|Year : 2017 | Volume
| Issue : 4 | Page : 164-169
Clinicians-related determinants of anticoagulation therapy and prophylaxis in Nigeria
Raphael Anakwue1, Theresa Nwagha2, Ogba J Ukpabi3, Ndudim Obeka4, Emmanuel Onwubuya5, Uwa Onwuchekwa6, Benjamin Azubuike7, Innocent Okoye8
1 Department of Medicine, Pharmacology/Therapeutics, University of Nigeria, Enugu Campus, Nigeria
2 Department of Haematology and Immunology, Thrombosis and Bleeding Unit, University of Nigeria Enugu Campus/University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
3 Department of Medicine, Federal Medical Centre, Umuahia, Nigeria
4 Department of Internal Medicine, Federal Teaching Hospital Abakaliki, Abakaliki, Nigeria
5 Department of Internal Medicine, Abia State University Teaching Hospital, Aba, Nigeria
6 Department of Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
7 Department of Medicine, Federal Medical Centre, Owerri, Nigeria
8 Department of Medicine, Chukwuemeka Odumegwu Ojukwu Teaching Hospital, Amaku Awka, Nigeria
|Date of Web Publication||16-Oct-2017|
Department of Haematology and Blood Transfusion, Thrombosis and Bleeding Unit, University of Nigeria Enugu Campus/University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Thromboembolic and hypercoagulable diseases are common life-threatening but treatable problems in hospital practice. Fortunately, anticoagulation is an efficacious management practice indicated for arterial, venous, and intracardiac thromboembolism. Clinicians in developing countries may have gaps in their knowledge of anticoagulation therapy/prophylaxis which could affect their clinical decision. Objectives: The study examined the knowledge and attitude of clinicians to anticoagulation therapy/prophylaxis in some tertiary hospitals in Nigeria. Methodology: The study was a multicenter survey. A pretested questionnaire was administered to clinicians in six tertiary hospitals in Southeast Nigeria. Results: A total of 528 questionnaires were returned by 419 (79.4%) residents and 109 (20.6%) consultants. We observed significant abysmal knowledge and lack of awareness of direct oral anticoagulants (DOACs) among most respondents irrespective of their job grades (P = 0.02, odds ratio [OR] 0.59, 95% confidence interval [CI] 0.38–0.90). Their knowledge of anti-Xa assay as laboratory monitoring tool was also significantly inadequate (P = 0.001, OR 0.23, 95% CI 0.10–0.51). On statement analysis on their attitude to anticoagulation therapy/prophylaxis, “Do you think anticoagulation therapy/prophylaxis is clinically relevant” had the highest mean of 4.60, P = 0.01, and a high degree of agreement; while “Should hospital inpatient with > 3 days admission routinely receive anticoagulation/prophylaxis?” had the lowest mean of 2.27, P = 0.02, and a low degree of agreement. Conclusion: There is the need to upscale knowledge of anticoagulation agents and an attitude change to anticoagulation therapy/prophylaxis, especially on the DOACs through continuing medical education activities in emerging countries such as Nigeria.
