Uptake Of Direct Oral Anticoagulants Research Articles

Abstract 16693: Trends in the Use of Oral Anticoagulation for Nonvalvular Atrial Fibrillation Vary by Specialty: Real World Results From a Large Integrated Health Care System 2011-2022

Introduction: Direct Oral anticoagulants (DOACs) have demonstrated superiority or non inferiority to vitamin K antagonists (VKAs) for stroke/embolic prevention in patients with nonvalvular atrial fibrillation (NVAF). However, clinical inertia may delay widespread adoption of newer therapies in medicine. Hypothesis: We evaluated whether uptake of DOACs into clinical medicine varied by physician specialty. Methods: We performed a retrospective review of patients with NVAF within the Geisinger Health System from 2011-2022. Longitudinal yearly trends for new/initial prescriptions (Rx) of DOAC vs VKA by cardiology or primary care (PCP) specialties Results: We identified patients with NVAF initiated on an oral anticoagulant from the years 2011 through 2023. Figures 1 and 2 demonstrate a statistically significant linear yearly increase in new Rx for DOACs for both cardiology and PCP specialties.By 2022, DOACs currently account for 96% of all new oral anticoagulant Rx by cardiologists and 90% of Rx by PCP. New Rx for DOAC by PCP lagged cardiology at all time points. Cardiology initial Rx >50% DOAC by 2015 while PCP did not achieve this mark until 2018. Conclusions: In this real-world setting, we observed a significant increase in DOAC use as the initial prescription for patients with NVAF by both cardiology and primary care specialties.Significant difference in the adoption of DOAC was noted between cardiology and primary care specialties.Primary care use of DOAC as first Rx for NVAF increased over time but lagged cardiology by 2-3 years.

Barriers and enablers to healthcare system uptake of direct oral anticoagulants for stroke prevention in atrial fibrillation: a qualitative interview study with healthcare professionals and policy makers in England

ObjectiveTo better understand the factors influencing the uptake of direct oral anticoagulants (DOACs) across different health economies in National Health Service England from the perspective of health professionals and other...

Abstract 738: Increasing uptake of direct oral anticoagulants for thromboprophylaxis among newly diagnosed multiple myeloma patients initiating immunomodulatory drug-based regimens, 2010 to 2017

Abstract Background: Multiple myeloma (MM) is associated with an increased incidence of venous thromboembolism (VTE) which results in greater morbidity and mortality in MM patients. Several MM treatments including receiving immunomodulatory drugs (IMiDs), cytotoxic chemotherapy, and high-dose dexamethasone also increase VTE risk. Clinical guidelines recommend thromboprophylactic regimens to mitigate the risk of VTE in MM patients. However, practices vary with respect to medications used for thromboprophylaxis, ranging from prescribing of aspirin to anticoagulant regimens with direct oral anticoagulants (DOAC) and warfarin. We aimed to describe patterns of warfarin- and DOAC-based thromboprophylaxis in newly diagnosed MM patients initiating IMiD-based treatment. Methods: We conducted a retrospective cohort study of MM patients using the IBM MarketScan Commercial Claims and Encounters and Medicare Supplemental databases. We included newly diagnosed MM patients initiating IMiD-based treatment between 2010 and 2017 with continuous health plan enrollment 12 months prior to and following diagnosis. We collected information on comorbidities, VTE risk factors and other MM therapies. The primary outcome of interest was initiating thromboprophylaxis with warfarin or DOAC within 90 days of treatment initiation. We evaluated prescribing trends over time and characteristics associated with DOAC- or warfarin-based thromboprophylaxis, we used univariate and multivariate multinomial logistic regression models comparing these two forms of thromboprophylaxis to those who did not receive thromboprophylaxis. Results: In a cohort of 6227 MM patients initiating IMiD-based regimens, the median age was 62 years and 43% were female. Over the entire study period, warfarin-based thromboprophylaxis was more prevalent relative to DOACs (10.5% vs. 6.9%). However, we observed a trend of increasing adoption of DOAC thromboprophylaxis from 2.4% of patients in 2010 to 12.7% in 2017; and the use of warfarin thromboprophylaxis consistently declined over time from 16.5% of patients in 2010 to 3.2% in 2017. In multivariable analyses, trends associated with increasing or decreasing odds of thromboprophylaxis with these agents were robust after adjustment for demographic and clinical characteristics including VTE risk factors and other MM treatment (DOAC: OR 1.35, 95% CI 1.28-1.44 and warfarin: OR 0.81, 95% CI 0.77-0.86). Conclusions: Over the study period, our findings indicate that DOAC-based thromobprophylaxis regimens were increasingly used over warfarin-based treatment in newly diagnosed commercially insured MM patients initiating IMiD therapy. Further research is needed to determine whether these patterns are associated with differences in clinical outcomes. Citation Format: Abdullah I. Abdelaziz, Karen Sweiss, Pritesh R. Patel, Brian C-H Chiu, Gregory S. Calip. Increasing uptake of direct oral anticoagulants for thromboprophylaxis among newly diagnosed multiple myeloma patients initiating immunomodulatory drug-based regimens, 2010 to 2017 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 738.

