Monitoring of atrial fibrillation in primary care patients prescribed direct oral anticoagulants for stroke prevention

Background: Direct oral anticoagulants (DOACs) are widely marketed as medicines that do not require routine laboratory monitoring. However, they do have complex pharmacological properties and side effects; hence prescribing and monitoring guidelines, such as the European Heart Rhythm Association (EHRA) guidelines, have emerged. These advocate monitoring for renal and hepatic impairment; bleeding episodes; liver function; co-medication; circulation, and occurrence of side effects. Though 3 to 6 month follow-up is advocated, this is currently not routine, and its implementation creates a potential obligation for general practitioners (GPs) managing atrial fibrillation (AF) patients in the community. Aims: This study investigates the frequency, the type of follow-up, and the factors that influenced follow-up among Irish GPs, who prescribed DOACs to patients with AF, to prevent strokes in 2015. Methods: The frequency and type of follow-up care is estimated, and a count model regression analysis is applied to determine the GP and practice characteristics that are associated with the implementation of follow-up. Results: The EHRA guidelines most frequently followed were those pertaining to renal function (82%), bleeding episodes (71%), liver function (69%), circulation (54%), and side effects (55%). The regression analysis revealed that female GPs (P = 0.05) and GPs who follow all seven guidelines (P = 0.06) practice more frequent follow-up while those in training practices (P = 0.09) provide less frequent follow-up. Conclusions: Results show that there was incomplete adherence to the 2013 EHRA prescribing guidelines with only 24% adhering to all seven guidelines, and patient follow-up was less frequent than has been suggested.