Effects of policy interventions on the introduction of novel oral anticoagulants in Stockholm: an interrupted time series analysis

Impact of COVID-19 pandemic on road traffic injuries in Iran: An interrupted time-series analysis

INTRODUCTION

Globally, the COVID-19 pandemic has affected the number of road accidents and deaths caused by them. The present study aimed to identify the effect of this epidemic on traffic accidents and their casualties in Iran.

METHODS

In this study, Interrupted Time Series Analysis (ITSA) was used in a semi-experimental design to measure the impact of the restrictive policies of COVID-19 on road accidents. Data were collected retrospectively from the Iran Red Crescent Society data set for 31 provinces from March 2017 to February 2022. The information related to the number of road accidents, injuries, deaths, and deaths in the hospital was collected. The Newey-West method is used for estimation. Statistical analyses were carried out using R software version 3.6.1.

RESULTS

Since February 2020 in Iran, the reduction in the number of road accidents and the number of injuries and deaths in these accidents was significant at 5% but the reduction of deaths in the scene and hospital was significant at 10%. In general, for all variables, the reduction trend was established only in the first months, and then it had an upward trend.

CONCLUSION

In the early months of the COVID-19 epidemic in Iran, the number of road accidents and their casualties decreased. Policies restricting traffic, quarantine, and fines for violators can be reasons for changing people's behavior and travel patterns and also lead to a reduction in traffic accidents and fatalities. Such studies can explain the importance of the policies in changing behavioural patterns and can be used as a guide in future policies.

Reimbursement and use of oral anticoagulants during 2014-2022 - A register-based study

Background

Vitamin K antagonists, warfarin in particular, have been the mainstay of anticoagulation therapy, but their use has declined in many countries since direct oral anticoagulants (DOACs) have entered the market.

Objective

To examine utilization trends of oral anticoagulants (OACs) in Finland considering the reimbursement of DOACs and changes to national treatment guidelines for the treatment of atrial fibrillation (AF).

Methods

Both public, aggregated data on reimbursed OAC dispensations and individual-level data on electronic dispensations during 2014-2022 were applied. Data on electronic dispensations during 2015-2016 were used to study OAC initiations. Data on entitlements to reimbursement for DOACs came from public data.

Results

In 2014, there were almost 20,000 DOAC users, rising to 214,000 in 2022. The number of warfarin users declined since 2015 from over 181,000 to around 59,000 users in 2022, DOACs exceeding warfarin in the number of users in 2019. The total DOAC costs were higher than warfarin costs each year. Rivaroxaban was the most widely used DOAC during 2014-2018, and apixaban during 2019-2022. In 2015, there were more warfarin (56.7%) than DOAC (43.3%) initiators, but the result was opposite for 2016 (warfarin 39.4%, DOACs 60.6%). The number of individuals entitled to reimbursement for DOACs has increased steadily, and in 2022, there were over 196,000 individuals entitled to this reimbursement due to AF.

Conclusions

The uptake of DOACs in Finland appears to have been gradual and slower than in many other countries. During the 2010s, the treatment guidelines for AF were more cautious in recommending DOACs than the European guidelines. The use of DOACs increased as their reimbursement became less restrictive.

Time trends in atrial fibrillation-related stroke during 2001–2020 in Sweden: a nationwide, observational study

Background

Great efforts have been made to improve stroke prevention in atrial fibrillation (AF) patients. Meanwhile, incidence of AF is increasing, which may affect the share of AF-related stroke on all strokes. We aimed to examine the temporal trends in the incidence of AF-related ischemic stroke between 2001 and 2020, if it varied by use of novel oral anticoagulant drugs (NOAC), and if the relative risk of ischemic stroke associated with AF changed over time.

Methods

Data from the total Swedish population aged ≥70 years during the period 2001-2020 were used. Annual incidence rate (IR) was calculated for overall and AF-related ischemic stroke which was defined as first-ever ischemic stroke with AF diagnosed up to 5 years before, on the same day, or within 2 months after the stroke event. Cox regression models were performed to examine if the hazard ratio (HR) between AF and stroke changed over time.

Findings

While IR of ischemic strokes declined during 2001-2020, IR of AF-related ischemic stroke remained stable between 2001 and 2010 but showed a consistent decline between 2010 and 2020. The HR of ischemic stroke within 3 years from an AF diagnosis came down from 2.39 (95% confidence interval: 2.31-2.48) to 1.54 (1.48-1.61) over the study period, which was largely explained by a substantial increase in the use of NOAC among AF patients after 2012. Yet, by the end of 2020, 24% of all ischemic strokes had a preceding or concurrent AF diagnosis, which is slightly higher than in 2001.

Interpretation

Even though both the absolute and relative risk of AF-related ischemic stroke declined over the past 20 years, every fourth ischemic stroke in 2020 still had a preceding or concurrent AF diagnosis. This represents a great potential for future gains in stroke prevention among AF patients.

Funding

Swedish Research Council and Loo and Hans Osterman Foundation for Medical Research.

Rapid Detection of Apixaban by a ROTEM-Based Approach and Reversibility with Andexanet Alfa or DOAC-Stop

Background  A rapid test to detect apixaban treatment would be useful in acute situations such as major bleeding, urgent surgery, or in acute thrombosis.

Objective  This article aims to study if the viscoelastic test rotational thromboelastometry (ROTEM) can rapidly detect apixaban in whole blood using modified triggers based on factor Xa (FXa) or Russell viper venom (RVV).

Method  ROTEM clotting time (CT) was measured in samples from 40 patients on apixaban treatment, and in vitro in samples spiked with apixaban (20–500 ng/mL). Commercially available trigger Ex-tem was compared with modified triggers based on FXa or RVV. Reversibility of apixaban in the samples was studied; CT was measured with and without addition of DOAC-Stop or andexanet alfa, respectively, and the difference in CT was calculated (CT _diff ).

Results  Using FXa as trigger, we detected apixaban concentrations at 20 ng/mL and above with 100% sensitivity and 100% specificity in patient samples and in vitro. Corresponding data for Ex-tem were 92% sensitivity and 100% specificity in patients, and 94% sensitivity and 100% specificity in vitro, and for RVV 97% sensitivity and 94% specificity in patients, and 97% sensitivity and 100% specificity in vitro, respectively. CT _diff data were similar. Patient sample data were obtained within 20 minutes from sampling.

Conclusion  Apixaban at low therapeutic concentrations was detected within 20 minutes, and with high sensitivity and specificity. A trigger based on FXa outperformed the commercial trigger Ex-tem and a trigger based on RVV. ROTEM with a FXa-based trigger is a promising method to detect apixaban bedside in acute settings.

The effect of COVID-19 on public hospital revenues in Iran: An interrupted time-series analysis

BACKGROUND

The "Coronavirus Disease 2019" (COVID-19) pandemic has become a major challenge for all healthcare systems worldwide, and besides generating a high toll of deaths, it has caused economic losses. Hospitals have played a key role in providing services to patients and the volume of hospital activities has been refocused on COVID-19 patients. Other activities have been limited/repurposed or even suspended and hospitals have been operating with reduced capacity. With the decrease in non-COVID-19 activities, their financial system and sustainability have been threatened, with hospitals facing shortage of financial resources. The aim of this study was to investigate the effects of COVID-19 on the revenues of public hospitals in Lorestan province in western Iran, as a case study.