| Abstract in French|| |
Contexte: Les maladies thromboemboliques et hypercoagulables sont des problèmes communs à la vie mais pouvant être traités dans la pratique hospitalière. Heureusement, l'anticoagulation est une pratique de gestion efficace indiquée pour le thromboembolisme artériel, veineux et intracardiaque. Cliniciens Dans les pays en développement, ils peuvent avoir des lacunes dans leur connaissance du traitement anticoagulant / prophylaxie qui pourrait affecter leur décision clinique. Objectifs: L'étude a examiné la connaissance et l'attitude des cliniciens en thérapie anticoagulante / prophylaxie dans certains hôpitaux tertiaires en Nigeria. Méthodologie: l'étude était une enquête multicentrique. Un questionnaire prétesté a été administré aux cliniciens de six hôpitaux tertiaires Nigeria sud-est. Résultats: Au total, 528 questionnaires ont été retournés par 419 (79,4%) des résidents et 109 consultants (20,6%). Nous avons observé Connaissance abyssale significative et manque de connaissance des anticoagulants oraux directs (DOAC) parmi la plupart des répondants indépendamment de leur travail Notes (P = 0,02, odds ratio [OR] 0,59, intervalle de confiance de 95% [IC] 0,38-0,90). Leur connaissance du dosage anti-Xa en tant que surveillance en laboratoire L'outil était également significativement inadéquat (P = 0,001, OR 0,23, IC 95%: 0,10-0,51). Sur l'analyse de la déclaration sur leur attitude à l'anticoagulation Thérapie/prophylaxie, “pensez-vous que la thérapie anticoagulante/la prophylaxie est cliniquement pertinente” a eu la plus forte moyenne de 4,60, P = 0,01 et une Degré élevé d'accord; Tandis que “un internat hospitalisé avec> 3 jours d'admission recevait-il régulièrement une anticoagulation / prophylaxie? La moyenne la plus basse de 2,27, P = 0,02 et un faible degré d'accord. Conclusion: il est nécessaire de développer la connaissance des agents anticoagulants Et un changement d'attitude à la thérapie anticoagulante/prophylaxie, en particulier sur les DOAC par des activités continues d'éducation médicale dans Pays émergents comme le Nigeria.
Mots-clés: prophylaxie anticoagulante, traitement anticoagulant, cliniciens, anticoagulants directs oraux
Keywords: Anticoagulation prophylaxis, anticoagulation therapy, clinicians, direct oral anticoagulants
|How to cite this article:|
Anakwue R, Nwagha T, Ukpabi OJ, Obeka N, Onwubuya E, Onwuchekwa U, Azubuike B, Okoye I. Clinicians-related determinants of anticoagulation therapy and prophylaxis in Nigeria. Ann Afr Med 2017;16:164-9
|How to cite this URL:|
Anakwue R, Nwagha T, Ukpabi OJ, Obeka N, Onwubuya E, Onwuchekwa U, Azubuike B, Okoye I. Clinicians-related determinants of anticoagulation therapy and prophylaxis in Nigeria. Ann Afr Med [serial online] 2017 [cited 2021 Jan 23];16:164-9. Available from: https://www.annalsafrmed.org/text.asp?2017/16/4/164/216713
| Introduction|| |
Thromboembolic and hypercoagulable diseases are common life-threatening but treatable problems in hospital practice. Fortunately, anticoagulation is an effective management practice indicated for arterial thromboembolism, venous thromboembolism (VTE), and intracardiac thromboembolism. VTE is a common but preventable cause of a considerable morbidity, mortality, and costs among hospitalized patients. Several clinical trials have demonstrated the effectiveness of thromboprophylaxis in reducing the rate of deep vein thrombosis (DVT) and fatal pulmonary embolism (PE) by >60%. Following from these findings, guidelines have been published for the prevention of VTE., Unfortunately, VTE risk continues to be high among hospitalized patients, and this to a large extent is attributable to underutilization of thromboprophylaxis according to data from the ENDORSE study.
Several randomized clinical trials have shown that anticoagulant therapy decreases the incidence of thromboembolism by about 70% in patients with chronic atrial fibrillation (AF).,,, This benefit was accompanied by a relatively low annual bleeding rate. Consequently, most evidence-based guidelines recommend anticoagulation therapy for chronic AF, with the provision that this must be individualized according to each patient's risk for thromboembolism., However, anticoagulation therapy tends to be underutilized in chronic AF patients even in Western countries. Physicians' knowledge and perceived risk of anticoagulants seem to be responsible for the reluctance of a good number of physicians to prescribe this therapy.