Abstract 10780: Uptake of Direct Oral Anticoagulants in Older Adults with Atrial Fibrillation in 2010-2018

Introduction: Under-treatment with oral anticoagulants (OAC) in atrial fibrilliation (AF) is a persistent management gap, particularly in older adults. Understanding patterns of OAC adoption may enable design of implementation strategies to improve evidence-based care. Objectives: Determine changes in OAC use and overall uptake of direct oral anticoagulants (DOACs) in older adults. Methods: We analyzed administrative claims data (years 2010 to 2018) from Optum Clinformatics Data Mart to identify Medicare Advance Plan beneficiaries (aged ≥65) with AF and CHA 2 DS 2 -VASc score ≥2. We excluded patients with history of intracranial hemorrhage and end-stage renal disease. We calculated the proportion of patients prescribed a DOAC, warfarin, or no OAC each year. We examined uptake by patient subgroups, including those with dementia diagnoses and those with frailty, defined by a claims-based frailty index. Results: Our sample size ranged from 123,700 in 2010 to 398,385 in 2018. The mean age ranged 76-79 years and the proportion of women ranged 50-53%. The proportion of eligible patients receiving OAC increased from 50.9% to 53.8% for the total sample (+2.9%) (Figure A). This increase was greater for younger patients (65-79 years: 53.7% to 58.1% vs ≥80 years: 48.9 to 49.5%) (Figures B & C), those with dementia (dementia: 39.6% to 44.8% vs no dementia: 52.5% to 55.3%) (Figures D & E), and those with frailty (frailty: 48.1% to 52.1% vs no frailty: 53.4% to 55.3%) (Figures F & G). There was a consistent decreasing trend in warfarin use in all subgroups from 2010 to 2018 (51 to 19 % in the total population, Figures A-G). Conclusion: Following the advent of DOACs, overall OAC use modestly increased in older adults, including for those with dementia and frailty. A large proportion of patients with guidelines-based eligibility for OAC remain untreated. Implementation strategies for improving OAC use are needed, particularly for high-risk older patients who stand to benefit the most.

Abstract 13791: Trends in the Use of Oral Anticoagulation for Nonvalvular Atrial Fibrillation in a Large Integrated Health Care System 2011-2020

Introduction: Direct Oral anticoagulants (DOACs) have demonstrated superiority or noninferiority to vitamin K antagonists (VKAs) for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). The uptake of DOACs into clinical medicine has been variable and may be influenced by many factors. Objective: To determine how the prescription (Rx) pattern for DOACs has evolved since their introduction and to evaluate the temporal effects of factors which may impact DOAC Rx. Methods: We performed a retrospective review of patients with NVAF within the Geisinger Health System from 2011-2020. We evaluated longitudinal yearly trends in anticoagulant use and new/initial Rx of DOAC vs VKA in NVAF. We examined subgroups based on clinical and demographic indices. Key points in the timeline regarding DOAC availability and medical society or institutional guidelines were incorporated to determine whether changes DOAC Rx were temporally associated with these events. Results: We identified 34, 936 patients with NVAF. The average age of the was 74.3 years, 48% were female and 98% white. The average CHA 2 DS 2 Vasc score was 2.5. There was a linear increase in overall and new Rx for DOACs with 77.7% of all new Rx for DOAC in 2020. The greatest increase in new DOAC Rx coincide with timepoints of DOAC incorporation into ACC/AHA Guidelines, approval of Xa reversal agent and institutional formulary change. Apixaban was the most common DOAC Rx since 2015 and now accounts for 70.9% of all new anticoagulation Rx and 91.3% of new DOAC Rx at our institution. Conclusions: There was a linear increase in DOACs use for NVAF over time and apixaban has become the most prescribed DOAC at our institution. Society guidelines, approval of reversal agents and institutional formulary changes appear to be temporally associated with increased Rx of DOACs for NVAF.

