This study demonstrated that antiplatelet therapy started prior to home-care service, especially aspirin therapy, was related to favorable survival among patients with a mean age of 79.4 years who received physician home visits.
One possible reason that antiplatelet therapy was associated with better outcomes is that patients who received physician home visits had a high prevalence of cardiovascular risk factors, resulting in secondary prevention. In other words, a previous physician’s decision to prescribe antiplatelet drugs may have been related to the patient’s underlying cardiovascular risk factors. Another possible reason is that intensive care by home visits from both physicians and nurses, which are usually provided together by our hospital, may have improved the patient’s adherence to medication and the physician’s evaluation of the patient’s condition.
Each patient received at least two visits by a physician and an average of six visits by nurses every month.14 Under the Japanese healthcare services, the physicians and nurses visited the patients and provided care, including emergency care 24 hours daily for 365 days a year. The collaboration of pharmacists may have had additional effects on drug adherence. Thus, a multidisciplinary approach to patient care may be synergistic.
Of the patients in the study, 314 (37.7%) had end-stage cancer. Meta-analyses of previous randomized prevention trials of aspirin showed a protective effect of aspirin on cancer-related death15 and death from the metastatic spread of cancer.16
The presence of cancer is now considered an independent risk factor for cardiovascular disease via the production of proinflammatory cytokines and chemokines by cancer cells.17,18 Given that patients receive intensive home care in Japan, the benefits of antiplatelet therapy may still exceed the harm from the therapy among patients with cancer.
Apart from the secondary prevention of cardiovascular diseases, many patients were receiving antiplatelet drugs throughout the study period. Although we cannot identify other primary reasons for prescribing antiplatelet drugs by some previous physicians, the patients’ risk factors for cardiovascular diseases might be relevant to the medication.
Patients taking antiplatelet drugs had only a few minor adverse events and no major bleeding events. On the other hand, two patients receiving direct oral anticoagulants had fatal adverse events. Among the patients receiving neither antiplatelet drugs nor anticoagulants, two patients died of intracranial hemorrhage and two patients experienced gastrointestinal bleeding that needed hospital admission.
Antiplatelet drugs may be tolerable in patients receiving home visit care, so that the home visit physician may not need to discontinue these drugs because of concern for unexpected, severe side effects. Therefore, it would be better not to stop the prescription for antiplatelet drugs after the initiation of physician home visits.
Our study has some limitations. First, because it was a retrospective study confined to the period of home visits, detailed prescription information, including the dates of starting and stopping prescriptions, was lacking. Some patients may have stopped taking antiplatelet drugs and others may have started taking antiplatelet drugs during follow-up. Therefore, among patients who were prescribed antiplatelet drugs by a previous physician prior to physician home visits, we cannot compare the outcome between patients who continued antiplatelet therapy and those who stopped antiplatelet therapy. Second, our study was conducted in Japan, where patients can receive intensive home healthcare services, and the results may not be generalizable to patients in other circumstances. Third, the mechanisms by which antiplatelet drugs could reduce mortality of these home-care patients remain unclear. A prospective, multicenter intervention study would be necessary to investigate this question.
In conclusion, the continuous prescription of antiplatelet drugs may have beneficial effects on mortality among patients who receive physician home visits.