METHOD

In this quasi-experimental study, we conducted the interrupted time series analysis to evaluate COVID-19 induced changes in monthly revenues of 18 public hospitals, from April 2018 to August 2021, in Lorestan, Iran. In doing so, public hospitals report their earnings to the University of Medical Sciences monthly; then, we collected this data through the finance office.

RESULTS

Due to COVID-19, the revenues of public hospitals experienced an average monthly decrease of $172,636 thousand (P-value = 0.01232). For about 13 months, the trend of declining hospital revenues continued. However, after February 2021, a relatively stable increase could be observed, with patient admission and elective surgeries restrictions being lifted. The average monthly income of hospitals increased by $83,574 thousand.

CONCLUSION

COVID-19 has reduced the revenues of public hospitals, which have faced many problems due to the high costs they have incurred. During the crisis, lack of adequate fundings can damage healthcare service delivery, and policymakers should allocate resources to prevent potential shocks.

Adherence to Direct Oral Anticoagulants in Patients With Non-Valvular Atrial Fibrillation: A Cross-National Comparison in Six European Countries (2008-2015)

Aims: To describe and compare the adherence to different direct oral anticoagulants (DOACs) in eight European databases representing six countries. Methods: Longitudinal drug utilization study of new users (≥18 years) of DOACs (dabigatran, rivaroxaban, apixaban) with a diagnosis of non-valvular atrial fibrillation (2008-2015). Adherence was examined by estimating persistence, switching, and discontinuation rates at 12 months. Primary non-adherence was estimated in BIFAP and SIDIAP databases. Results: The highest persistence rate was seen for apixaban in the CPRD database (81%) and the lowest for dabigatran in the Mondriaan database (22%). The switching rate for all DOACs ranged from 2.4 to 13.1% (Mondriaan and EGB databases, respectively). Dabigatran had the highest switching rate from 5.0 to 20.0% (Mondriaan and EGB databases, respectively). The discontinuation rate for all DOACs ranged from 16.0 to 63.9% (CPRD and Bavarian CD databases, respectively). Dabigatran had the highest rate of discontinuers, except in the Bavarian CD and AOK NORDWEST databases, ranging from 23.2 to 64.6% (CPRD and Mondriaan databases, respectively). Combined primary non-adherence for examined DOACs was 11.1% in BIFAP and 14.0% in SIDIAP. There were differences in population coverage and in the type of drug data source among the databases. Conclusion: Despite the differences in the characteristics of the databases and in demographic and baseline characteristics of the included population that could explain some of the observed discrepancies, we can observe a similar pattern throughout the databases. Apixaban was the DOAC with the highest persistence. Dabigatran had the highest proportion of discontinuers and switchers at 12 months in most databases (EMA/2015/27/PH).

Secondary Stroke Prevention After Ischemic Stroke in Patients with Alzheimer's Disease and Other Dementia Disorders

Background:

Recurrent ischemic stroke (IS) increases the risk of cognitive decline. To lower the risk of recurrent IS, secondary prevention is essential.

Objective:

Our aim was to compare post-discharge secondary IS prevention and its maintenance up to 3 years after first IS in patients with and without Alzheimer’s disease and other dementia disorders.

Methods:

Prospective open-cohort study 2007–2014 from the Swedish national dementia registry (SveDem) and the Swedish national stroke registry (Riksstroke). Patients with dementia who experienced an IS (n = 1410; 332 [23.5%] with Alzheimer’s disease) were compared with matched non-dementia IS patients (n = 7150). We analyzed antiplatelet, anticoagulant, blood pressure lowering, and statin treatment as planned medication initiation at discharge and actual dispensation of medications at first, second, and third year post-stroke.

Results:

At discharge, planned initiation of medication was higher in patients with dementia compared to non-dementia patients for antiplatelets (OR with 95% CI for fully adjusted models 1.23 [1.02–1.48]) and lower for blood pressure lowering medication (BPLM; 0.57 [0.49–0.67]), statins (0.57 [0.50–0.66]), and anticoagulants (in patients with atrial fibrillation – AF; 0.41 [0.32–0.53]). When analysis for antiplatelets was stratified according to the presence of AF, ORs for receiving antiplatelets remained significant only in the presence of AF (in the presence of AF 1.56 [1.21–2.01], in patients without AF 0.99 [0.75–1.33]). Similar trends were observed in 1st, 2nd, and 3rd year post-stroke.

Conclusions:

Dementia was a predictor of lower statin and BPLM use. Patients with dementia and AF were more likely to be prescribed antiplatelets and less likely to receive anticoagulants.

Uninterrupted Oral Anticoagulant Therapy in Patients Undergoing Unplanned Percutaneous Coronary Intervention

OBJECTIVES

This study sought to compare interrupted and uninterrupted oral anticoagulant therapy (I-OAC vs. U-OAC) in patients on OAC undergoing percutaneous coronary intervention.

BACKGROUND

There is a paucity of data regarding the optimal peri-procedural management of OAC-treated patients.

METHODS

In the SWEDEHEART registry, all patients on OAC who were admitted acutely and underwent percutaneous coronary intervention or coronary angiography with a diagnostic procedure, from 2005 to 2017, were included. Outcomes were major adverse cardiac and cerebrovascular events (MACCE; death, myocardial infarction, or stroke) and bleeds at 120 days. Propensity score was used to adjust for the nonrandomized treatment selection.

RESULTS

The study included 6,485 patients: 3,322 in the I-OAC group and 3,163 in the U-OAC group. The cumulative incidence of MACCE was 8.2% (269 events) versus 8.2% (254 events) in the I-OAC and the U-OAC groups, respectively. The adjusted risk for MACCE did not differ between the groups (I-OAC vs. U-OAC hazard ratio: 0.89; 95% confidence interval: 0.71 to 1.12). Similarly, no difference was found in the risk for MACCE or bleeds (12.6% vs. 12.9%, adjusted hazard ratio: 0.87; 95% confidence interval: 0.70 to 1.07). The risk for major or minor in-hospital bleeds did not differ between the groups. However, U-OAC was associated with a significantly shorter duration of hospitalization: 4 (3 to 7) days versus 5 (3 to 8) days; p < 0.01.

CONCLUSIONS

I-OAC and U-OAC were associated with equivalent risk for MACCE and bleeding complications. An U-OAC strategy was associated with shorter length of hospitalization. These data support U-OAC as the preferable strategy in patients on OAC undergoing coronary intervention.

