Coagulation

ISTH focus on improving child and young adult adherence to anticoagulants


An international survey of clinicians involved in anticoagulation management in children and/or adolescents and young adults (AYA) has identified clues to improving medication adherence.

The survey, published in the Journal of Thrombosis and Hemostasis, covered perceived prevalence and impact of non-adherence, adherence clinical practices, and adherence-related needs. Of the 200 clinicians who completed the survey, 90% were paediatric haematology/oncology physicians.

Auspiced by a working group of the ISTH SSC on Paediatric and Neonatal Thrombosis and Haemostasis, the survey found 36.0% of clinicians “often or always worry” about non-adherence and 52.5% of physicians “sometimes worry”.

“Missed or skipped doses and non-adherence to lab monitoring recommendations were endorsed as the most frequent concerns,” the study said.

A significant minority of clinicians (43.5%) participants indicated that they have cared for paediatric patients when non-adherence resulted in new or recurrent thrombosis and 18.0% when non-adherence resulted in bleeding.

The vast majority (89.5%) said they assess non-adherence however fewer (38%) were “often” or “always” confident about identifying those who were non-adherent.

“The primary methods used to assess adherence were clinical interview, lab results and time in therapeutic range (TTR), and pharmacy refill records.”

“Several providers described the need for objective measurement strategies that seamlessly relay adherence data to providers.”

“They identified a critical need to explore novel tools such as patient portals and adherence tracking, as well as reporting applications that can be integrated within the electronic health record.”

Barriers to overcome

The top three barriers to regularly assessing adherence were insufficient time (n= 108, 54.0%), the need to prioritise other concerns (n= 99, 49.5%), and/or insufficient resources (n= 90, 45.0%).

Only about half of clinicians (48.5%) reported that they often or always have the resources to effectively address non-adherence.

“Barriers to adherence can include patient- (e.g., forgetting, lack of understanding of how/when to take medication), family- (e.g., lack of transportation to pick up medication), and healthcare system- (e.g., cost of medication) factors and adequately addressing barriers requires involvement of a multidisciplinary team.”

“The varied nature of barriers may explain why fifty providers reported that they regularly involve multidisciplinary team members and the most commonly reported resource that could improve adherence care was the creation of new clinical teams.”

The authors, including Professor Vera Ignjatovic, Group Leader of Haematology Research from the Murdoch Children’s Research Institute, recommended that providers draw on the larger health behaviour change literature to select evidence-based strategies specific to the identified barriers.

“For example, a provider may consider recommending prompts/cues (e.g., cell phone reminders) to target forgetting or restructuring the physical environment (e.g., providing access to lab draws at local labs or via drive-thru if POC is not feasible) if access is a barrier to lab adherence.”

They said switching medications to improve adherence, without addressing the underlying reasons for non-adherence, warranted caution.

“In addition to considering change in anticoagulant, some providers indicated a risk:benefit assessment to decide whether anticoagulation should be discontinued. Such decisions should be informed by evolving data on optimal duration of anticoagulation in children in the context of patient-level factors.”

In addition, they said the extent to which anticoagulation non-adherence is associated with adverse health outcomes in children and AYA also deserves further study.

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