Direct Oral Anticoagulant (DOAC) Dosing in Patients with Non-valvular Atrial Fibrillation (NVAF) in the United Kingdom: A Retrospective Cohort Study Using CPRD Gold Database.

INTRODUCTION: Per-label dosing of direct oral anticoagulants (DOACs) is important for the prevention of stroke and systemic embolism among patients with non-valvular atrial fibrillation (NVAF), especially those with poor renal function, advanced age, low body weight or concomitant P-glycoprotein inhibitors. The study described DOAC use and dosing patterns in patients with NVAF in the UK. METHODS: Using Clinical Practice Research Datalink (CPRD Gold), patients' profiles were described at DOAC initiation (1 January 2016-31 March 2021) and followed for a mean [standard deviation (SD)] 2 (1) years. Patients were categorised as under-dosing: received a lower dose with no indication for a reduced dose; over-dosing: received a standard dose with an indication for a reduced dose; per-label dosing, according to Summary Product Characteristics (SmPC). RESULTS: Forty thousand seven hundred forty-four adult patients with NVAF were identified (mean age: 75.3 (11.2) years; males: 55.4%); 22,827 (56.0%) initiated treatment with apixaban, 930 (2.3%) dabigatran, 5633 (13.8%) edoxaban and 11,354 (27.9%) rivaroxaban. Baseline Charlson comorbidity index ≥ 4 was 65.1%; CHA2DS2-VASc score ≥ 4 was 22.5%; HAS-BLED score ≥ 3 was 18.3%; ~ 2% had prior major bleed and 4.4% a stroke ≤ 2 years before DOAC initiation. Overall, 18.0% of patients received incorrect dosing (~ one in five). Under-dosing was highest for dabigatran (156, 16.8%) and over-dosing was highest for rivaroxaban (1084, 9.6%). Per-label dosing was highest for edoxaban (4773, 84.7%), followed by apixaban (18,756, 82.2%), rivaroxaban (9161, 80.7%) and dabigatran (732, 78.7%). Treatment persistence (no switching or discontinuation) was 79% among edoxaban users, followed by 75% for apixaban, 69% for rivaroxaban and 62% for dabigatran. About 15% of dabigatran users, 10% of rivaroxaban users, 5% of apixaban users and 4% of edoxaban users switched treatment to another DOAC during follow-up. CONCLUSION: Although most patients received per-label dosing, ~ one in five patients was incorrectly dosed with DOAC, which may lead to serious clinical consequences and increased healthcare burden.

Impact of COVID-19 Exclusive Allocation Strategy on Quality of Healthcare: A Study From Jordan, 2020.

The COVID-19 pandemic has brought uncertainty to everyday medical practice. Deciding how to ration limited healthcare resources is difficult and requires the involvement of higher authorities in each country. In this article we focus on the Jordanian strategy of allocating tertiary healthcare centers exclusively for COVID-19 patients and postponing all other treatments and healthcare provision. We collected secondary data on admissions, occupancy of hospital beds, and length of stay at emergency departments and outpatient clinics, as well as surgeries conducted, between March and May 2020 at King Abdullah University Hospital in Irbid, Jordan. We also conducted a literature review to explore health resource utilization and allocation in terms of health service quality. Our findings showed a major decrease in the demand for health services at the hospital including admissions, emergency department visits, outpatient clinic visits, surgeries, and radiology during the study period. These findings indicate the enormous impact of the pandemic on the largest segment of patients in Jordan-those who depend on government health insurance-to manage their routine healthcare needs, which may affect the health status of patients. Authorities should address the COVID-19 pandemic holistically by prioritizing both COVID-19 cases and non-COVID-19 cases and should draft a framework for managing future pandemics. Moreover, planning a strategy to accommodate the number of people waiting for elective surgeries and routine healthcare should be in place to minimize the burden of this pandemic.