The most effective and economical approach to decreasing the burden of VTE is to prevent the development of DVT and PE in patients at high risk, including major orthopedic surgery, moderate and high-risk general surgery patients, and acutely ill hospitalized medical patients. The implementation of international guidelines for the treatment and prevention of VTE remains suboptimal and results in patient morbidity and mortality, with a substantial economic burden. Health-care providers in developing countries such as Nigeria may have significant gaps in their anticoagulation knowledge that could affect their decision to prescribe anticoagulation therapy. Currently, there are no national guidelines on the use of anticoagulation in Nigeria.
The purpose of this present study was to examine the knowledge and attitude of clinicians on anticoagulation in some tertiary hospitals in Nigeria.
| Methodology|| |
The present study is a multicenter cross-sectional survey of use of anticoagulants among clinicians in Southeast Nigeria. A pretested questionnaire was administered to clinicians in six tertiary hospitals in the Southeast of Nigeria; University of Nigeria Teaching Hospital, Enugu; Federal Medical Centre, Umuahia; Federal Teaching Hospital, Abakaliki; Abia State Teaching Hospital, Aba; Nnamdi Azikiwe University Teaching Hospital, Nnewi; Federal Medical Centre, Owerri; and Chukwuemeka Odumegwu Ojukwu Teaching Hospital, Amaku, Awka. The questionnaire was designed to assess the knowledge and attitude of clinicians to anticoagulation therapy. To assess clarity and consistency of questions, a pilot study was done before the final draft was prepared. The questionnaire was administered consecutively on medical doctors in the participating centers.
Respondents were required to fill in their age, gender, number of years since graduating, specialty, or grade and then answer questions on the knowledge and attitude to anticoagulation therapy in their center. The name of the respondents and hospitals was not requested. Ethical approval was obtained from the institutions' ethics committee.
The Likert scale used was from Grades 1 to 5: 1 strongly disagree, 2 disagree, 3 neutral, 4 agree, and 5 strongly disagree. To determine the agreement degree, three levels were identified (high, medium, and low).
- The low-level agreement degree has a mean < 3and P < 0.05%
- The medium-level agreement degree has P > 0 when the mean < or > 3
- The high-level agreement degree has a mean > 3 and P < 0.05% and this is a favorable advantage.
Descriptive statistics with counts and percentages were used to illustrate the results. The data were also analyzed using Fisher's exact test to detect any association between demographic profiles and anticoagulation knowledge and attitude. A P < 0.05 was considered statistically significant. Statistical Package for the Social Science (SPSS) software, version 18 (SPSS Inc., Chicago, IL, USA) was used.
| Results|| |
Clinicians sampled were from the six teaching hospitals located in Southeast Nigeria. Of 528 respondents, there were more males 378 (71.6%) than females 150 (28.4%). The clinicians who practiced for < 5 years were in the majority, i.e., 189 (35.8%), and those with 15–20 years, i.e., 46 (8.7%), were in the minority. The residents were in the majority 419 (79.4%) and the consultants were in the minority 109 (20.6%). Full demographic characteristics of the respondents are presented in [Table 1] and [Table 2].
Knowledge of anticoagulation
We have tabulated summary of the clinicians' response on questions testing their knowledge of anticoagulation; types anticoagulant agents used, indications for anticoagulation, laboratory monitoring tools, and differences between the conventional anticoagulant agents and the direct oral anticoagulants (DOACs). Their responses were tabulated against job grades [Table 3],[Table 4],[Table 5],[Table 6].
|Table 3: Summary of the knowledge of indications of anticoagulation therapy|
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|Table 4: Summary of the analysis showing respondents knowledge on laboratory monitoring tools for anticoagulant agents|
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|Table 5: Summary of the analysis showing respondents knowledge on difference between warfarin and direct oral anticoagulants|
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|Table 6: Summary of the analysis of respondents' attitude to anticoagulation therapy|
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We observed that most respondents irrespective of their job grades did not know about fondaparinux and the DOAC. There was a significant abysmal knowledge of the DOACs (P = 0.02, odds ratio [OR] 0.59, 95% confidence interval [CI] 0.38–0.90) [Table 3]. Most respondents knew of the different indications for anticoagulation therapy/prophylaxis; this was not statistically significant [Table 4].
