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We thank Dr. Reiffel for his interest in our study1Rodwin B.A. Salami J.A. Spatz E.S. et al.Variation in the use of warfarin and direct oral anticoagulants in atrial fibrillation and associated cost implications.Am J Med. 2019; 132: 61-70.e1Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar and for his thoughtful comments. We agree that the improved efficacy of the direct oral anticoagulants (DOACs) has an important impact on total cost of care over time in patients with atrial fibrillation. Our study was intended to evaluate the changes in use of anticoagulation after the incorporation of the DOACs into routine clinical care and evaluate disparities in use of these new medications and anticoagulation overall. We also evaluated the costs of these medications as it pertains to the direct costs of the medications themselves. As we note in our limitations, our evaluation focused solely on the cost of the anticoagulants themselves and did not account for differences in overall health care costs, including laboratory monitoring or hospitalizations, such as those related to embolic events including strokes. Our evaluation was not intended to be viewed as a comprehensive cost-effectiveness analysis. Several studies looking at this topic have been published and shown that over time, DOACs do appear to be as cost effective as warfarin.2Lopez-Lopez J.A. Sterne J.A.C. Thom H.H.Z. et al.Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis.BMJ. 2017; j5058: 359Google Scholar, 3Reddy V.Y. Akehurst R.L. Armstrong S.O. Amorosi S.L. Beard S.M. Holmes Jr, D.R. Time to cost-effectiveness following stroke reduction strategies in af: warfarin versus noacs versus laa closure.J Am Coll Cardiol. 2015; 66: 2728-2739Crossref PubMed Scopus (68) Google Scholar, 4You J.H. Novel oral anticoagulants versus warfarin therapy at various levels of anticoagulation control in atrial fibrillation—a cost-effectiveness analysis.J Gen Intern Med. 2014; 29: 438-446Crossref PubMed Scopus (41) Google Scholar The recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend DOACs instead of warfarin for the treatment of atrial fibrillation.5January C.T. Wann L.S. Calkins H. et al.AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation [epub ahead of print]. Circulation.in: 2019:CIR0000000000000665. 2019Google Scholar We believe our study provides important insights as to how DOACs have been incorporated into clinical practice and demonstrates that much work remains to be done to improve the quality of care for patients with atrial fibrillation as it pertains to frequency of anticoagulation in those who would qualify for treatment based on these guidelines and sociodemographic disparities in use. The direct cost burden of the DOACs may be a factor that contributes to these disparities. When an Omission Alters the Message, Missing Facts Must be AddedThe American Journal of MedicineVol. 132Issue 9PreviewIn January 2019, a paper by Rodwin et al titled: Variation in the use of warfarin and direct oral anticoagulants in atrial fibrillation and associated cost implications was published in this journal.1 While the published manuscript was well written, timely, and important, it ignored a major component of costs in this arena, both in the main text and in the limitations section. That is, the cost and consequences of strokes and intracranial bleeds. The manuscript focused on “the national trends in anticoagulation use for atrial fibrillation” and reported “a rapid increase in the use of DOACs [direct oral anticoagulants], significant disparities in anticoagulation use and choice of anticoagulant based on sociodemographic and clinical risk factors, and an increase in the overall and out-of-pocket costs for anticoagulants corresponding to the increased use of DOACs. Full-Text PDF