, the Association for Acute Cardiovascular Care and the Asia-Pacific Heart Rhythm Society. Europace 24 (11):1844–1871, doi:10.1093/europace/euac020, pmid:35323922.
    OpenUrlCrossRefPubMed
  21. 21.↵
    1. British Health Foundation
    (2019) Atrial fibrillation: finding the missing 300,000. accessed. https://www.bhf.org.uk/for-professionals/healthcare-professionals/blog/2019/atrial-fibrillation-finding-the-missing-300000. 11 Mar 2024.
  22. 22.
    1. Han TS,
    2. Fry CH,
    3. Fluck D,
    4. et al.
    (2018) Anticoagulation therapy in patients with stroke and atrial fibrillation: a registry-based study of acute stroke care in Surrey, UK. BMJ Open 8 (7), doi:10.1136/bmjopen-2018-022558, pmid:29997144. e022558.
    OpenUrlAbstract/FREE Full Text
  23. 23.↵
    1. Ajabnoor AM,
    2. Zghebi SS,
    3. Parisi R,
    4. et al.
    (2022) Incidence of nonvalvular atrial fibrillation and oral anticoagulant prescribing in England, 2009 to 2019: a cohort study. PLoS Med 19 (6), doi:10.1371/journal.pmed.1004003, pmid:35671329. e1004003.
    OpenUrlCrossRefPubMed
  24. 24.↵
    1. Royal College of General Practitioners
    (2022) Brief: GP shortages in England, accessed. https://www.rcgp.org.uk/getmedia/3613990d-2da8-458a-b812-ed2cf6d600a6/RCGP-Brief_GP-Shortages-in-England.pdf. 11 Mar 2024.
  25. 25.↵
    1. NHS England
    NHS England’s work on stroke. accessed. https://www.england.nhs.uk/ourwork/clinical-policy/stroke. 11 Mar 2024.
  26. 26.
    1. NHS
    Cardiovascular disease. accessed. https://www.longtermplan.nhs.uk/areas-of-work/cardiovascular-disease. 11 Mar 2024.
  27. 27.
    1. Barber M,
    2. Brennan K,
    3. Dennis M,
    4. et al.
    (2018) Scottish Stroke Improvement Programme. accessed. https://www.strokeaudit.scot.nhs.uk/Publications/docs/2018-07-10-SSCA-Report.pdf. 5 Apr 2024.
  28. 28.↵
    1. Health Innovation Wessex
    Atrial fibrillation: detect, protect, perfect. accessed. https://wessexahsn.org.uk/programmes/29/atrial-fibrillation-detect-protect-perfect. 11 Mar 2024.
  29. 29.↵
    1. Al-Khatib SM,
    2. Pokorney SD,
    3. Al-Khalidi HR,
    4. et al.
    (2020) Underuse of oral anticoagulants in privately insured patients with atrial fibrillation: A population being targeted by the implementation of a randomized controlled trial to imProve treatment with oral anticoagulants in patients with atrial fibrillation (IMPACT-Afib). Am Heart J 229 110–117, doi:10.1016/j.ahj.2020.07.012, pmid:32949986.
    OpenUrlCrossRefPubMed
  30. 30.
    1. Park S,
    2. Je NK
    (2022) Underutilization of anticoagulants in patients with Nonvalvular atrial fibrillation in the era of non-vitamin K antagonist oral anticoagulants. Int J Arrhythm 23 (1):1–8, doi:10.1186/s42444-021-00053-9.
    OpenUrlCrossRef
  31. 31.↵
    1. Ogilvie IM,
    2. Newton N,
    3. Welner SA,
    4. et al.
    (2010) Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med 123 (7):638–645, doi:10.1016/j.amjmed.2009.11.025, pmid:20609686.
    OpenUrlCrossRefPubMed
  32. 32.↵
    1. Lakshmi R,
    2. James E,
    3. Kirthivasan R
    (2013) Study on impact of clinical pharmacist’s interventions in the optimal use of oral anticoagulants in stroke patients. Indian J Pharm Sci 75 (1):53–59, doi:10.4103/0250-474X.113550, pmid:23901161.
    OpenUrlCrossRefPubMed
  33. 33.↵
    1. Bastida C,
    2. Corominas N,
    3. Sotoca JM,
    4. Rovira M
    (2017) Anticoagulation in atrial fibrillation: NOAC prescribing in primary health care. Int J Clin Pharm 39 (2):478–482, doi:10.1007/s11096-017-0431-9, pmid:28188509.
    OpenUrlCrossRefPubMed
  34. 34.↵
    1. Osasu YM,
    2. Cooper R,
    3. Mitchell C
    (2021) Patients' and clinicians' perceptions of oral anticoagulants in atrial fibrillation: a systematic narrative review and meta-analysis. BMC Fam Pract 22 (1), doi:10.1186/s12875-021-01590-x, pmid:34937557. 254.
    OpenUrlCrossRefPubMed
  35. 35.
    1. Wang Y,
    2. Bajorek B
