Adherence and persistence to direct oral anticoagulants in atrial fibrillation: a population-based study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Incident non-valvular atrial fibrillation (n=36652). Intervention: Apixaban vs. Vitamin K antagonists (VKA). Primary outcome: Non-persistence at 1 year (HR 0.53, 95% CI 0.46-0.60).

Q: What does this research mean for the field?

Apixaban is associated with a 47% lower risk of non-persistence at 1 year compared to vitamin K antagonists (HR 0.53) in patients with incident atrial fibrillation, though overall adherence and persistence across oral anticoagulants remain suboptimal. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Amitava Banerjee; Valerio Benedetto; Philip Gichuru; Jane Burnell; Sotiris Antoniou; Richard J. Schilling; W. David Strain; Ronan Ryan; Caroline Watkins; Tom Marshall; Chris Sutton

doi:10.1136/heartjnl-2019-315307

October 10, 2019HeartOpen Access

Adherence and persistence to direct oral anticoagulants in atrial fibrillation: a population-based study

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Key result

Apixaban is linked to ~47% lower risk of 1-year non-persistence vs. VKAs in AF.

HR 0.53
95% CI 0.46-0.60
n=36,652

Figures

Why the study?

Despite simpler regimens than VKAs for stroke prevention in AF, adherence and persistence to direct oral anticoagulants are suboptimal and understudied in electronic health records.

Do direct oral anticoagulants improve adherence and persistence compared to vitamin K antagonists in patients with incident atrial fibrillation?

Key Points

To examine 1-year adherence and persistence trends, patterns, and risk factors for direct oral anticoagulants and vitamin K antagonists in adults with incident atrial fibrillation.
Retrospective population-based cohort study using UK primary care electronic health records from The Health Information Network (2011–2016) in adults with incident atrial fibrillation (N=36,652).
Analyzed patients prescribed vitamin K antagonists (n=25,008), dabigatran (n=1285), rivaroxaban (n=5855), or apixaban (n=4504) for 1-year adherence (proportion of days covered >80%) and persistence (prescription gap ≤90 days).
Evaluated predictors of non-adherence and non-persistence using multivariable logistic and Cox proportional hazards regression models.
One-year adherence was 55.2% (95% CI 54.6 to 55.7) for all anticoagulants, with 51.2% (95% CI 50.6 to 51.8) for vitamin K antagonists, 66.5% (95% CI 63.7 to 69.2) for dabigatran, 63.1% (95% CI 61.8 to 64.4) for rivaroxaban, and 64.7% (95% CI 63.2 to 66.1) for apixaban.
One-year persistence was 65.9% (95% CI 65.4 to 66.5) overall, measuring 63.4% (95% CI 62.8 to 64.0) for vitamin K antagonists, 61.4% (95% CI 58.3 to 64.2) for dabigatran, 72.3% (95% CI 70.9 to 73.7) for rivaroxaban, and 78.7% (95% CI 77.1 to 80.1) for apixaban.
Compared with vitamin K antagonists, adjusted odds ratios for non-adherence were 0.54 (95% CI 0.48 to 0.62) for dabigatran, 0.76 (95% CI 0.71 to 0.82) for rivaroxaban, and 0.77 (95% CI 0.71 to 0.84) for apixaban; apixaban had the lowest initial hazard of non-persistence (HR 0.53, 95% CI 0.46 to 0.60).

Study Design

Type

Cohort (n=36,652)

Multicenter

Yes

Structured PICO

Do direct oral anticoagulants improve adherence and persistence compared to vitamin K antagonists in patients with incident atrial fibrillation?

P

Population

36,652 adults with incident non-valvular atrial fibrillation in the UK, mean age 74.4 years, followed for 1 year to assess adherence and persistence to oral anticoagulants.

E

Exposure

Direct oral anticoagulants (dabigatran, rivaroxaban, apixaban)

C

Comparator

Vitamin K antagonists (VKA)

O

Outcome

Adherence (proportion of days covered >80%) and persistence (no prescription gap >90 days) at 1 year

Main Result

Hazard Ratio: 0.53 (95% CI 0.46–0.6)

Absolute Event Rate: 21.3% vs 36.6%

Adherence and persistence to oral anticoagulants in AF are suboptimal at 1 year, highlighting the need for long-term monitoring and interventions.

Limitations

Lack of dispensing data (relied on prescription data)
Missing prescription data leading to incomplete follow-up
Relatively small numbers of patients for DOACs
Inability to estimate TTR for VKA due to lack of INR data
No dispensing data (relied on prescription data)

Implication

May favor apixaban for persistence in atrial fibrillation; extends observational data but leaves outcome impact open.

Abstract

BACKGROUND: Despite simpler regimens than vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF), adherence (taking drugs as prescribed) and persistence (continuation of drugs) to direct oral anticoagulants are suboptimal, yet understudied in electronic health records (EHRs). OBJECTIVE: We investigated (1) time trends at individual and system levels, and (2) the risk factors for and associations between adherence and persistence. METHODS: In UK primary care EHR (The Health Information Network 2011-2016), we investigated adherence and persistence at 1 year for oral anticoagulants (OACs) in adults with incident AF. Baseline characteristics were analysed by OAC and adherence/persistence status. Risk factors for non-adherence and non-persistence were assessed using Cox and logistic regression. Patterns of adherence and persistence were analysed. RESULTS: VASc[Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category] 3) and polypharmacy (median number of drugs 6) were common. Adherence was 55.2% (95% CI 54.6 to 55.7), 51.2% (95% CI 50.6 to 51.8), 66.5% (95% CI 63.7 to 69.2), 63.1% (95% CI 61.8 to 64.4) and 64.7% (95% CI 63.2 to 66.1) for all OACs, VKA, dabigatran, rivaroxaban and apixaban. One-year persistence was 65.9% (95% CI 65.4 to 66.5), 63.4% (95% CI 62.8 to 64.0), 61.4% (95% CI 58.3 to 64.2), 72.3% (95% CI 70.9 to 73.7) and 78.7% (95% CI 77.1 to 80.1) for all OACs, VKA, dabigatran, rivaroxaban and apixaban. Risk of non-adherence and non-persistence increased over time at individual and system levels. Increasing comorbidity was associated with reduced risk of non-adherence and non-persistence across all OACs. Overall rates of 'primary non-adherence' (stopping after first prescription), 'non-adherent non-persistence' and 'persistent adherence' were 3.5%, 26.5% and 40.2%, differing across OACs. CONCLUSIONS: Adherence and persistence to OACs are low at 1 year with heterogeneity across drugs and over time at individual and system levels. Better understanding of contributory factors will inform interventions to improve adherence and persistence across OACs in individuals and populations.

Discussion

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Cite This Study

Banerjee et al. (2019) conducted a cohort in Incident non-valvular atrial fibrillation (n=36,652). Apixaban vs. Vitamin K antagonists (VKA) was evaluated on Non-persistence at 1 year (HR 0.53, 95% CI 0.46-0.60). Apixaban was associated with a 47% lower risk of non-persistence at 1 year compared to vitamin K antagonists (HR 0.53) in patients with incident atrial fibrillation.

synapsesocial.com/papers/6a1ff48f702b8f8c062e61c2 https://doi.org/10.1136/heartjnl-2019-315307

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Adherence and persistence to direct oral anticoagulants in atrial fibrillation: a population-based study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Adherence and persistence to direct oral anticoagulants in atrial fibrillation: a population-based study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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