The Impact of the Social Distancing Policy on COVID-19 Incidence Cases and Deaths in Iran from February 2020 to January 2021: Insights from an Interrupted Time Series Analysis

Background: In December 2019, a viral outbreak occurred in China, and rapidly spread out worldwide. Due to the lack of immediately available vaccines and effective drugs, many policy- and decision-makers have focused on non-pharmacological methods, including social distancing. This study was aimed at assessing the effects of the implementation of this policy in Iran, one of the countries most affected by COVID-19. We conducted a quasi-experimental study, utilizing the interrupted time series analysis (ITSA) approach. Methods: We collected daily data between February 20, 2020 and January 29, 2021, through governmental websites from 954 public hospitals and healthcare settings. The Iranian government launched the social distancing policy on March 27, 2020. Statistical analyses, including ITSA, were carried out with R software Version 3.6.1 (London, UK). Results: During the study period, 1,398,835 confirmed incidence cases and 57,734 deaths occurred. We found a decrease of -179.93 (95% CI: -380.11 to -20.25, P-value=0.078) confirmed incidence cases following the implementation of the social distancing policy, corresponding to a daily decrease in the trend of -31.17 (95% CI: -46.95 to -15.40, P-value=0.08). Moreover, we found a decrease of -28.28 (95% CI: -43.55 to -13.01, P-value=0.05) deaths, corresponding to a daily decrease in the trend of -4.52 (95% CI: -5.25 to -3.78, P-value=0.003). Conclusion: The growth rate of confirmed incidence cases and deaths from COVID-19 in Iran has decreased from March 27, 2020 to January 29, 2021, after the implementation of social distancing. By implementing this policy in all countries, the burden of COVID-19 may be mitigated.

Risk of Stroke and Bleeding in Atrial Fibrillation Treated with Apixaban Compared with Warfarin

BACKGROUND

A previous FDA study reported a favorable benefit risk for apixaban compared with warfarin for stroke prevention in older non-valvular atrial fibrillation (NVAF) patients (≥ 65 years). However, it remains unclear whether this favorable benefit risk persists in other populations including younger users. We examined if a similar benefit risk was observed in the Sentinel System and if it varied by age group.

OBJECTIVE

To examine the risk of ischemic stroke, gastrointestinal (GI) bleeding, and intracranial hemorrhage (ICH) in apixaban users compared with warfarin users in Sentinel Distributed Database (SDD).

DESIGN AND PARTICIPANTS

A retrospective new user cohort study was conducted among patients, 21 years and older initiating apixaban and warfarin for NVAF, between December 28, 2012, and June 30, 2018, in the SDD.

MAIN MEASURES

Cox proportional hazard regression was used to estimate the hazard ratios (HR) and 95% confidence intervals (95% CI) for each outcome (ischemic stroke, GI bleeding, and ICH) in propensity score matched apixaban users compared with the warfarin users. Subgroup analyses by age (21-64, 65-74, and 75+ years) were conducted.

KEY RESULTS

After matching, 55.3% and 58.4% (n = 55,038) of the apixaban and warfarin users were included in the main analysis. GI bleeding was the most common outcome. The HR (95% CI) for GI bleeding, ICH, and ischemic stroke in apixaban users compared with warfarin users were 0.57 (0.50-0.66), 0.53 (0.40-0.70), and 0.56 (0.45-0.71) respectively. The reduced risk of these outcomes in apixaban compared with warfarin users persisted across age groups.

CONCLUSION

In NVAF patients of all ages initiating either apixaban or warfarin for stroke prevention in the Sentinel System, apixaban was associated with a decreased risk of GI bleeding, ICH, and ischemic stroke compared with warfarin. Among patients less than 65 years of age, apixaban use was associated with a decreased risk of GI bleeding and ischemic stroke.

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review.

OBJECTIVES

To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes.

SEARCH METHODS

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies.

MAIN RESULTS

We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend.

AUTHORS' CONCLUSIONS

The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Epidemiology and treatment of atrial fibrillation in patients with type 2 diabetes in the UK, 2001-2016

Patients with Type 2 diabetes mellitus (T2DM) have an increased risk of atrial fibrillation (AF). The current study aimed to investigate the prevalence and treatment of AF in patients with T2DM, assess the impact of direct oral anticoagulants (DOACs) introduction on oral anticoagulant (OACs) prescribing rates, and factors associated with OAC initiations in patients with T2DM and AF. The Health Improvement Network (THIN) database (2001-2016), was used to examine the annual prevalence and treatment of AF in T2DM. The impact of DOACs introduction on OAC prescribing rates were investigated using interrupted time series analysis (ITS). Factors associated with OAC initiations were also identified using multivariate logistic regression. The prevalence of AF increased from 2.7 [95% confidence intervals (CI) 2.5-2.8] in 2001 to 5.0 (4.9-5.1) in 2016 per 100 persons. OACs prescribing within 30-days of AF diagnosis increased from 21.5% in 2001 to 56.8% in 2016. ITS analysis showed that OAC prescribing increased after DOAC introduction (P < 0.001), however, no immediate change was observed (P = 0.29). T2DM patients with AF, aged 60-79, male gender and BMI ≥ 25 were more likely to receive OAC, adjusted OR 1.3 (1.2-1.5) for aged 60-79, 1.3 (1.2-1.4) for male gender and 2.0 (1.9-2.2) for BMI ≥ 25, respectively. This study highlighted an increase in prevalence of AF in patients with T2DM during the study period. Further studies are warranted to investigate factors contributing to the underuse of OAC in patients with T2DM and AF.

Factors Affecting Usage Levels and Trends of Innovative Oncology Drugs Upon and After Reimbursement Under Taiwan National Health Insurance: Interrupted Time Series Analysis

Healthcare expenditure on pharmaceuticals, especially innovative oncology drugs, is escalating. Current knowledge on this topic is largely limited to studies conducted upon reimbursement of new drugs. We investigated how endogenous factors (e.g., changed reimbursement criteria, such as an expanded indication) and exogenous factors (e.g., competing drugs) affect the level and trends of innovative oncology drug utilization in the Taiwan National Health Insurance (NHI) system, both upon reimbursement and afterward. This retrospective longitudinal study analyzed monthly data (January 2009 to December 2014) from the NHI Research Database on the consumption (prescribing volume) of 15 innovative oncology drugs reimbursed by the NHI between 2007 and 2013. Effects of endogenous and exogenous factors on drug utilization were evaluated using interrupted time series analyses. In segmented regression analyses, changed drug prescribing volume after the indication expanded (endogenous factor) was statistically significant; however, drug volume did not change significantly after prescription restrictions changed. First‐competitors and non‐first‐competitors (exogenous factors) were significantly associated with drug prescription levels or utilization rates. Taking sorafenib as an example, the post‐reimbursement drug prescribing volume did not change significantly after its therapy line changed (endogenous factor), whereas the reimbursement of first‐competitors (exogenous factor) was significantly associated with a lower level or usage rate of sorafenib. Utilization of innovative oncology drugs in Taiwan changed dramatically after NHI reimbursement, driven largely by expanded indications and new competitors. Drug utilization evaluations should investigate both endogenous and exogenous factors.

Decrease in blood donation rates in Japan: a time series analysis

OBJECTIVE

To clarify that one of the causes for the decrease in blood donation (BD) rates was the introduction of the 400 ml BD program in 1986.

METHOD

BP rates were monitored over 48 years (1965-2012) and were divided into pre- and post-intervention periods prior to analysis. An interrupted time series analysis was performed using annual data on BD rates, and the impact of the 400 ml BD program was investigated.