Epidemiología del ictus cardioembólico y su asociación con la penetración de los ACOD en España: primer estudio poblacional 2005-2018

Introduction and objectivesThe incidence and prevalence of atrial fibrillation (AF), a major risk factor for stroke, has increased substantially in the past few years. However, several studies have reported a decline in AF-related stroke rates associated with higher uptake of direct oral anticoagulants (DOACs). This ecological study evaluated the association between DOAC uptake in Spain and the incidence rate (IR) of AF-related ischemic stroke. MethodsData were obtained from the Registry of Activity of Specialized Healthcare of the Spanish Ministry of Health (RAE-MDS). AF-related ischemic strokes were identified using International Classification of Diseases codes. IR were age-standardized and adjusted to the 2013 European standard population. Poisson regression models were used to identify the association between DOAC uptake and AF-related ischemic stroke in patients aged ≥ 65 years. ResultsBefore the use of DOACs, the adjusted IR of AF-related ischemic stroke increased steadily from 2005 (IR=2.20 per 100 000 person/y) to 2012 (IR=2.67). Upon DOAC uptake in Spain from 2012 onwards for AF-related ischemic stroke prevention, the IR remained constant or decreased slightly (IR in 2018=2.66). Poisson regression showed that DOAC uptake was a significant predictor for the rate of AF-related ischemic stroke in patients older than 65 years (IRR=0.995; 95%CI, 0.995-0.996). ConclusionsThis study shows an association between DOAC use and a reduced incidence of AF-related ischemic stroke. While this association is based on aggregate data and cannot demonstrate causality, these findings suggest that higher DOAC uptake could improve health outcomes in AF patients in Spain.Full English text available from:www.revespcardiol.org/en

Epidemiology of atrial fibrillation-related ischemic stroke and its association with DOAC uptake in Spain: first national population-based study 2005 to 2018

Introduction and objectivesThe incidence and prevalence of atrial fibrillation (AF), a major risk factor for stroke, has increased substantially in the past few years. However, several studies have reported a decline in AF-related stroke rates associated with higher uptake of direct oral anticoagulants (DOACs). This ecological study evaluated the association between DOAC uptake in Spain and the incidence rate (IR) of AF-related ischemic stroke. MethodsData were obtained from the Registry of Activity of Specialized Healthcare of the Spanish Ministry of Health (RAE-MDS). AF-related ischemic strokes were identified using International Classification of Diseases codes. IR were age-standardized and adjusted to the 2013 European standard population. Poisson regression models were used to identify the association between DOAC uptake and AF-related ischemic stroke in patients aged ≥ 65 years. ResultsBefore the use of DOACs, the adjusted IR of AF-related ischemic stroke increased steadily from 2005 (IR=2.20 per 100 000 person/y) to 2012 (IR=2.67). Upon DOAC uptake in Spain from 2012 onwards for AF-related ischemic stroke prevention, the IR remained constant or decreased slightly (IR in 2018=2.66). Poisson regression showed that DOAC uptake was a significant predictor for the rate of AF-related ischemic stroke in patients older than 65 years (IRR=0.995; 95%CI, 0.995-0.996). ConclusionsThis study shows an association between DOAC use and a reduced incidence of AF-related ischemic stroke. While this association is based on aggregate data and cannot demonstrate causality, these findings suggest that higher DOAC uptake could improve health outcomes in AF patients in Spain.

Practice patterns surrounding referral to a specialty venous thromboembolism (VTE) clinic: a retrospective review.

This study audited prescribing practices for patients with acute venous thromboembolism (VTE) prior to and after being seen in an outpatient VTE clinic. This retrospective chart review conducted between June 2018 through May 2019 included patients with confirmed acute VTE, seen for an initial appointment. Exclusion criteria were patients with additional indications for anticoagulation, lack of information to determine primary outcome and active cancer. To assess practices, the time taken to be seen in clinic, anticoagulant therapies (prior to/following clinic) used and concordance of anticoagulant use with product monographs were assessed. Of the 325 (40.6%) patients included, the median age was 57.7 years, most were referred with pulmonary embolism (PE) (54.5%) and the majority of referrals came through the emergency department (45.2%). The median time to be seen in clinic was 13 days, with no differences in time between type of VTE or proximity of clot. Prior to being seen in VTE clinic, most were prescribed direct oral anticoagulants (DOACs) (81.9%), with a small portion receiving low molecular weight heparin (LMWH) (12.9%) and warfarin (5.2%). Most received anticoagulants concordant with product monographs (87.7%), with more discordance with warfarin (52.9%) and LMWH (14.3%) compared to DOACs (9.4%) (P < 0.001). At the initial VTE clinic visit, 70 (21.5%) patients had therapy changes, with most being from LMWH/warfarin to a DOAC (47.1%). Our data reflects high uptake of DOACs for acute VTE treatment with most prescribed in accordance with product monographs.

