Patient-specific and healthcare real-world costs of atrial fibrillation in individuals treated with direct oral anticoagulant agents or warfarin

Abstract Background Anticoagulant therapies are used to prevent atrial fibrillation-related strokes, with warfarin and direct oral anticoagulant (DOAC) the most common. In this study, we incorporate direct health care costs, drug costs, travel costs, and lost working and leisure time costs to estimate the total costs of the two therapies. Methods This retrospective study used individual-level patient data from 4000 atrial fibrillation (AF) patients from North Karelia, Finland. Real-world data on healthcare use was obtained from the regional patient information system and data on reimbursed travel costs from the database of the Social Insurance Institution of Finland. The costs of the therapies were estimated between June 2017 and May 2018. Using a Geographical Information System (GIS), we estimated travel time and costs for each journey related to anticoagulant therapies. We ultimately applied therapy and travel costs to a cost model to reflect real-world expenditures. Results The costs of anticoagulant therapies were calculated from the standpoint of patient and the healthcare service when considering all costs from AF-related healthcare visits, including major complications arising from atrial fibrillation. On average, the annual cost per patient for healthcare in the form of public expenditure was higher when using DOAC therapy than warfarin therapy (average cost = € 927 vs. € 805). Additionally, the average annual cost for patients was also higher with DOAC therapy (average cost = € 406.5 vs. € 296.7). In warfarin therapy, patients had considerable more travel and time costs due the different implementation practices of therapies. Conclusion The results indicated that DOAC therapy had higher costs over warfarin from the perspectives of the patient and healthcare service in the study area on average. Currently, the cost of the DOAC drug is the largest determinator of total therapy costs from both perspectives. Despite slightly higher costs, the patients on DOAC therapy experienced less AF-related complications during the study period.

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Direct Oral Anticoagulant (DOAC) to Warfarin Transitions in a Pharmacist-led Anticoagulation Clinic

Journal of Contemporary Pharmacy Practice ◽

10.37901/jcphp17-00024 ◽

2019 ◽

Vol 66 (1) ◽

pp. 48-51

Author(s):

Ashley Woodhouse ◽

Madeline Burke ◽

Anne Misher

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulant ◽

Warfarin Therapy ◽

Bridge To Surgery ◽

Direct Oral Anticoagulant ◽

Inclusion Criteria ◽

Practice Recommendations ◽

Clinical Trial Evidence ◽

Caucasian Patients ◽

Trial Evidence

Purpose Patients with non-valvular atrial fibrillation or venous thromboembolism have historically been treated with vitamin-k antagonist therapy; however, due to well-documented limitations, direct oral anticoagulant (DOAC) use has been increasing.(1)(2) The convenience and clinical utility of DOACs is not applicable to all patients, and some must be transitioned to warfarin therapy. Despite practice recommendations, suggestions from package inserts, and clinical trial evidence, there remains a lack of literature describing real-word examples of patient transition from DOACs to warfarin.(3–11) Summary All patients who were transitioned from a DOAC to warfarin from January to December 2016 and were managed by the clinic were included. Patients were excluded if the transition to warfarin did not include ≥ 2 days of DOAC overlap or if DOAC therapy was used as a bridge to surgery or procedure. St. Joseph's/Candler Health System IRB granted expedited approval and waived informed consent. Four elderly, Caucasian patients met the inclusion criteria. Four patients were successfully transitioned from a DOAC to warfarin for their atrial fibrillation, 3 were transitioned from apixaban and 1 was transitioned from rivaroxaban. Conclusion Overall the purpose of this retrospective, observational study was to highlight real-world management of the transition of DOACs to warfarin in an outpatient, pharmacist-led clinic.

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Impact of Direct Oral Anticoagulant Off-Label Reduced Dose in Combination With Antiplatelet Agents on Clinical Outcome　― Propensity Score-Matching Analysis From the DIRECT Real-World Non-Valvular Atrial Fibrillation Registry ―

Circulation Reports ◽

10.1253/circrep.cr-20-0026 ◽

2020 ◽

Vol 2 (6) ◽

pp. 289-296 ◽

Cited By ~ 1

Author(s):

Tomoaki Kobayashi ◽

Yohei Sotomi ◽

Akio Hirata ◽

Yasushi Sakata ◽

Atsushi Hirayama ◽

...

Keyword(s):

Atrial Fibrillation ◽

Propensity Score ◽

Clinical Outcome ◽

Real World ◽

Oral Anticoagulant ◽

Antiplatelet Agents ◽

Direct Oral Anticoagulant ◽

Off Label ◽

Propensity Score Matching Analysis ◽

Reduced Dose

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Real-World Prevalence of Direct Oral Anticoagulant Off-Label Doses in Atrial Fibrillation: An Epidemiological Meta-Analysis

Frontiers in Pharmacology ◽

10.3389/fphar.2021.581293 ◽

2021 ◽

Vol 12 ◽

Author(s):

Nan-Nan Shen ◽

Chi Zhang ◽

Ying Hang ◽

Zheng Li ◽

Ling-Cong Kong ◽

...

Keyword(s):

Atrial Fibrillation ◽

Real World ◽

Oral Anticoagulant ◽

Meta Analysis ◽

Anticoagulation Therapy ◽

Direct Oral Anticoagulant ◽

Prevalence Data ◽

Off Label ◽

Significant Difference ◽

Subgroup Analyses

Background: The use of direct oral anticoagulant (DOAC) off-label doses in atrial fibrillation (AF) patients may result in poor clinical outcomes. However, the true prevalence remains scarce. This study aims at estimating the prevalence of DOAC off-label doses in AF patients.Methods: Databases of MEDLINE, EMBASE, and COCHRANE were searched from inception through February 2020 for real-world studies that reported the off-label definition and prevalence data of AF patients using DOACs. The primacy outcomes were the overall prevalence of DOAC off-label doses and the corresponding underdose and overdose. The random-effects model was used for data synthesis. Variations on individual DOAC and different regions were examined by subgroup analyses.Results: A total of 23 studies involving 162,474 AF patients were finally included. The overall prevalence of DOAC off-label doses was 24% (95% CI, 19–28%), with 18% for dabigatran, 27% for rivaroxaban, 24% for apixaban, and 26% for edoxaban. The prevalence of underdosed DOACs was 20% (95% CI, 16–24%) with significant difference among individual anticoagulants (13% for dabigatran, 22% for rivaroxaban, 22% for apixaban, and 18% for edoxaban; Pinteraction=0.02). The prevalence of overdosed DOACs was 5% (95% CI, 3–7%), with the lowest prevalence observed in apixaban (2%). Subgroup analyses by regions demonstrated that the prevalence of DOAC off-label doses was higher in Asia (32%) than in North America (14%) and in Europe (22%), with underdose being predominant. Regardless of different regions, the prevalence of overdose was relatively low (4–6%).Conclusion: This study provides an estimation of DOAC off-label doses in the real-world setting. The prevalence rate of DOAC off-label doses in AF patients was relatively high, with underdose being predominant. Clinicians in Asia preferred to prescribe underdose of DOACs to AF patients. More evidence about the appropriateness of DOAC off-label doses in AF patients is urgently needed. Education programs concerning the appropriate prescription of DOACs within the drug labels and accepted guidelines are necessary to DOAC prescribers to ensure the safety and effectiveness of anticoagulation therapy for patients with AF.

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