    (2016) Decision-making around antithrombotics for stroke prevention in atrial fibrillation: the health professionals' views. Int J Clin Pharm 38 (4):985–995, doi:10.1007/s11096-016-0329-y, pmid:27286973.
    OpenUrlCrossRefPubMed
  36. 36.↵
    1. Savickas V,
    2. Stewart AJ,
    3. Rees-Roberts M,
    4. et al.
    (2020) Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study. PLoS Med 17 (7), doi:10.1371/journal.pmed.1003197, pmid:32678820. e1003197.
    OpenUrlCrossRefPubMed
  37. 37.↵
    1. Patel M,
    2. Ali S,
    3. Robson J,
    4. et al.
    (2022) Pharmacist-led multidisciplinary approach in preventing strokes in people with atrial fibrillation. Eur J Cardiovasc Nurs 21 (Supplement_1), doi:10.1093/eurjcn/zvac060.001. zvac060.001.
    OpenUrlCrossRef
  38. 38.↵
    1. Chahal JK,
    2. Antoniou S,
    3. Earley M,
    4. et al.
    (2019) Preventing strokes in people with atrial fibrillation by improving ABC. BMJ Open Qual 8 (4), doi:10.1136/bmjoq-2019-000783, pmid:31803855. e000783.
    OpenUrlAbstract/FREE Full Text
  39. 39.↵
    1. Virdee MS,
    2. Stewart D
    (2017) Optimizing the use of oral anticoagulant therapy for atrial fibrilation in primary care: a pharmacist-led intervention. Int J Clin Pharm 39 (1):173–180, doi:10.1007/s11096-016-0419-x, pmid:28050712.
    OpenUrlCrossRefPubMed
  40. 40.↵
    1. NHS Digital
    (2023) Quality and Outcomes Framework (QOF) and primary care business rules. accessed. https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-collections/quality-and-outcomes-framework-qof. 11 Mar 2024.
  41. 41.↵
    1. Fanikos J,
    2. Burnett AE,
    3. Mahan CE,
    4. Dobesh PP
    (2017) Renal function considerations for stroke prevention in atrial fibrillation. Am J Med 130 (9):1015–1023, doi:10.1016/j.amjmed.2017.04.015, pmid:28502818.
    OpenUrlCrossRefPubMed
  42. 42.↵
    1. Potpara T,
    2. Dagres N,
    3. Arbelo E,
    4. Bax JJ,
    5. et al.
    (2021) ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic surgery (EACTS). Eur Heart J 42 373–498, pmid:32860505.
    OpenUrlCrossRefPubMed
  43. 43.↵
    1. Pisters R,
    2. Lane DA,
    3. Nieuwlaat R,
    4. et al.
    (2010) A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 138 (5):1093–1100, doi:10.1378/chest.10-0134, pmid:20299623.
    OpenUrlCrossRefPubMed
  44. 44.↵
    1. electronic medicines compendium (emc)
    (2023) Xarelto 20mg film-coated tablets. accessed. https://www.medicines.org.uk/emc/product/2793/smpc. 11 Mar 2024.
  45. 45.
    1. emc
    (2024) Apixaban 5mg film-coated tablets. accessed. https://www.medicines.org.uk/emc/product/13690/smpc. 11 Mar 2024.
  46. 46.
    1. emc
    (2024) Lixiana 60mg film-coated tablets. accessed. https://www.medicines.org.uk/emc/product/6905/smpc. 11 Mar 2024.
  47. 47.
    1. emc
    (2022) Pradaxa 150 mg hard capsules. accessed. https://www.medicines.org.uk/emc/product/4703/smpc. 11 Mar 2024.
  48. 48.
    1. emc
    (2020) Sinthrome 1 mg tablets. accessed. https://www.medicines.org.uk/emc/product/2058. 11 Mar 2024.
  49. 49.↵
    1. emc
    (2021) Warfarin 0.5mg tablets. accessed. https://www.medicines.org.uk/emc/product/3064/smpc. 11 Mar 2024.
  50. 50.↵
    1. Gillott RG,
    2. Willan K,
    3. Kain K,
    4. et al.
    (2017) South Asian ethnicity is associated with a lower prevalence of atrial fibrillation despite greater prevalence of established risk factors: a population-based study in Bradford metropolitan district. Europace 19 (3):356–363, doi:10.1093/europace/euw010, pmid:26941337.
    OpenUrlCrossRefPubMed
  51. 51.↵
    1. Apenteng PN,
    2. Virdone S,
    3. Hobbs FR,
    4. et al.
    (2022) Two-year outcomes of UK patients newly diagnosed with atrial fibrillation: findings from the prospective observational cohort study GARFIELD-AF. Br J Gen Pract 72 (723):e693–e701, doi:10.3399/BJGP.2021.0548, pmid:35577587.
    OpenUrlAbstract/FREE Full Text
  52. 52.↵
    1. Banerjee A,
    2. Lane DA,
    3. Torp-Pedersen C,
    4. Lip GYH
