Abstract
Ensuring the appropriateness of prescriptions of oral antithrombotics (ATs, including antiplatelet and anticoagulant agents) is a crucial safety issue, particularly for patients with multiple chronic conditions. Our main objective was to assess the impact of a prescription support tool, synthesized from international guidelines on oral ATs in adult outpatients, on improving physician adherence to the guidelines for prescription of oral ATs. A web-based, open randomized controlled trial using clinical vignettes was conducted in France from November 2018 to February 2019. General practitioners and cardiologists with outpatient practice were contacted to participate in a web-based survey involving three clinical vignettes illustrating cases of adult outpatients with common neuro-cardiovascular diseases. They were asked to answer four multiple-choice questions related to the number of oral AT(s), drug class, dosage and duration of the prescription. Physicians assigned to the experimental arm had access to the prescription support tool. Physicians assigned to the control arm had no access to the tool. The primary outcome measure was the appropriate prescription of oral ATs (i.e., complied with guidelines in terms of the number, drug class, dosage and duration of prescription). An intent-to-treat analysis was performed using a logistic mixed model with a clinical vignette effect and a physician effect nested in the arm of the trial. Four hundred and forty-one general practitioners and 37 cardiologists were randomized to the experimental (n = 238) and to the control arm (n = 240), respectively. In the experimental arm, 55.0% of the prescriptions were appropriate versus 29.4% in the control arm (Odds Ratio (OR): 3.61 (2.60 to 5.02)). Access to the first prescription support tool synthesizing the use of oral ATs for outpatients significantly improved the rate of appropriate oral AT prescriptions according to the guidelines.
Highlights
Antithrombotics (ATs), which include antiplatelet and anticoagulant therapies, are the most frequent drug class implicated in serious and fatal adverse drug events (ADEs) occurring in outpatient settings [1]—among which, 40% to 70% could be preventable [2,3]
Many physicians had to deal with prescriptions of oral AT combinations in their daily practice; 38% (n = 183) reported that at least 5% of their patients took an oral AT combination
Cardiologists felt more comfortable with these prescriptions (76% of cardiologists vs. 26% of general practitioners felt rather comfortable or very comfortable with prescribing oral AT combinations) and more often knew where to find the guidelines (92% vs. 54%)
Summary
Antithrombotics (ATs), which include antiplatelet and anticoagulant therapies, are the most frequent drug class implicated in serious and fatal adverse drug events (ADEs) occurring in outpatient settings [1]—among which, 40% to 70% could be preventable [2,3]. Several studies have reported the inappropriate use of oral ATs in patients with non-valvular atrial fibrillation (concomitant use of drugs increasing the risk of bleeding, insufficient dose of anticoagulant or use of antiplatelet agents instead of anticoagulants) [4,6,7,8]. Regardless of the indication, approximately 15% of patients with AT combinations had inappropriate dual or triple oral AT therapy according to a Canadian survey [9]. The appropriateness of the prescribing was limited to the type of drugs combined and did not cover the dosage and duration of prescription. No study evaluates the rate of appropriate oral AT prescriptions (in terms of the number of drugs, drug class, dosage and duration of prescription), regardless of the indication, in outpatient settings
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