Geographic Variation in Persistence of Oral Anticoagulant Treatment Among Patients with Non-Valvular Atrial Fibrillation in the United States

Background/Objectives: Geographical variations in outcomes and oral anticoagulant (OAC) initiation among patients with nonvalvular atrial fibrillation (NVAF) in the United States (US) have been characterized; however, regional effects on OAC persistence are unknown. The study described variation in persistence with OACs among patients with NVAF across different US regions. Methods: The Komodo Healthcare Map was used to evaluate adult patients with NVAF, elevated stroke risk, and ≥1 pharmacy claim for an OAC between 1 January 2015 and 31 August 2022. Patients initiating treatment with an OAC (treatment-naïve) and having ≥12 months continuous enrollment were included. Persistence rates were assessed at 6, 9, 12 and 18 months among OAC- and direct OAC (DOAC)-naïve patients by 3-digit zip codes. Results: Of the 260,001 (Northeast = 72,507, Midwest = 59,979, South = 83,880, West = 42,778, Other/Unknown = 857) OAC-naïve patients identified, 82.2% were DOAC-naïve while 17.8% initiated warfarin. Mean follow-up time was 1101 (median = 964) and 1073 days (median = 938) in OAC and DOAC cohorts, respectively, while mean time to discontinuation was 342 (median = 190) and 329 days (median = 181), respectively. At 12 months, persistence rates ranged from 40.3% to 78.8% for OAC-naïve patients and 40.6% to 81.4% for DOAC-naïve patients. Average OAC and DOAC 12-month persistence rates were highest in the Northeast (63.5% and 63.7%, respectively) and lowest in the South (57.1% and 56.9%, respectively). Conclusions: Variations in 12-month persistence were consistent with existing evidence on geographic variation in NVAF-related disease burden and treatment initiation. Understanding geographic trends in prescribing patterns may provide insights into differences in treatment persistence that are relevant for clinicians seeking to address real-world barriers to care.