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Abstract
Objective: Non-valvular atrial fibrillation (NVAF), a common cardiac arrhythmia, is associated with high morbidity and carries a substantial economic burden. Historically, vitamin K antagonists (VKAs; e.g. warfarin) have been used for therapy of NVAF, but recently several direct oral anticoagulants (DOACs) have been approved for prevention of stroke in patients with NVAF. This review summarizes the real-world evidence (RWE) for healthcare resource utilization (HRU) in patients receiving oral anticoagulants (VKAs and/or DOACs) for therapy of NVAF.
Methods: A PRISMA-compliant literature search assessed Medline® and Embase® databases from 1 January 2011 to 4 May 2017, and the National Health Service Economic Evaluation Database from 1 January 2011 to 31 December 2015. Publications were included if they reported observational data from real-world use of one or more anticoagulant therapies. Outcomes of interest included hospitalizations, length of stay (LOS), mortality and costs.
Results: Twenty-eight publications were included. Apixaban and dabigatran were associated with fewer bleed-related hospitalizations than warfarin. Bleed-related LOS were generally longer for warfarin than for DOACs. Bleed-related treatment costs were lower for patients receiving apixaban or receiving dabigatran than patients receiving rivaroxaban or receiving warfarin. Bleed-related mortality in patients receiving oral anticoagulation for treatment of NVAF were low across all DOACs and warfarin.
Conclusions: The limited available evidence for HRU burden among patients receiving oral anticoagulation for NVAF suggests that DOACs (particularly apixaban and dabigatran) offer some degree of benefit in terms of HRU outcomes, compared with warfarin. Further work is required to understand HRU outcomes in patients receiving DOACs.
Transparency
Declaration of interests
Bimal R. Shah is an employee and shareholder of Livongo Health and is currently a paid consultant for Medtronic and Premier Inc. Catherine Rolland and Eva Scholtus are employees of, and hold stock in, Envision Pharma Group, which received funding from BIPI in relation to the development of this manuscript. Ariane Batscheider is an employee of IQVIA Commercial GmbH & Co. OHG, which has received funding from BIPI in relation to the development of this manuscript. Jason N. Katz and Kent R. Nilsson have no disclosures. CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
Author contributions
The systematic search and screening of identified publications was performed by Eva Scholtus and Catherine Rolland. All authors contributed to the analysis and interpretation of the data, and revised the manuscript for intellectual content. All authors approve the final manuscript and agree to be held accountable for all aspects of this work.
Acknowledgements
The authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICMJE). BIPI was provided with the opportunity to review the manuscript for medical and scientific accuracy as well as intellectual property considerations. BIPI was not involved in the analysis, or interpretation of data or in writing the report. Writing and editorial support was provided by Martin Bell, PhD, of Envision Pharma Group, which was contracted and funded by Boehringer Ingelheim Pharmaceuticals, Inc. (BIPI).