    (2012) Net clinical benefit of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus no treatment in a 'real world' atrial fibrillation population: a modelling analysis based on a nationwide cohort study. Thromb Haemost 107 (3):584–589, doi:10.1160/TH11-11-0784, pmid:22186961.
    OpenUrlCrossRefPubMed
  53. 53.↵
    1. McAlister FA,
    2. Garrison S,
    3. Kosowan L,
    4. et al.
    (2018) Use of direct oral anticoagulants in Canadian primary care practice 2010–2015: a cohort study from the Canadian Primary Care Sentinel Surveillance Network. J Am Heart Assoc 7 (3), doi:10.1161/JAHA.117.007603, pmid:29374047. e007603.
    OpenUrlAbstract/FREE Full Text
  54. 54.↵
    1. Ruiz Ortiz M,
    2. Muñiz J,
    3. Raña Míguez P,
    4. et al.
    (2018) Inappropriate doses of direct oral anticoagulants in real-world clinical practice: prevalence and associated factors. A subanalysis of the FANTASIIA Registry. Europace 20 (10):1577–1583, doi:10.1093/europace/eux316, pmid:29095971.
    OpenUrlCrossRefPubMed
  55. 55.↵
    1. Steinberg BA,
    2. Shrader P,
    3. Thomas L,
    4. et al.
    (2016) Off-label dosing of non-vitamin K antagonist oral anticoagulants and adverse outcomes: the ORBIT-AF II Registry. J Am Coll Cardiol 68 (24):2597–2604, doi:10.1016/j.jacc.2016.09.966, pmid:27978942.
    OpenUrlFREE Full Text
  56. 56.↵
    1. Miele C,
    2. Taylor M,
    3. Shah A
    (2017) Assessment of direct oral anticoagulant prescribing and monitoring pre- and post-implementation of a pharmacy protocol at a community teaching hospital. Hosp Pharm 52 (3):207–213, doi:10.1310/hpj5203-207, pmid:28439135.
    OpenUrlCrossRefPubMed
  57. 57.↵
    1. Williams H
    (2020) Guidance for the safe switching of warfarin to direct oral anticoagulants (DOACs) for patients with non-valvular AF and venous thromboembolism (DVT / PE) during the coronavirus pandemic. accessed. https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Coronavirus/FINAL%20Guidance%20on%20safe%20switching%20of%20warfarin%20to%20DOAC%20COVID-19%20Mar%202020.pdf?ver=2020-03-26-180945-627. 11 Mar 2024.
  58. 58.↵
    1. Orlowski A,
    2. Gale CP,
    3. Ashton R,
    4. et al.
    (2021) Clinical and budget impacts of changes in oral anticoagulation prescribing for atrial fibrillation. Heart 107 (1):47–53, doi:10.1136/heartjnl-2020-317006, pmid:33122302.
    OpenUrlAbstract/FREE Full Text
  59. 59.↵
    1. Tan ECK,
    2. Stewart K,
    3. Elliott RA,
    4. George J
    (2014) Pharmacist services provided in general practice clinics: a systematic review and meta-analysis. Res Social Adm Pharm 10 (4):608–622, doi:10.1016/j.sapharm.2013.08.006, pmid:24161491.
    OpenUrlCrossRefPubMed
  60. 60.↵
    1. Gebreyohannes EA,
    2. Mill D,
    3. Salter S,
    4. et al.
    (2021) Strategies for improving guideline adherence of anticoagulants for patients with atrial fibrillation in primary Healthcare: a systematic review. Thromb Res 205 128–136, doi:10.1016/j.thromres.2021.07.014, pmid:34333301.
    OpenUrlCrossRefPubMed
  61. 61.↵
    1. Crespo-Gonzalez C,
    2. Benrimoj SI,
    3. Scerri M,
    4. Garcia-Cardenas V
    (2020) Sustainability of innovations in Healthcare: a systematic review and conceptual framework for professional Pharmacy services. Res Social Adm Pharm 16 (10):1331–1343, doi:10.1016/j.sapharm.2020.01.015, pmid:32063499.
    OpenUrlCrossRefPubMed
Back to top

In this issue

BJGP Open
Vol. 8, Issue 2
July 2024
Download PDF
Download PowerPoint
Email Article
Citation Tools
Pharmacist-led interventions in optimising the use of oral anticoagulants in patients with atrial fibrillation in general practice in England: a retrospective observational study
Raman Sharma, Syed Shahzad Hasan, Ishtiaq A Gilkar, Waheed F Hussain, Barbara R Conway, Muhammad Usman Ghori
BJGP Open 2024; 8 (2): BJGPO.2023.0113. DOI: 10.3399/BJGPO.2023.0113
del.icio.us logo Twitter logo Facebook logo Mendeley logo

Jump to section

Keywords

Intended for Healthcare Professionals

 
 

British Journal of General Practice