Majority of respondents had a significant knowledge of prothrombin test (P = 0.03*, OR 2.04, 95% CI 1.10–3.78). On the contrary, most also had a significant abysmal knowledge of anti-Xa assay, as a laboratory monitoring tool (P = 0.001***, OR 0.2, 95% CI 0.10–0.51) [Table 5].
On their knowledge of the difference between warfarin and the DOACs, there was numerous none responses to the questions, but analysis of responses received showed was a significant knowledge of reversal agent for warfarin (P = 0.03, OR 2.30, 95% CI 1.07–4.98). On the other hand, there was abysmal significant knowledge onset of action and multiple drug reactions as major differences between the warfarin and the NOACs (P = 0.01, OR 2.50, 95% CI 1.18–5.29 and P = 0.005, OR 3.20, 95% CI 1.32–7.70, respectively) [Table 6].
Attitude on anticoagulation
Based on results of the statement analysis as summarized in [Table 6], the variables were ranked according to the value of their mean. All, except one, variable had P < 0.05. The statement “Do you think anticoagulation therapy/prophylaxis is clinically important” had the highest mean of 4.60 and had a high degree of agreement. The statement “Should hospital inpatient with >3 days admission routinely receive anticoagulation?” had the lowest mean of 2.27 with P = 0.015 had a low degree of agreement.
| Discussion|| |
Paucity of data on what the anticoagulation practices are in Nigeria negates any meaningful intervention being implemented. Our study showed that most clinicians knew of and were aware of the conventional anticoagulation agents; unfractionated heparin, warfarin, low molecular weight heparin, and fondaparinux. Our results were not consistent with a Brazilian survey done which showed that most emergency room doctors' knowledge of oral anticoagulants was low; unfortunately, these groups of doctors were not reflected in our survey. Our findings regarding clinicians' knowledge and awareness with DOACs are consistent with other studies which had demonstrated similar incomplete knowledge among primary care physicians of guidelines for cardiovascular disease prevention in general.,,
With the growing popularity of the DOACs among clinicians as standard of care in different categories of patient needing anticoagulation, our study highlights this shocking evidence why most patients are not receiving these agents simply because some clinicians are not aware they exist or are available/accessible for use in the country. Lack of hospital policies on coagulation or any dedicated anticoagulation clinic at the different centers of the respondents may contribute to this low level of knowledge.
The absence of which encourages the plethora of clinician-specific treatment protocols some of which are still in the era when conventional anticoagulants (heparins and Vitamin K antagonists) were considered the drug treatment of choice for anticoagulation episodes. We observed a dearth of knowledge on the various clinical indications for anticoagulation practice. While majority of respondents agreed that conditions such as VTE, prolonged surgery, immobilization, and stroke required either anticoagulation treatment or prophylaxis, approximately more than half would not use anticoagulation therapy or prophylaxis in patients with malignancies and postoperative periods though this was statistically insignificant. Arguably though some malignancies and postoperative conditions are more thrombogenic than others, again there is a low incidence of thromboembolic events in AF patients. The absence of policies, hospital guidelines, or doctor utilization of available guidelines, may play a major contributory role.
Inability to monitor the use of anticoagulation agents has been documented to be one of the reasons of poor use of anticoagulation agents in resource-poor nations like Nigeria. Majority of the respondents were able to recognize prothrombin time (PT) and activated partial thromboplastin time (APTT) as some laboratory monitoring tools for anticoagulation therapy. This agreed with their response of heparin and warfarin as the highest known group anticoagulation agents among respondents.
