Clinical and budget impacts of changes in oral anticoagulation prescribing for atrial fibrillation

Abstract

ObjectiveTo assess temporal clinical and budget impacts of changes in atrial fibrillation (AF)-related prescribing in England.MethodsData on AF prevalence, AF-related stroke incidence and prescribing for all National Health Service general practices, hospitals and registered patients with hospitalised AF-related stroke in England were obtained from national databases. Stroke care costs were based on published data. We compared changes in oral anticoagulation prescribing (warfarin or direct oral anticoagulants (DOACs)), incidence of hospitalised AF-related stroke, and associated overall and per-patient costs in the periods January 2011–June 2014 and July 2014–December 2017.ResultsBetween 2011–2014 and 2014–2017, recipients of oral anticoagulation for AF increased by 86.5% from 1 381 170 to 2 575 669. The number of patients prescribed warfarin grew by 16.1% from 1 313 544 to 1 525 674 and those taking DOACs by 1452.7% from 67 626 to 1 049 995. Prescribed items increased by 5.9% for warfarin (95% CI 2.9% to 8.9%) but by 2004.8% for DOACs (95% CI 1848.8% to 2160.7%). Oral anticoagulation prescription cost rose overall by 781.2%, from £87 313 310 to £769 444 028, (£733,466,204 with warfarin monitoring) and per patient by 50.7%, from £293 to £442, giving an incremental cost of £149. Nevertheless, as AF-related stroke incidence fell by 11.3% (95% CI −11.5% to −11.1%) from 86 467 in 2011–2014 to 76 730 in 2014–2017 with adjustment for AF prevalence, the overall per-patient cost reduced from £1129 to £840, giving an incremental per-patient saving of £289.ConclusionsDespite nearly one million additional DOAC prescriptions and substantial associated spending in the latter part of this study, the decline in AF-related stroke led to incremental savings at the national level.

Clinical outcomes in patients with atrial fibrillation and frailty: insights from the ENGAGE AF-TIMI 48 trial

“…Therefore, anticoagulation is recommended for men with AF and a CHA 2 DS 2 -VASc score of 2 or greater and in women with a score of 3 or greater [18,19]. Large randomised controlled trials have established the efficacy and safety of direct oral anticoagulant medications (DOACs) in comparison to warfarin for stroke prevention in non-valvular AF [20][21][22][23], including in people aged over 75 years [24], and they are associated with a per patient cost saving [25]. However, we lack data on the efficacy and safety of DOAC in older people with AF who are also frail [3].…”

Acute Upper Gastrointestinal Bleeding: Less Severe Bleeding in More Frail and Older Patients, Comparison Between Two Time Periods Fifteen Years Apart

“…On the other hand, we observed a higher use of oral anticoagulants, either warfarin or NOACs, in our patients with AUGIB recently and probably use of these medications will expand in the future due to the increasing indications of oral anticoagulantion in a variety of diseases, especially in the elderly population. Orlowski and colleagues compared the time periods of 2011 - 2014 versus 2014 - 2017 in the UK, using National Health Service data, and demonstrated a dramatic increase (over 85%) in oral anticoagulation prescribing, mostly due to the increased use of NOACs [ 24 ]. NOACs, which are increasingly prescribed, are associated with the same risk of major gastrointestinal bleeding compared with conventional vitamin K antagonists [ 25 ].…”

Effectiveness of Hemopatch® versus Surgicel® Original to control mild and moderate liver bleeding

“…Given the increasing number of patients receiving anticoagulant prescriptions for long-term management of cardiac, cerebrovascular or peripheral vascular conditions [ 26 , 27 ], surgeons frequently encounter patients taking these medications in both elective and emergency surgery settings, possibly leading to increased blood loss, longer operative times, greater use of surgical consumables, and higher costs [ 2 ]. Heparinization was therefore used in this study to mimic these clinical scenarios as well as intraoperative anticoagulation of patients.…”