title: Addressing barriers to optimal oral anticoagulation use and persistence among patients with atrial fibrillation: Proceedings, Washington, DC, December 3-4, 2012.
abstract: Approximately half of patients with atrial fibrillation and with risk factors for stroke are not treated with oral anticoagulation (OAC), whether it be with vitamin K antagonists (VKAs) or novel OACs (NOACs); and of those treated, many discontinue treatment. Leaders from academia, government, industry, and professional societies convened in Washington, DC, on December 3-4, 2012, to identify barriers to optimal OAC use and adherence and to generate potential solutions. Participants identified a broad range of barriers, including knowledge gaps about stroke risk and the relative risks and benefits of anticoagulant therapies; lack of awareness regarding the potential use of NOAC agents for VKA-unsuitable patients; lack of recognition of expanded eligibility for OAC; lack of availability of reversal agents and the difficulty of anticoagulant effect monitoring for the NOACs; concerns with the bleeding risk of anticoagulant therapy, especially with the NOACs and particularly in the setting of dual antiplatelet therapy; suboptimal time in therapeutic range for VKA; and costs and insurance coverage. Proposed solutions were to define reasons for oral anticoagulant underuse classified in ways that can guide intervention and improve use, to increase awareness of stroke risk as well as the benefits and risks of OAC use via educational initiatives and feedback mechanisms, to better define the role of VKA in the current therapeutic era including eligibility and ineligibility for different anticoagulant therapies, to identify NOAC reversal agents and monitoring strategies and make knowledge regarding their use publicly available, to minimize the duration of dual antiplatelet therapy and concomitant OAC where possible, to improve time in therapeutic range for VKA, to leverage observational data sets to refine understanding of OAC use and outcomes in general practice, and to better align health system incentives.
authors.affiliation: Duke Clinical Research Institute, Durham, NC. Electronic address: p.hess@duke.edu.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Hess
authors.affiliation: Parkview Health System, Fort Wayne, IN.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Mirro
authors.affiliation: University Hospital Essen, Essen, Germany.
authors.forename: Hans-Christoph
authors.initials: HC
authors.lastname: Diener
authors.affiliation: Population Health Research Institute, Hamilton, Canada.
authors.forename: John W
authors.initials: JW
authors.lastname: Eikelboom
authors.affiliation: Duke Clinical Research Institute, Durham, NC.
authors.forename: Sana M
authors.initials: SM
authors.lastname: Al-Khatib
authors.affiliation: Boston University School of Medicine, Boston, MA.
authors.forename: Elaine M
authors.initials: EM
authors.lastname: Hylek
authors.affiliation: Duke Clinical Research Institute, Durham, NC; Durham Veterans Affairs Medical Center, Durham, NC.
authors.forename: Hayden B
authors.initials: HB
authors.lastname: Bosworth
authors.affiliation: Mayo Clinic College of Medicine, Rochester, MN.
authors.forename: Bernard J
authors.initials: BJ
authors.lastname: Gersh
authors.affiliation: Massachusetts General Hospital, Boston, MA.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Singer
authors.affiliation: University of Missouri, Columbia, MO.
authors.forename: Greg
authors.initials: G
authors.lastname: Flaker
authors.affiliation: Brigham and Women's Hospital, Boston, MA.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Mega
authors.affiliation: Duke Clinical Research Institute, Durham, NC.
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.affiliation: VA Eastern Colorado Health Care System, Denver, CO.
authors.forename: John S
authors.initials: JS
authors.lastname: Rumsfeld
authors.affiliation: Duke Clinical Research Institute, Durham, NC.
authors.forename: Benjamin A
authors.initials: BA
authors.lastname: Steinberg
authors.affiliation: Thrombosis Research Institute and University College London, London, United Kingdom.
authors.forename: Ajay K
authors.initials: AK
authors.lastname: Kakkar
authors.affiliation: Duke Clinical Research Institute, Durham, NC.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
authors.affiliation: Duke Clinical Research Institute, Durham, NC.
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Granger
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000517:prevention & control*; D004219:District of Columbia; D004359:Drug Therapy, Combination; D006801:Humans; D019458:Insurance Coverage; D010349:Patient Compliance; D018570:Risk Assessment; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D014812:Vitamin K / Q000037:antagonists & inhibitors*
chemical_list: D000925:Anticoagulants; D014812:Vitamin K