On the other hand, most respondents did not know anti-Xa assay and dilute thrombin time are tests that could also be used to monitor anticoagulation use. It could not be determined if the few who knew about these agents knew the exact anticoagulation agents that these tests are used for it was not covered by the questionnaire. Another could be that these tests were not routinely ordered for like PT and APTT. Most treatment protocols and guidelines updated regularly serve are clinicians aid in using the current evidence-based treatment protocol for anticoagulant therapy.
We found a high degree of agreement on the importance of commencement of anticoagulant therapy/prophylaxis as well as the positive impact of early commencement of anticoagulant therapy in stroke patients among clinicians studied. This would suggest that clinicians will be favorably disposed to these variables as policies or guidelines in their various institutions. On the contrary, our studies also showed that they had a low level of agreement on routinely placing hospital inpatients on > 3 days admission on anticoagulation prophylaxis and commencement of anticoagulation therapy preceding diagnosis of VTE. These could be responsible for the undocumented increase in VTE among hospital inpatients as well PE-related mortality resulting from late or no commencement of anticoagulation therapy in hospital in patients. A sharp contrast from studies of hospitals in the United Kingdom which showed a marked reduction in morbidity and mortality resulting from VTE of hospital inpatients.
| Conclusion|| |
Clearly, the study has shown that there is need for upscale knowledge attitude and practice of the use anticoagulation agents, especially the DOACs through well-articulated continuing medical education educational activities. This could be made more robust to involve other health-care personnel involved in anticoagulation practice. Similar efforts have been used recently to successfully improve adherence to cardiovascular guidelines in primary care. A limitation of this study is the relatively small number of study participants and some subspecialties that were not reflected in this survey. However, the diverse perspectives of respondents provided a rich data set from which we highlighted the deficiencies in our anticoagulation practice. Social desirability bias is a potential limitation given that physicians may not be inclined to discuss their lack of familiarity with new medications.
We attempted to limit this risk by asking open-ended questions. In addition, it is ambiguous whether our findings can be applied across board to other subspecialties not reflected or other geopolitical zones of the country. To address this, a multicenter survey among physicians in our health system would help generate the necessary national data to that would bring out required changes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ahsin S, Bashir E, Abdullah Faiz S, Tahir J, Ijaz A. Estimation and comparison of intra operative blood loss in patients with and without venous thromboembolism prophylaxis. Pak Armed Forces Med J 2014;64:71-4.
Selby R, Geerts W. Prevention of venous thromboembolism: Consensus, controversies, and challenges. Hematology Am Soc Hematol Educ Program 2009:286-92.
Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al
. Prevention of venous thromboembolism: American College of Chest Physicians evidence-Based clinical practice guidelines (8th
edition). Chest 2008;133:381S-453S.
Fitz Maurice DA, Murray E. Thrombophylaxis for adults in hospital. BMJ 1997;1017-8.
Cohen AT, Tapson VF, Bergmann JF, Goldhaber SZ, Kakkar AK, Deslandes B, et al.
Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): A multinational cross-sectional study. Lancet 2008;371:387-94.
Connolly SJ, Laupacis A, Gent M, Roberts RS, Cairns JA, Joyner C, et al.
Canadian atrial Fibrillation Anticoagulation (CAFA) study. J Am Coll Cardiol 1991;18:349-55.
Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. EAFT (European Atrial Fibrillation Trial) Study Group. Lancet 1993;342:1255-62.
Ezekowitz MD, Bridgers SL, James KE, Carliner NH, Colling CL, Gornick CC, et al.
Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation. Veterans affairs stroke prevention in nonrheumatic atrial fibrillation investigators. N
Engl J Med 1992;327:1406-12.
Stroke prevention in atrial fibrillation study. final results. Circulation 1991;84:527-39.
Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al.
2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation. developed with the special contribution of the european heart rhythm association. Eur Heart J 2012;33:2719-47.