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

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

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

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.

Oral Presentations

Introduction: The National Institute for Health and Care Excellence (NICE) recommended direct oral anticoagulants (DOACs) for a variety of indications as equal alternatives to warfarin, and stated that the patient's values and preferences should be used to guide choice of agent in a shared decision making process [1]. However, uptake of DOACs had been patchy and slow across the UK [2]. Identifying the perceived barriers to using DOACs could help to develop strategies to overcome these and enable their use where appropriate. Aim: The study aimed to investigate the attitudes and perceptions of professionals towards oral anticoagulation, and the choice between warfarin and the DOACs.

Association of stroke and bleed events in non-valvular atrial fibrillation patients with direct oral anticoagulant prescriptions in NHS England between 2013 and 2016

Prescription of direct oral anticoagulants (DOAC) compared to warfarin for treating atrial fibrillation patients have increased substantially since their introduction in the England’s National Health Service. Assessment of the risk of strokes and bleeds in relation to the large-scale uptake in DOACs compared to warfarin at the clinical commissioning group (CCG) level needs to be carried out. Publicly available- aggregated, CCG level, multi-source health and prescription records data were interrogated to investigate the association between prescription rate of DOACs and stroke/ bleed events during the period of 2013 to 2016. Variability of prescription rates and patient numbers across 208 CCGs were used to infer the effect of DOACs on stroke and bleed risk. Relative risk (RR) and 95% credible intervals (CI) were estimated using Markov chain Monte Carlo approach in JAGS. During the study period, the proportion of DOAC prescriptions increased at an average rate of 122% per annum. DOAC prescription was association with a 50% reduction in ischaemic (RR = 0.48, 95% CI = 0.39, 0.57) and haemorrhagic stroke (RR = 0.50, 95% CI = 0.26–0.77). In contrast, DOAC prescription reached significant association with reduction in gastrointestinal bleeds (RR = 0.86, 95% CI = 0.73–0.98) but not clinically relevant bleeds (RR = 0.95, 95% CI = 0.85–1.05). Sex stratified data showed significant association between DOAC prescription and reduction in haemorrhagic stroke risk (RR = 0.40, 95% CI = 0.28–0.52) and gastrointestinal bleeds (RR = 0.76, 95% CI = 0.63–0.93) in males only. Age stratified data suggested significant association with reduction in risk of both ischaemic and haemorrhagic strokes in patients aged 70 years and above, and reduction in risk of clinically relevant and gastrointestinal bleeds in patients aged 70–79 years only. Publicly available health and prescription data for the English population indicates reduction in stroke and bleed risk in specific age and sex sub-groups with the uptake of DOACs compared to warfarin between 2013 and 2016.

Uptake of Oral Anticoagulants for Stroke Prevention in Patients with Atrial Fibrillation in a Single Clinical Commissioning Group in England Without Restrictions to Their Use.

In England, the uptake of direct oral anticoagulants (DOACs) for stroke prevention in atrial fibrillation has been slow and varied across different Clinical Commissioning Groups (CCGs). This study aimed to profile the prescribing of oral anticoagulants for stroke prevention in patients with atrial fibrillation over 3years in a CCG without restrictions to DOACs use to understand more about organisational and/or individual barriers to the early uptake of DOACs. Data were collected from nine general practices between 1 April 2012 and 31 March 2015 of patients who were initiated on the oral anticoagulant therapy. Data were analysed descriptively and with independent Student's t test and Chi square test to explore if there was an association between type of oral anticoagulant initiated and sex, age, type of prescriber and prior aspirin use. The early uptake of DOACs significantly increased over the study period (p < 0.0001; medium size effect φc = 0.372). There was no statistically significant difference between sex or age and type of oral anticoagulant initiated. Primary-care prescribers were responsible for initiating the majority of oral anticoagulants (71%; N = 257) and driving the use of DOACs (72%, N = 71). Patients switched from aspirin to an oral anticoagulant were more likely to be initiated on warfarin thana DOAC. The early use of DOACs, in a CCG without restrictions to their use, was embraced by primary-care prescribers in this particular CCG.

PHP162 - Market Uptake Of Direct Oral Anticoagulants (Doacs) In Germany

PHP162 - Market Uptake Of Direct Oral Anticoagulants (Doacs) In Germany