RESULTS

In a raw series, autoregressive integrated moving average analysis revealed a significant change in slope between the pre- and post-intervention periods in which the intervention factor was the 400 ml BD program. The parameters were as follows: intercept (initial value) = 0.315, confidence interval (CI) = (0.029, 0.601); slope (pre-intervention) = 0.316, CI = (0.293, 0.340); slope difference = -0.435, CI = (-0.462, -0.408); slope (post-intervention) = -0.119, CI = (-0.135, -0.103); all, p = 0.000; goodness-of-fit, R2 = 0.963. After adjusting for stationarity and autocorrelation, the parameters were as follows: intercept (initial value) = -0.699, CI = (-0.838, -0.560); slope (pre-intervention) = 0.136, CI = (0.085, 0.187); slope difference = -0.165, CI = (-0.247, -0.083); slope (post-intervention) = -0.029, CI = (-0.070, 0.012); all, p = 0.000 (except for slope (post-intervention), p = 0.170); goodness-of-fit, R2 = 0.930.

CONCLUSION

One of the causes for decrease in BD rates may be due to the introduction of the 400 ml BD program in Japan.

Venous thromboembolism 2011-2018 in Stockholm: a demographic study

Venous thromboembolism (VTE) is an important cause of morbidity and mortality in Western countries. The incidence rate of VTE is estimated at 1-2 cases per 1000 annually. This study was a population-based cohort study of previously treatment naïve patients with a first occurrence of venous thromboembolism (VTE), using data from the administrative health data register of the Stockholm Region 2011-2018. Data on anticoagulant treatment was taken from the Swedish Prescribed Drug Register. We also analyzed all VTE events between 2011 and 2018. Altogether 14,849 naïve incident VTE cases were identified. In 2011 the majority of patients with a first episode of VTE were prescribed warfarin versus non-vitamin K antagonist oral anticoagulants (NOACs), 1144 versus 5. In contrast in 2018, the majority of patients were treated with NOACs, 1049 versus 59 treated with warfarin. Treatment with low molecular weight heparin only decreased from 814 to 683 patients. The frequency of all VTE events in the population increased over time from 1.88/1000 to 1.93/1000 (p = 0.072), and PE diagnoses increased from 0.69/1000 to 0.76/1000 (p = 0.003). In conclusion, during 2011-2018 there has been a shift of prescription of warfarin to a clear predominance of NOACs in the treatment of VTE in the Stockholm Region, in line with current recommendations. In the clinical situation, treatment has been simplified as monitoring of warfarin has decreased substantially. PE events increased during the time period in the population even if the increase was rather modest, while all VTE events did not increase significantly.

Clinical characteristics and antithrombotic prescription in elderly hospitalized atrial fibrillation patients: A cross-sectional analysis of a Swedish single-center clinical cohort

BACKGROUND

Antithrombotic treatment represents a dilemma in elderly patients with atrial fibrillation since both risk of thromboembolism and bleeding are age-dependent complications. A paradigm shift occurred over the past 10 years when aspirin was overcome by warfarin and further by the direct oral anticoagulants. Here we present a clinical practice-based analysis of a cohort of elderly inpatient atrial fibrillation patients and investigate the influence of clinical factors in the choice of antithrombotic strategy.

METHODS

Study participants (n = 2943) are consecutive patients aged 75-104 years discharged from a Swedish university hospital with atrial fibrillation or atrial flutter as main diagnosis between November 1st 2010 and December 31st 2017. Cardiovascular risk factors, comorbidities and antithrombotic treatment at discharge were manually extracted from medical charts. A logistic regression analysis was performed to estimate predictors of the probability to receive direct oral anticoagulants (DOACs) compared to warfarin.

RESULTS

Patients aged ≥90 y (n = 446, women 73%) showed the highest prevalence of cardiovascular comorbidities and the highest bleeding and thromboembolic risk. DOACs became more commonly prescribed than warfarin in 2016/2017 across all ages. However, the probability to receive DOAC as compared to warfarin was lower in the presence of high bleeding risk (OR 0,55; 95% CI 0,40-0,77; p = 0,00) and high thromboembolic risk (OR 0,74; 95% CI 0,59-0,94; p = 0,01).

CONCLUSION

Elderly atrial fibrillation patients represent a heterogenous group where the oldest (≥90 years) show both a very high thromboembolic and bleeding risk profile. In the presence of high thromboembolic and bleeding risk, warfarin was still preferred over DOAC.

Risk factors for severe bleeding events during warfarin treatment: the influence of sex, age, comorbidity and co-medication

PURPOSE

To investigate risk factors for severe bleeding during warfarin treatment, including the influence of sex, age, comorbidity and co-medication on bleeding risk.

METHODS

Patients initiating warfarin treatment between 2007 and 2011 were identified in the nationwide Swedish Prescribed Drug Register, and diagnoses of severe bleeding were retrieved from the National Patient Register. Hazard ratios (HR) with 95% confidence intervals (CI) for severe bleeding were estimated using multiple Cox regression adjusting for indications and including covariates age, sex, comorbidities and co-medications. Interactions between sex and other covariates were investigated.

RESULTS

The study cohort included 232,624 patients ≥ 18 years (101,011 women and 131,613 men). The incidence rate of severe bleeding was 37 per 1000 person-years, lower among women than men with an adjusted HR (95% CI) of 0.84 (0.80-0.88). Incidence of bleeding increased with age, HR 2.88 (2.37-3.50) comparing age ≥ 80 to < 40 years, and comorbidities associated with the highest risk of severe bleeding were prior bleeding, HR 1.85 (1.74-1.97); renal failure, HR 1.82 (1.66-2.00); and alcohol dependency diagnosis, HR 1.79 (1.57-2.05). Other comorbidities significantly associated with bleeding events were hypertension, diabetes, peripheral vascular disease, congestive heart failure, liver failure, stroke/TIA, COPD and cancer.

CONCLUSION

Most of the well-established risk factors were found to be significantly associated with bleeding events in our study. We additionally found that women had a lower incidence of bleeding. Potential biases are selection effects, residual confounding and unmeasured frailty.

Continued vs. interrupted direct oral anticoagulants at the time of device surgery, in patients with moderate to high risk of arterial thrombo-embolic events (BRUISE CONTROL-2)

Aims

Guidelines recommend warfarin continuation rather than heparin bridging for pacemaker and defibrillator surgery, after the BRUISE CONTROL trial demonstrated an 80% reduction in device pocket haematoma with this approach. However, direct oral anticoagulants (DOACs) are now used to treat the majority of patients with atrial fibrillation. We sought to understand the best strategy to manage the DOACs at the time of device surgery and specifically hypothesized that performing device surgery without DOAC interruption would result in a reduced haematoma rate.

Methods and results

We randomly assigned patients with atrial fibrillation and CHA2DS2-VASc score ≥2, to continued vs. interrupted DOAC (dabigatran, rivaroxaban, or apixaban). The primary outcome was blindly evaluated, clinically significant device pocket haematoma: resulting in re-operation, interruption of anticoagulation, or prolonging hospital stay. In the continued arm, the median time between pre- and post-operative DOAC doses was 12 h; in the interrupted arm the median time was 72 h. Clinically significant haematoma occurred in of 7 of 328 (2.1%; 95% CI 0.9-4.3) patients in the continued DOAC arm and 7 of 334 (2.1%; 95% CI 0.9-4.3) patients in the interrupted DOAC arm (P = 0.97). Complications were uncommon, and included one stroke and one symptomatic pericardial effusion in each arm.

Conclusions

These results suggest that, dependent on the clinical scenario, either management strategy (continued DOAC or interrupted DOAC) might be reasonable, at least for patients similar to those enrolled in our trial.