January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, et al
. 2014 AHA/ACC/HRS Guidelines for the management of patients with atrial fibrillation: A report of the ACC/AHA TaskForce on Practice Guidelines and the HRS. J Am Coll Cardiol 2014;64:el-76.
Bungard TJ, Ghali WA, Teo KK, McAlister FA, Tsuyuki RT. Why do patients with atrial fibrillation not receive warfarin? Arch Intern Med 2000;160:41-6.
Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, et al
. Prevention of VTE in orthopaedic surgery patients; antithrombotic therapy and prevention of thrombosis 9th
ed.; American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141:e278s-325s.
Kakkar AK. Prevention of venous thromboembolism in general surgery. In: Colman RW, Cloves AW, George JN, Marder VJ, Goldhaber SZ, ed. Haemostasis and Thrombosis: Basic Principles and Clinical Practice. 5th
ed. Philadelphia: Lippincott, William and Wilkins; 2006. p. 1361-7
Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, et al
. Prevention of VTE in nonsurgical patients: Antithrombotic therapy and prevention of thrombosis, 9th
ed.: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141:e195S-226S.
Caprini JA, Botteman MF, Stephens JM, Nadipelli V, Ewing MM, Brandt S, et al.
Economic burden of long-term complications of deep vein thrombosis after total hip replacement surgery in the united states. Value Health 2003;6:59-74.
Anakwue RC, Ocheni S, Madu J. Utilisation of oral anticoagulation in a teaching hospital in Nigeria. Ann Med Health Sci Res 2014;4:286-90.
] [Full text]
Mba A, Arfaja A. the competitiveness of Saudi pharmaceutical industry using porter 5 forces analysis. Eur J Bus Manage 2016;8:58-66.
Periotto BL, Ewerson S, Cavalcanti L, Ghislandi C, Timi J, Rufino R. Emergency-room doctors' knowledge about oral anticoagulants and its management. J Vasc Bras 2010;9:24-8.
Doroodchi H, Abdolrasulnia M, Foster JA, Foster E, Turakhia MP, Skelding KA, et al.
Knowledge and attitudes of primary care physicians in the management of patients at risk for cardiovascular events. BMC Fam Pract 2008;9:42.
Mosca L, Linfante AH, Benjamin EJ, Berra K, Hayes SN, Walsh BW, et al.
National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation 2005;111:499-510.
Kirley K, GouthamRao, Bauer V, Masi C. The role of NOACs in atrial fibrillation management: A qualitative study. J Atr Fibrillation 2016;9:1416.
Oktay E. Will NOACs become the new standard of care in anticoagulation therapy? Int J Cardiovasc Acad 2015;1:1-4.
Watson HG, Keeling DM, Laffan M, Tait RC, Makris M, British Committee for Standards in Haematology; et al.
Guideline on aspects of cancer-related venous thrombosis. Br J Haematol 2015;170:640-8.
Okeahialam BN. Challenges of anticoagulation in atrial fibrillation: An African perspective. Trop Card 2005;31:19-22.
Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, et al.
Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149:315-52.
Keeling D, Baglin T, Tait C, Watson H, Perry D, Baglin C, et al.
Guidelines on oral anticoagulation with warfarin-Fourth edition. Br J Haematol 2011;154:311-24.
Nwagha TU, Omunakwe HE. Understanding the RECORDS 3 trial and its impact on anticiagulation practice in resource poor countries. Niger J Clin Pract 2016;19:695-99.
] [Full text]
van der Meer FJ, Rosendaal FR, Vandenbroucke JP, Briët E. Bleeding complications in oral anticoagulant therapy. An analysis of risk factors. Arch Intern Med 1993;153:1557-62.
Harris MF, Parker SM, Litt J, van Driel M, Russell G, Mazza D, et al.
Implementing guidelines to routinely prevent chronic vascular disease in primary care: The preventive evidence into practice cluster randomised controlled trial. BMJ Open 2015;5:e009397.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]