The Guideline-Policy Gap in Direct-Acting Oral Anticoagulants Usage in Atrial Fibrillation: Evidence, Practice, and Public Policy Considerations

Wan, Douglas; Healey, Jeff S.; Simpson, Chris

doi:10.1016/j.cjca.2018.07.476

Cited by 11 publications

(13 citation statements)

References 88 publications

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“…Recent large randomised controlled trials have demonstrated noninferiority for DOAC compared to warfarin with overall similar or reduced major bleeding risk, including a reduction in intracranial bleeding. [4][5][6][7] Their efficacy in stroke prevention in AF and in the treatment/prevention of VTE has been extensively investigated, but only recently has there been initial investigation into patient satisfaction with DOAC therapy.…”

Section: Plos Onementioning

confidence: 99%

“…[4][5][6] Rivaroxaban and apixaban were associated with equal or less major bleeding events than warfarin for the treatment of acute VTE and less intracranial haemorrhage in AF studies. [4][5][6][7] Patients with high risk of recurrence of VTE such as those suffering from an unprovoked VTE, have the choice of long-term risk reduction with dose reduced DOAC anticoagulation for secondary prevention of recurrent VTE with a low risk of major bleeding. [8,9] Patient satisfaction with medication is an important determinant of long-term patient compliance.…”

Section: Introductionmentioning

confidence: 99%

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Patient satisfaction after conversion from warfarin to direct oral anticoagulants for patients on extended duration of anticoagulation for venous thromboembolism – The SWAN Study

et al. 2020

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Background Warfarin is an anticoagulant medication proven effective in the initial treatment and secondary prevention of venous thromboembolism. Anti-Xa direct oral anticoagulants are alternatives to warfarin; however there is limited data assessing satisfaction after switching from warfarin to an anti-Xa direct oral anticoagulant in patients for treatment of venous thromboembolism. Objectives To assess medication satisfaction in patients requiring anticoagulation for venous thromboembolism after conversion from warfarin to an anti-Xa direct oral anticoagulant. Methods A retrospective cohort study with prospective assessment of satisfaction and review of adverse events following anti-Xa direct oral anticoagulant replacement of warfarin for treatment of venous thromboembolism. Out of 165 patients who had switched from warfarin to rivaroxaban or apixaban from an outpatient haematology practice, 126 patients consented for a survey of patient's relative satisfaction of anti-Xa direct oral anticoagulant therapy compared with previous warfarin therapy using the Anti-Clot Burden and Benefits Treatment Scale and SWAN Score. Results The mean Anti-Clot Burden and Benefits and SWAN Score was 93% (56/60) and 83% (24.8/30) respectively reflecting high satisfaction with anti-Xa direct oral anticoagulants. 120

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Section: Plos Onementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Patient satisfaction after conversion from warfarin to direct oral anticoagulants for patients on extended duration of anticoagulation for venous thromboembolism – The SWAN Study

et al. 2020

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“…But the initial cost of a prescription for a DOAC is much higher than that of warfarin, which may give pause to local commissioning agencies. Also, while several realworld studies on DOACs have established reassuring safety profiles [7,8], fears of increased bleeding linger, particularly in the media [9]. There existed no antidote for rivaroxaban or apixaban until the introduction of andexanet alfa in 2018-and still, no antidote has been recommended by a NICE technology appraisal.…”

Section: Introductionmentioning

confidence: 99%

Trends in anticoagulant prescribing: a review of local policies in English primary care

Hove

Leng

2020

BMC Health Serv Res

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Background: Oral anticoagulants are prescribed for stroke prophylaxis in patients with atrial fibrillation, which is the most common heart arrhythmia worldwide. The vitamin K antagonist (VKA) warfarin is a long-established anticoagulant. However, newer direct oral anticoagulants (DOACs) have been recently introduced as an alternative. Given the prevalence of atrial fibrillation, anticoagulant choice has substantial clinical and financial implications for healthcare systems. In this study, we explore trends and geographic variation in anticoagulant prescribing in English primary care. Because national guidelines in England do not specify a first-line anticoagulant, we investigate the association between local policies and prescribing data. Methods: Primary care prescribing data of anticoagulants for all NHS practices from 2014 to 2019 in England was obtained from the ePACT2 database. Public formularies were accessed online to obtain local anticoagulation prescribing policies for 89.5% of clinical commissioning groups (CCGs). These were categorized according to their recommendations: no local policies, warfarin as first-line, or identification of a preferred DOAC (but not a preferred anticoagulant). Local policies were cross-tabulated with pooled prescribing data to measure the strength of association with Cramér's V. Results: Nationally, prescribing of DOACs increased from 9% of all anticoagulants in 2014 to 74% in 2019, while that of warfarin declined accordingly. Still, there was significant local variation. Across geographical regions, DOACs ranged from 53 to 99% of all anticoagulants. Most CCGs (73%) did not specify a first-line choice, and 16% recommended warfarin first line. Only 11% designated a preferred DOAC. Policies with a preferred DOAC indeed correlated with increased prescribing of that DOAC (Cramér's V = 0.25, 0.27, 0.38 for rivaroxaban, apixaban, edoxaban respectively). However, local policies showed a negligible relationship with the classes of anticoagulants prescribed-DOAC or VKA (Cramér's V = 0.01). Conclusions: Nationally, the use of DOACs to treat atrial fibrillation has increased rapidly. Despite this, significant geographical variation in uptake remains. This study provides insights on how local policies relate to this variation. Our findings suggest that, in the absence of a nationally recommended first-line anticoagulant, local prescribing policies may aid in deciding between individual DOACs, but not in adjudicating between DOACs and vitamin K antagonists (i.e. warfarin) as general classes.

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“…A 2018 study reviewed randomized clinical trials and real-life outcomes and focused on DOACs. [28] A further review focused on trends in the prescription of antithrombotic medications, and patient compliance and persistence to OACs. [29] The present review seeks to determine the extent of non-adherence to thromboprophylaxis guidelines in AF and factors associated with guideline non-adherence.…”

Section: Introductionmentioning

confidence: 99%

Non-adherence to Thromboprophylaxis Guidelines in Atrial Fibrillation: A Narrative Review of the Extent of and Factors in Guideline Non-adherence

Gebreyohannes

Salter

Chalmers

et al. 2020

Am J Cardiovasc Drugs

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The Guideline-Policy Gap in Direct-Acting Oral Anticoagulants Usage in Atrial Fibrillation: Evidence, Practice, and Public Policy Considerations

Cited by 11 publications

References 88 publications

Patient satisfaction after conversion from warfarin to direct oral anticoagulants for patients on extended duration of anticoagulation for venous thromboembolism – The SWAN Study

Patient satisfaction after conversion from warfarin to direct oral anticoagulants for patients on extended duration of anticoagulation for venous thromboembolism – The SWAN Study

Trends in anticoagulant prescribing: a review of local policies in English primary care

Non-adherence to Thromboprophylaxis Guidelines in Atrial Fibrillation: A Narrative Review of the Extent of and Factors in Guideline Non-adherence

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