Concomitant Anticoagulant and Antidepressant Therapy in Atrial Fibrillation Patients and Risk of Stroke and Bleeding

We aimed to quantify the effects of antidepressant (AD) use in oral anticoagulant (OAC)-treated patients with atrial fibrillation (AF). Using the Stockholm Healthcare database, we analyzed AF patients initiated with an OAC. Outcomes were severe bleeds and strokes and were analyzed using Cox models. We included 17,210 patients claiming warfarin and 13,385 claiming a non-vitamin K OAC. The number of patients that claimed an AD during follow-up was 4,303. Concomitant OAC and AD use was associated with increased rates of severe bleeds (4.7 vs. 2.7 per 100 person-years) compared with OAC treatment alone (adjusted hazard ratio (aHR) 1.42, confidence interval (CI): 1.12-1.80), but not significantly associated with increased stroke rates (3.5 vs. 2.1 per 100 person-years, aHR 1.23, CI: 0.93-1.62). No significant differences in risks were observed between different OAC classes or different AD classes. In conclusion, concomitant use of an OAC and an AD is associated with an increased bleeding risk.

Incidence of direct oral anticoagulant use in patients with nonvalvular atrial fibrillation and characteristics of users in 6 European countries (2008-2015): A cross-national drug utilization study

Aims

To estimate the incidence of direct oral anticoagulant drug (DOAC) use in patients with nonvalvular atrial fibrillation and to describe user and treatment characteristics in 8 European healthcare databases representing 6 European countries.

Methods

Longitudinal drug utilization study from January 2008 to December 2015. A common protocol approach was applied. Annual period incidences and direct standardisation by age and sex were performed. Dose adjustment related to change in age and by renal function as well as concomitant use of potentially interacting drugs were assessed.

Results

A total of 186 405 new DOAC users (age ≥18 years) were identified. Standardized incidences varied from 1.93–2.60 and 0.11–8.71 users/10 000 (2011–2015) for dabigatran and rivaroxaban, respectively, and from 0.01–8.12 users/10 000 (2012–2015) for apixaban. In 2015, the DOAC incidence ranged from 9 to 28/10 000 inhabitants in SIDIAP (Spain) and DNR (Denmark) respectively. There were differences in population coverage among the databases. Only 1 database includes the total reference population (DNR) while others are considered a population representative sample (CPRD, BIFAP, SIDIAP, EGB, Mondriaan). They also varied in the type of drug data source (administrative, clinical). Dose adjustment ranged from 4.6% in BIFAP (Spain) to 15.6% in EGB (France). Concomitant use of interacting drugs varied between 16.4% (SIDIAP) and 70.5% (EGB). Cardiovascular comorbidities ranged from 25.4% in Mondriaan (The Netherlands) to 82.9% in AOK Nordwest (Germany).

Conclusion

Overall, apixaban and rivaroxaban increased its use during the study period while dabigatran decreased. There was variability in patient characteristics such as comorbidities, potentially interacting drugs and dose adjustment. (EMA/2015/27/PH).

Comparative effectiveness of warfarin, dabigatran, rivaroxaban and apixaban in non-valvular atrial fibrillation: A nationwide pharmacoepidemiological study

OBJECTIVE

To compare effectiveness and safety of warfarin and the direct oral anticoagulants (DOAC) dabigatran, rivaroxaban and apixaban in non-valvular atrial fibrillation in routine care.

METHODS

From nationwide registries, we identified treatment-naïve patients initiating warfarin, dabigatran, rivaroxaban or apixaban for non-valvular atrial fibrillation from July 2013 to December 2015 in Norway. We assessed prescription duration using reverse waiting time distribution. Adjusting for confounding in a Cox proportional hazards model, we estimated one-year risks for ischemic stroke, transient ischemic attack (TIA) or systemic embolism, major or clinically relevant non-major bleeding; intracranial; gastrointestinal; and other bleeding. We censored at switch of treatment or 365 days of follow-up.

RESULTS

We included 30,820 treatment-naïve patients. Compared to warfarin, the adjusted hazard ratios (HR) for ischemic stroke, TIA or systemic embolism were 0.96 (95% CI 0.71-1.28) for dabigatran, 1.12 (95% CI 0.87-1.45) for rivaroxaban and 0.97 (95% CI 0.75-1.26) for apixaban. Corresponding hazard ratios for major or clinically relevant non-major bleeding were 0.73 (95% CI 0.62-0.86) for dabigatran, 0.97 (95% CI 0.84-1.12) for rivaroxaban and 0.71 (95% CI 0.62-0.82) for apixaban. Statistically significant differences of other safety outcomes compared to warfarin were fewer intracranial bleedings with dabigatran (HR 0.28, 95% CI 0.14-0.56), rivaroxaban (HR 0.40, 95% CI 0.23-0.69) and apixaban (HR 0.56, 95% CI 0.34-0.92); fewer gastrointestinal bleedings with apixaban (HR 0.70, 95% CI 0.52-0.93); and fewer other bleedings with dabigatran (HR 0.67, 95% CI 0.55-0.81) and apixaban (HR 0.70, 95% CI 0.59-0.83).

CONCLUSION

After 1 year follow-up in treatment-naïve patients initiating oral anticoagulation for non-valvular atrial fibrillation, all DOACs were similarly effective as warfarin in prevention of ischemic stroke, TIA or systemic embolism. Safety from bleedings was similar or better, including fewer intracranial bleedings with all direct oral anticoagulants, fewer gastrointestinal bleedings with apixaban and fewer other bleedings with dabigatran and apixaban.

Anticoagulant Prescribing for Non-Valvular Atrial Fibrillation in the Veterans Health Administration

Background

Direct acting oral anticoagulants (DOACs) theoretically could contribute to addressing underuse of anticoagulation in non‐valvular atrial fibrillation (NVAF). Few studies have examined this prospect, however. The potential of DOACs to address underuse of anticoagulation in NVAF could be magnified within a healthcare system that sharply limits patients’ exposure to out‐of‐pocket copayments, such as the Veterans Health Administration (VA).

Methods and Results

We used a clinical data set of all patients with NVAF treated within VA from 2007 to 2016 (n=987 373). We examined how the proportion of patients receiving any anticoagulation, and which agent was prescribed, changed over time. When first approved for VA use in 2011, DOACs constituted a tiny proportion of all prescriptions for anticoagulants (2%); by 2016, this proportion had increased to 45% of all prescriptions and 67% of new prescriptions. Patient characteristics associated with receiving a DOAC, rather than warfarin, included white race, better kidney function, fewer comorbid conditions overall, and no history of stroke or bleeding. In 2007, before the introduction of DOACs, 56% of VA patients with NVAF were receiving anticoagulation; this dipped to 44% in 2012 just after the introduction of DOACs and had risen back to 51% by 2016.

Conclusions

These results do not suggest that the availability of DOACs has led to an increased proportion of patients with NVAF receiving anticoagulation, even in the context of a healthcare system that sharply limits patients’ exposure to out‐of‐pocket copayments.

