Uptake of direct oral anticoagulants in primary care: an ecological and economic study

Abstract

BackgroundClinical trials indicate that direct oral anticoagulants (DOACs) are as effective as warfarin at preventing ischaemic stroke. It is unclear, however, whether relative changes in DOAC uptake have affected clinical and economic outcomes in practice.AimTo investigate variations in DOAC uptake and the relationship with hospital admissions and cost.Design & settingAn ecological study using electronic administrative records from England, April 2012 to March 2017.MethodMultivariable regression was used to model practice variation in DOAC prescribing, and the relationship with clinical and economic outcomes.ResultsIn quarter 1 of 2017, 55.0% of the 2 695 262 patients dispensed an anticoagulant were given a DOAC. There was a two-fold difference in odds of dispensing DOACs between clinical commissioning groups (CCGs) between those with the highest and lowest usage of these drugs. Increases in the relative uptake of DOACs were not associated with hospital admissions for ischaemic stroke (adjusted incidence rate ratio [IRR] = 1.00; 95% confidence intervals [CI] = 0.999 to 1.001), nor gastrointestinal or intracranial bleeds (IRR = 1.001; 95% CI = 1.000 to 1.002). In 2017, quarter 1, CCGs spent £9247 (inter-quartile range £7751 to £10 853) per 1000 patients on anticoagulants. The marginal effect of a 5% increase in DOAC uptake was associated with a £17.95 (£8.75 to £27.15) increase in total costs, per 1000 patient population.ConclusionThere were significant differences in the relative uptake of DOACs across practices, with greater costs but no reduction in hospital admissions in those with higher levels of dispensing. Findings indicate that clinical and economic benefits of DOACs identified by clinical trials are not realised in practice.

Prescribing of direct oral anticoagulants and warfarin to older people with atrial fibrillation in UK general practice: a cohort study

“…Numerous studies have confirmed an increase in OAC prescribing over the last decade in the UK for prevention of stroke in AF in the general population [ 11 , 18 – 20 ] and to older people [ 21 ]. This change has also been observed at practice level, with general practices with a higher ratio of older people and a higher prevalence of AF more likely to prescribe DOACs [ 22 ]; however, there is a risk of ecological fallacy if wishing to extrapolate this practice level data to prescribing to individuals. Whilst some of the increase in prescribing of OACs may be due to the introduction of DOACs, it may also be attributed to the introduction of Quality Outcome Frameworks for AF which incentivised the diagnosis of AF and prescribing of anticoagulants [ 23 , 24 ].…”

SAIL study of stroke, systemic embolism and bleeding outcomes with warfarin anticoagulation in non-valvular atrial fibrillation (S4-BOW-AF)

“…Historically, vitamin K antagonists (VKA) therapy has been the anticoagulant of choice to reduce the risk of stroke in patients with non-valvular atrial fibrillation (NVAF). 1 However, successful VKA therapy has important practical limitations, including regular monitoring of patients’ international normalised ratio (INR) due to variability of control. 2 , 3 The target INR range is 2–3 (unless otherwise indicated) 4–8 with net clinical benefit closely related to the proportion of time that INRs remain in this range [time in therapeutic range (TTR)].…”