Real-world comparison of all-cause hospitalizations, hospitalizations due to stroke and major bleeding, and costs for non-valvular atrial fibrillation patients prescribed oral anticoagulants in a US health plan

Abstract

Aims: To compare the risk of all-cause hospitalization and hospitalizations due to stroke/systemic embolism (SE) and major bleeding, as well as associated healthcare costs for non-valvular atrial fibrillation (NVAF) patients initiating apixaban, dabigatran, rivaroxaban, or warfarin.

Materials and methods: NVAF patients initiating apixaban, dabigatran, rivaroxaban, or warfarin were selected from the OptumInsight Research Database from January 1, 2013–September 30, 2015. Propensity score matching (PSM) was performed between apixaban and each oral anticoagulant. Cox models were used to estimate the risk of stroke/SE and major bleeding. Generalized linear and 2-part models were used to compare healthcare costs.

Results: Of the 47,634 eligible patients, 8,328 warfarin-apixaban pairs, 3,557 dabigatran-apixaban pairs, and 8,440 rivaroxaban-apixaban pairs were matched. Compared to apixaban, warfarin patients were associated with a significantly higher risk of all-cause (hazard ratio [HR] = 1.30; 95% confidence interval [CI] = 1.21–1.40) as well as stroke/SE-related (HR = 1.60; 95% CI = 1.23–2.07) and major bleeding-related (HR = 1.95; 95% CI = 1.60–2.39) hospitalization; rivaroxaban patients were associated with a higher risk of all-cause (HR = 1.15; 95% CI = 1.07–1.24) and major bleeding-related hospitalization (HR = 1.71; 95% CI = 1.39–2.10); and dabigatran patients were associated with a higher risk of major bleeding hospitalization (HR = 1.46, 95% CI = 1.02–2.10). Warfarin patients had significantly higher major bleeding-related and total all-cause healthcare costs compared to apixaban patients. Rivaroxaban patients had significantly higher major bleeding-related costs compared to apixaban patients. No significant results were found for the remaining comparisons.

Limitations: No causal relationships can be concluded, and unobserved confounders may exist in this retrospective database analysis.

Conclusions: This study demonstrated a significantly higher risk of hospitalization (all-cause, stroke/SE, and major bleeding) associated with warfarin, a significantly higher risk of major bleeding hospitalization associated with dabigatran or rivaroxaban, and a significantly higher risk of all-cause hospitalization associated with rivaroxaban compared to apixaban. Lower major bleeding-related costs were observed for apixaban patients compared to warfarin and rivaroxaban patients.

Keywords:

• Cardiac arrhythmias
• anticoagulants
• major bleeding
• stroke
• costs
• cost analysis

Transparency

Declaration of funding

This work was funded by Pfizer, Inc. and Bristol-Myers Squibb.

Declaration of financial relationships

AA is an employee of the University of California, Irvine, and was a paid consultant to Bristol-Myers Squibb. AA has also served as a consultant and/or speaker for Bristol-Myers Squibb, Pfizer, Boehringer-Ingelheim, and Portola. AK and QZ are employees of STATinMED Research, a paid consultant to Pfizer in connection with this study and the development of this manuscript. KO, OD, and JT are employees of Pfizer, Inc. LV and CP are employees of Bristol-Myers Squibb.

Acknowledgments

Christopher Haddlesey of STATinMED Research provided editorial assistance in the preparation of this manuscript. Juan Du of STATinMED Research provided statistical support for this manuscript.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.