Secondary prevention after stroke/transient ischemic attack: A randomized audit and feedback trial

OBJECTIVES

The clinical benefits of use of secondary preventive pharmacotherapy in ischemic stroke/TIA have been previously demonstrated. A potential target for facilitating the use of recommended medications is primary care physicians. Therefore, we carried out an audit and feedback intervention aimed at primary care centers. The aim was to improve the use of secondary preventive stroke medications and diagnosis recording in ischemic stroke/TIA.

MATERIALS AND METHODS

The intervention consisted of structured, healthcare database-derived quality reports on secondary preventive medication use and diagnosis recording, sent in 2015 to half of the primary care centers in Stockholm County, with information specific to each primary care center. Medication dispensation (primary outcome) for statins, antihypertensives, antiplatelets, and anticoagulants, as well as diagnosis recording (secondary outcome), was compared between intervention centers and control centers in the 18 months following the intervention. Outcome data were derived from the healthcare databases of Stockholm County (VAL).

RESULTS

Dispensation of medications to the 12 766 patients analyzed in the study was high. Over 77% of patients used antihypertensives and antithrombotics, and 65%-68% used statins. After the intervention, no differences in medication dispensation were seen between the intervention and control centers, even after adjusting for potential confounders.

CONCLUSIONS

A simple audit and feedback intervention directed toward physicians in primary care did not improve medication dispensation to ischemic stroke/TIA patients 18 months later. Any future audit and feedback intervention aimed at improving adherence to guidelines for secondary prevention in primary care should consider multiple and continuous reminders, the graphical appeal, and widening the recipients to include patients.

Predictors of NOAC versus VKA use for stroke prevention in patients with newly diagnosed atrial fibrillation: Results from GARFIELD-AF

INTRODUCTION

A principal aim of the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) was to document changes in treatment practice for patients with newly diagnosed atrial fibrillation during an era when non-vitamin K antagonist oral anticoagulants (NOACs) were becoming more widely adopted. In these analyses, the key factors which determined the choice between NOACs and vitamin K antagonists (VKAs) are explored.

METHODS

Logistic least absolute shrinkage and selection operator regression determined predictors of NOAC and VKA use. Data were collected from 24,137 patients who were initiated on AC ± antiplatelet (AP) therapy (NOAC [51.4%] or VKA [48.6%]) between April 2013 and August 2016.

RESULTS

The most significant predictors of AC therapy were country, enrolment year, care setting at diagnosis, AF type, concomitant AP, and kidney disease. Patients enrolled in emergency care or in the outpatient setting were more likely to receive a NOAC than those enrolled in hospital (OR 1.16 [95% CI: 1.04-1.30], OR: 1.15 [95% CI: 1.05-1.25], respectively). NOAC prescribing seemed to be favored in lower-risk groups, namely, patients with paroxysmal AF, normotensive patients, and those with moderate alcohol consumption, but also the elderly and patients with acute coronary syndrome. By contrast, VKAs were preferentially used in patients with permanent AF, moderate to severe kidney disease, heart failure, vascular disease, and diabetes and with concomitant AP.

CONCLUSION

GARFIELD-AF data highlight marked heterogeneity in stroke prevention strategies globally. Physicians are adopting an individualized approach to stroke prevention where NOACs are favored in patients with a lower stroke risk but also in the elderly and patients with acute coronary syndrome.

Nonaspirin Nonsteroidal Antiinflammatory Drug Use in the Nordic Countries from a Cardiovascular Risk Perspective, 2000-2016: A Drug Utilization Study

STUDY OBJECTIVE

Evidence on the cardiotoxicity of nonaspirin nonsteroidal antiinflammatory drugs (NSAIDs), particularly diclofenac and the newer selective cyclooxygenase (COX)-2 inhibitors, has accumulated over the last decade. Our objective was to examine whether the use of NSAIDs in the Nordic countries changed with the emerging evidence, regulatory statements, and clinical guidelines advocating caution for the use of specific NSAIDs.

DESIGN

Drug utilization study.

DATA SOURCES

Nationwide wholesale statistics and prescription registries in Denmark, Finland, Iceland, Norway, and Sweden (2000-2016).

MEASUREMENTS AND MAIN RESULTS

Our main outcome measures were yearly total sales, expressed as number of sold defined daily doses (DDDs)/1000 inhabitants/day, and yearly prevalence of prescription use, expressed as number of prescription users per 1000 inhabitants. The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults. Total sales of NSAIDs increased in all countries and were highest in Iceland, with 74.3 DDDs/1000 inhabitants/day sold in 2016, followed by Finland (73.9), Sweden (54.4), Norway (43.8), and Denmark (31.8). Diclofenac use declined after 2008 in all countries but remained the most widely prescribed NSAID in Norway, with 63 prescription users/1000 inhabitants in 2016. Diclofenac sales also remained high in Iceland (12.7 DDD/1000 inhabitants/day), Norway (8.1), and Sweden (7.8). Since its introduction in 2003, the use of etoricoxib, a newer selective COX-2 inhibitor, increased in all countries except Denmark, with highest sales in Finland (6.7 DDD/1000 inhabitants/day in 2016).

CONCLUSION

Sales and prescription patterns of NSAIDs in the Nordic countries has changed along with the accumulating evidence for the cardiovascular risks of specific NSAIDs. However, given existing evidence on the cardiovascular risks associated with the use of diclofenac and etoricoxib, the persistent high use of diclofenac in Iceland, Norway, and Sweden, the persistent over-the-counter availability of diclofenac in Norway and Sweden, and the increasing use of etoricoxib in most of the Nordic countries pose a cardiovascular health concern.

Risk factors for stroke and choice of oral anticoagulant in atrial fibrillation

PURPOSE

To investigate risk factors for stroke in patients initiating oral anticoagulants for atrial fibrillation in Norway and their association with receiving DOACs versus warfarin.

METHODS

From nationwide registries, we identified naïve users initiating treatment with warfarin, dabigatran, rivaroxaban, or apixaban for atrial fibrillation from 2010 to 2015 in Norway. We studied temporal changes in the CHA₂DS₂-VASc score and its component risk factors. We used multiple logistic regressions to identify CHA₂DS₂-VASc risk factors associated with receiving DOACs versus warfarin in 2015.

RESULTS

From 2010 to 2015, the yearly number of new oral anticoagulant users increased from 7588 to 13,344. All new users initiated warfarin in 2010, while 86% initiated a DOAC in 2015. The mean CHA₂DS₂-VASc score decreased from 3.2 (SD 1.7) to 3.1 (SD 1.6) in the same period. Vascular disease (0.56 [0.49-0.63]), congestive heart failure (OR 0.65 [95% CI 0.58-0.72]), and diabetes (0.83 [0.73-0.95]) decreased the odds of receiving DOACs instead of warfarin, and ischemic stroke/transient ischemic attack/arterial thromboembolism (1.31 [1.12-1.54]), age 65-74 (1.23 [1.06-1.43]), and female sex (1.22 [1.10-1.36]) increased it. Age ≥ 75 (reference age < 65) and hypertension had no impact.

CONCLUSIONS

The uptake of DOACs was rapid and spurred an increase in new users of oral anticoagulants for atrial fibrillation from 2010 to 2015 in Norway. The mean CHA₂DS₂-VASc score did not change substantially during this period. Vascular disease, heart failure, and diabetes were associated with initiation of warfarin, and previous stroke, age 65-74 and female sex with initiation of DOACs.

