Trends in the Use of Oral Anticoagulants for Adults With Venous Thromboembolism in the US, 2010-2020.
JAMA Netw Open
; 6(3): e234059, 2023 03 01.
Article
in En
| MEDLINE
| ID: mdl-36947039
ABSTRACT
Importance The introduction of direct oral anticoagulants (DOACs) has transformed the treatment of venous thromboembolism (VTE). Large health care databases offer valuable insight into how oral anticoagulants (OACs) are used in clinical practice and may aid in understanding reasons for changes in therapy. Objectives:
To evaluate prescribing patterns of OACs for patients with VTE and identify clinical events that precede treatment changes. Design, Setting, andParticipants:
This retrospective cohort study used data from a public (Medicare fee-for-service) and a commercial (IBM MarketScan) health insurance database on 298â¯609 patients initiating OACs within 90 days of index VTE hospitalization from January 1, 2009, to December 31, 2020. Statistical analysis was conducted from April to August 2022. Exposures Warfarin and the DOACs rivaroxaban, apixaban, dabigatran, and edoxaban. Main Outcomes andMeasures:
Characteristics of patients initiating different OACs, along with trends over time of patients initiating OACs, were compared. Time receiving continuous anticoagulant therapy, patterns of anticoagulant discontinuation (treatment gap of ≥30 days), and treatment switches were assessed. Clinical events in the 30 days preceding treatment modifications were identified.Results:
A total of 203â¯378 individuals with Medicare (mean [SD] age, 76.9 [7.6] years; 122â¯554 women [60.3%]) and 95â¯231 with commercial insurance (mean [SD] age, 57.6 [15.8] years; 47â¯139 women [49.5%]) were included (N = 298â¯609). Warfarin was the most frequent OAC prescribed (163â¯044 [54.6%]), followed by rivaroxaban (66â¯882 [22.3%]) and apixaban (65â¯997 [22.1%]). The proportion of patients initiating DOACs increased from 0% in 2010 to 86.8% (22â¯420 of 25â¯817) in 2019 for patients with Medicare and 92.1% (4012 of 4357) in 2020 for commercially insured patients. Patients with chronic kidney disease were more likely to initiate warfarin (35â¯561 [11.9%]) or apixaban (16â¯294 [5.5%]) than rivaroxaban (10â¯136 [3.4%]), and those with a history of bleeding were more likely to initiate apixaban (5424 [1.8%]) than rivaroxaban (3007 [1.0%]). Overall, patients received persistent OAC treatment for approximately 6 months (Medicare median, 175 days [IQR, 76-327 days]; commercial insurance median, 168 days [IQR, 83-279 days]). A total of 33â¯011 patients (11.1%) switched anticoagulant therapy within a year. Switching to another anticoagulant was preceded most frequently by codes for a VTE diagnostic procedure (27.2% of all switchers [8983 of 33â¯011]). Conclusions and Relevance This cohort study using data from 2 US health insurance databases suggests that most patients with VTE continued oral anticoagulant treatment for approximately 6 months. Clinical reasons for modifying anticoagulant therapy were identified in one-third of patients. Identifying reasons for treatment modification is crucial for generating valid evidence on drug safety and effectiveness.
Full text:
1
Collection:
01-internacional
Database:
MEDLINE
Main subject:
Warfarin
/
Venous Thromboembolism
Type of study:
Etiology_studies
/
Incidence_studies
/
Observational_studies
/
Prognostic_studies
/
Risk_factors_studies
Limits:
Adult
/
Aged
/
Female
/
Humans
/
Middle aged
Country/Region as subject:
America do norte
Language:
En
Journal:
JAMA Netw Open
Year:
2023
Document type:
Article