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.
Highlights
Warfarin has been the dominant preventive treatment for ischaemic stroke for patients with atrial fibrillation (AF) and venous thromboembolism
Increases in the relative uptake of direct oral anticoagulants (DOACs) were not associated with hospital admissions for ischaemic stroke, nor gastrointestinal or intracranial bleeds (IRR = 1.001; 95% CI = 1.000 to 1.002)
Author Keywords: anticoagulant, warfarin, economics, hospitalization, direct oral anticoagulants, commissioning, randomized controlled trials, primary health care, general practice. How this fits in Evidence from randomised controlled trials (RCTs) indicate that DOACs are as effective as warfarin at reducing the risk of ischaemic stroke, with greater incremental net benefit
Summary
Warfarin has been the dominant preventive treatment for ischaemic stroke for patients with atrial fibrillation (AF) and venous thromboembolism. The cost per patient of DOACs is substantially higher than that of warfarin, but cost-effectiveness analysis has suggested this is offset by reduced therapeutic monitoring, and improved effectiveness and safety.[11] To date, no economic evaluation has been undertaken using ‘real world’ data, which is needed for health service planning and commissioning. Clinical trials indicate that direct oral anticoagulants (DOACs) are as effective as warfarin at preventing ischaemic stroke. It is unclear, whether relative changes in DOAC uptake have affected clinical and economic outcomes in practice
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