Trends and Variation in Oral Anticoagulant Choice in Patients with Atrial Fibrillation, 2010-2017

OBJECTIVE

Since 2010, several non-vitamin K antagonist oral anticoagulants (NOACs) have been brought to the U.S. market, yet little is known regarding their evolving adoption for prophylaxis of atrial fibrillation (AF)-related stroke. We examined temporal trends in choice of oral anticoagulants (OACs) among incident OAC users with AF and its association with patient demographic and clinical characteristics.

METHODS

We conducted a serial cross-sectional analysis of medical and pharmacy claims for commercial and Medicare Advantage enrollees in a large, private, U.S. health plan. We identified 112,187 adults with nonvalvular AF starting OACs between October 2010 and March 2017. Multivariable logistic regression was used to examine the associations of patient characteristics with prescription of NOACs versus warfarin. Multinomial logistic regression was used to test the associations of patient characteristics with choice among NOACs.

RESULTS

The prescription of NOACs has increased dramatically since their introduction in October 2010. In the first quarter of 2017 (2017Q1), 7502 patients started OACs, of whom 78.9% used NOACs and 21.1% warfarin. For NOACs, 3.8% used dabigatran, 25.0% rivaroxaban, and 50.1% apixaban. In multivariable analyses, factors associated with choice of NOACs versus warfarin included younger age, lower stroke or bleeding risk, fewer comorbidities, higher education level or household net worth, and prescription by cardiologists (all p<0.001). There was no sex difference in likelihood of filling NOACs versus warfarin in 2010Q4-2012, but women had higher odds of starting NOACs (odds ratio = 1.19; 95% confidence interval = 1.14-1.25) in 2015-2017Q1. Among NOAC users, the odds of apixaban prescription increased with age, female sex, stroke or bleeding risk, and comorbidities (all p<0.05).

CONCLUSION

NOAC prescriptions have increased substantially among incident OAC users with nonvalvular AF, predominantly driven by increased prescription of apixaban. Warfarin and apixaban were generally preferred for elderly patients, patients with higher stroke or bleeding risk, and patients with more comorbidities.

Impact of the Health Insurance Coverage Policy on Oral Anticoagulant Prescription among Patients with Atrial Fibrillation in Korea from 2014 to 2016

BACKGROUND

To evaluate oral anticoagulant (OAC) utilization in patients with atrial fibrillation after the changes in the health insurance coverage policy in July 2015.

METHODS

We used the Health Insurance Review and Assessment Service-National Patient Samples (HIRA-NPS) between 2014 and 2016. The HIRA-NPS, including approximately 1.4 million individuals, is a stratified random sample of 3% of the entire Korean population using 16 age groups and 2 sex groups. The HIRA-NPS comprises personal and medical information such as surgical or medical treatment provided, diagnoses, age, sex, region of medical institution, and clinician characteristics. The studied drugs included non-vitamin K antagonist OACs (NOACs) such as apixaban, dabigatran, edoxaban, and rivaroxaban, and were compared with warfarin. We analyzed drug utilization pattern under three aspects: person, time, and place.

RESULTS

The number of patients with atrial fibrillation who were prescribed OACs was 3,114, 3,954, and 4,828; and the proportions of prescribed NOACs to total OACs were 5.1%, 36.2%, and 60.8% in 2014, 2015, and 2016, respectively. The growth rate of OACs prescription increased from 61.4 patients/quarter before June 2015 to 147.7 patients/quarter thereafter. These changes were predominantly in elderly individuals aged more than 70 years. The proportion of NOACs to OACs showed significant regional difference.

CONCLUSION

The change of health insurance coverage policy substantially influenced OACs prescription pattern in whole Korean region. But the impact has been significantly different among regions and age groups, which provides the evidence for developing standard clinical practice guideline on OACs use.

The changing multiple sclerosis treatment landscape: impact of new drugs and treatment recommendations

PURPOSE

The purpose of this study is to describe the utilization of disease-modifying treatments (DMTs) in relapsing-remitting multiple sclerosis (MS) and assess the impact of both the introduction of new drugs and treatment recommendations (local recommendation on rituximab use issued at the largest MS clinic in Stockholm and regional Drug and Therapeutics Committee (DTC) recommendation on how dimethyl fumarate should be used).

METHODS

Interrupted time series analyses using monthly data on all MS patients treated with DMTs in the Stockholm County, Sweden, from January 2011 to December 2017.

RESULTS

There were 4765 individuals diagnosed with MS residing in the Stockholm County from 2011 to 2017. Of these, 2934 (62%) were treated with an MS DMT. Since 2011, fingolimod, alemtuzumab, teriflunomide, dimethyl fumarate, peginterferon beta-1a, and daclizumab were introduced. Only fingolimod and dimethyl fumarate significantly impacted MS DMT utilization. In parallel, the use of rituximab off-label increased steadily, reaching 58% of all DMT-treated MS patients by the end of the study period. The local recommendation on rituximab was associated with an increase in rituximab use. The regional DTC recommendation on dimethyl fumarate was associated with a decrease in dimethyl fumarate use.

CONCLUSIONS

Three MS DMTs-fingolimod, dimethyl fumarate, and rituximab off-label-impacted MS DMT utilization in the Stockholm County. The associations between the treatment recommendations and the subsequent changes in MS DMT utilization indicate that such interventions can influence the uptake and utilization of new drugs used in the specialized care setting.

Changes in Oral Anticoagulant Prescribing for Stroke Prevention in Patients With Atrial Fibrillation

Suboptimal guideline adherence and underuse of anticoagulants in patients with atrial fibrillation (AF) have been reported worldwide. This study aimed to compare anticoagulation practice in Australia during the pre- and postdirect oral anticoagulant (DOAC) eras. Between January 2011 and July 2015, patients with nonvalvular AF (NVAF) admitted to the Royal Hobart Hospital, Tasmania, Australia, were retrospectively reviewed. The pre- and post-DOAC era cohorts included admissions from January 2011 to July 2013 and August 2013 to July 2015, respectively. Overall, 2,118 patients met our inclusion criteria. The overall rate of anticoagulation increased from 52.5% in the pre-DOAC era to 60.7% in the post-DOAC era (p <0.001). Moreover, prescribing of OACs among high-risk patients improved significantly (63.1% vs 55.2%, p = 0.001). OAC overprescribing in low-risk patients did not change significantly between the 2 cohorts (35.0% vs 42.9% in the pre- and post-DOAC eras, respectively, p = 0.59). In multivariate analysis, DOAC era (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.17 to 1.68 and CHA₂DS₂-VASc ≥2 (OR 1.95, 95% CI 1.36 to 2.80) were independent predictors of OAC prescribing in both eras and the whole study period. Conversely, aging and previous bleeding were inversely associated with OAC prescribing. In conclusion, there has been a significant increase in OAC prescribing in the post-DOAC era, potentially driven by the widespread availability of DOACs. However, OAC underuse in high-risk patients and overuse in low-risk patients was apparent throughout our study. These findings highlight the need to identify the drivers of anticoagulant underuse and overuse and address them accordingly.

Direct oral anticoagulants: analysis of worldwide use and popularity using Google Trends

BACKGROUND

Four direct oral anticoagulants (DOACs) have been approved for clinical use by many medicines regulatory agencies around the world. Due to increasing use of these drugs in routine practice, we planned an original study to investigate their worldwide diffusion using a popular Web-search engine.

METHODS

Two electronic searches were performed using Google Trends, the former using the keywords "warfarin" AND "heparin" AND "fondaparinux", and the latter using the keywords "warfarin" AND "dabigatran" AND "rivaroxaban" AND "apixaban" AND "edoxaban", both using the search criterion "prescription drug". No language restriction was applied, and the searches were carried out from the first date available in Google Trends (January 1^st, 2004) to present time (June 1^st, 2017).

RESULTS

The median Google Trends score of warfarin (i.e., 86) was consistently higher than that of heparin (54; P<0.001), fondaparinux (6; P<0.001), dabigatran (11; P<0.001), rivaroxaban (5; P<0.001), apixaban (1; P<0.001) and edoxaban (1; P<0.001). Specific analysis of the trends shows that the score of warfarin exhibits a highly significant decrease over time (r=-0.40; P<0.001), whilst that of heparin has remained virtually unchanged (r=0.12; P=0.127), and that of fondaparinux has marginally increased (r=0.16; P=0.038). As regards DOACs, the scores of these drugs significantly increased during the search period (dabigatran, r=0.79; rivaroxaban, r=0.99; apixaban, r=0.98; edoxaban, r=0.78; all P<0.001). When the analysis was limited to the past five years, the dabigatran score significantly decreased (r=-0.57; P<0.001), whereas that of the other DOACs exhibited an even sharper increase. Most Google searches for DOACs were performed in North America, central-eastern Europe and Australia.

CONCLUSIONS

The results of our analysis suggest that the popularity of DOACs is constantly increasing around the world, whereas that of warfarin has exhibited a constant and inexorable decline.

Factors associated with antithrombotic treatment decisions for stroke prevention in atrial fibrillation in the Stockholm region after the introduction of NOACs

Purpose

The purpose of this study was to investigate the influence of patient characteristics such as age and stroke and bleeding risks on decisions for antithrombotic treatment in patients with atrial fibrillation (AF).

Methods

This was a retrospective, population-based study including AF patients initiated with either warfarin, dabigatran, rivaroxaban, apixaban, or low-dose aspirin (ASA) between March 2015 and February 2016. Multivariate models were used to calculate adjusted odds ratios (aOR) for factors associated with treatment decisions.

Results

A total of 6765 newly initiated patients were included, most with apixaban (46.4%) and least with ASA (6.7%). There were more comorbidities in patients initiated with ASA or warfarin compared to the cohort average. Patients with high stroke risks had higher chances of receiving ASA (CHA₂DS₂-VASc ≥5 vs 0; aOR 2.01; 95% confidence interval (CI) 1.12–3.33). Among patients receiving oral anticoagulants, patients with high bleeding risks more often received warfarin (ATRIA score 5–10 vs 0–3; aOR 1.40; CI 1.20–1.64). Among NOACs, apixaban was preferred for patients with higher stroke risks (aOR 1.78; CI 1.31–2.41), high bleeding risks (aOR 1.54; CI 1.26–1.88) and high age (age group ≥85 vs 0–65; aOR 1.84; CI 1.44–2.35). Conversely, dabigatran treatment was associated with lower ages and lower risks.

Conclusions

High stroke and bleeding risks favored choices of warfarin or ASA. Among patients receiving NOACs, apixaban was favored for elderly and high-risk patients whereas dabigatran was used in lower risk patients. The inadvertent use of ASA, especially among those with high stroke risks, should be further discouraged.

Electronic supplementary material

The online version of this article (doi:10.1007/s00228-017-2289-0) contains supplementary material, which is available to authorized users.

High adherence to the 'Wise List' treatment recommendations in Stockholm: a 15-year retrospective review of a multifaceted approach promoting rational use of medicines

OBJECTIVES

To present the 'Wise List' (a formulary of essential medicines for primary and specialised care in Stockholm Healthcare Region) and assess adherence to the recommendations over a 15-year period.

DESIGN

Retrospective analysis of all prescription data in the Stockholm Healthcare Region between 2000 and 2015 in relation to the Wise List recommendations during the same time period.

SETTING

All outpatient care in the Stockholm Healthcare Region.

PARTICIPANTS

All prescribers in the Stockholm Healthcare Region.

MAIN OUTCOME MEASURES

The number of core and complementary substances included in the Wise List, the adherence to recommendations by Anatomic Therapeutic Chemical (ATC) 1st level using defined daily doses (DDDs) adjusted to the DDD for 2015, adherence to recommendations over time measured by dispensed prescriptions yearly between 2002 and 2015.

RESULTS

The number of recommended core substances was stable (175-212). Overall adherence to the recommendations for core medicines for all prescribers increased from 75% to 84% (2000 to 2015). The adherence to recommendations in primary care for core medicines increased from 80% to 90% (2005 to 2015) with decreasing range in practice variation (32% to 13%). Hospital prescriber adherence to core medicine recommendations was stable but increased for the combination core and complementary medicines from 77% to 88% (2007 to 2015). Adherence varied between the 4 therapeutic areas studied.

CONCLUSIONS

High and increasing adherence to the Wise List recommendations was seen for all prescriber categories. The transparent process for developing recommendations involving respected experts and clinicians using strict criteria for handling potential conflicts of interests, feedback to prescribers, continuous medical education and financial incentives are possible contributing factors. High-quality evidence-based recommendations to prescribers, such as the Wise List, disseminated through a multifaceted approach, will become increasingly important and should be developed further to include recommendations and introduction protocols for new expensive medicines.

Effects of policy interventions on the introduction of novel oral anticoagulants in Stockholm: an interrupted time series analysis

AIMS

The aim of the present study was to assess the effect of policy interventions - i.e. reimbursement decisions, guidelines and regional recommendations - on the prescribing of oral anticoagulant treatment in patients with atrial fibrillation (AF).

METHODS

Interrupted time series analyses were carried out using monthly data on all patients with a recorded diagnosis of AF newly initiated (switchers and anticoagulant-naïve patients alike) on warfarin, dabigatran, rivaroxaban or apixaban in the Stockholm region from April 2011 until February 2016.

RESULTS

A total of 34 165 initiations in 27 942 patients were included. The publication of the European Guidelines was associated with an increase in novel oral anticoagulant (NOAC) initiations of 12.5% [95% confidence interval (CI) 7.3, 17.7] after 5 months. The choice between the different NOACs was mainly associated with changes in the regional recommendations, with apixaban initiations increasing by 19.5% (95% CI 16.3, 22.7) 5 months after the drug was recommended as a first-line alternative to warfarin. Dabigatran received a second-line recommendation but initiations decreased by -9.5% (95% CI -12.6, -6.4), and initiations of rivaroxaban, which had no specific recommendation, decreased by -9.2% (95% CI -12.7, -5.7). A steady decrease in warfarin and increase in NOAC initiations was seen throughout the study period and from November 2015, AF patients were more likely to receive apixaban than any other anticoagulant, while less than 20% of the initiations were with warfarin.

CONCLUSIONS

After reimbursement and inclusion in the European guidelines, the NOACs started gaining in popularity, while changes in regional recommendations were associated with the biggest change in prescribers' choice between the different NOACs.