Adherence to oral anticoagulants in patients with non-valvular atrial fibrillation: the role of patients’ characteristics and out-of-pocket payments

ABSTRACT

Background

Recent practice guidelines favor direct oral anticoagulants (DOACs) over warfarin for primary stroke prevention in patients with non-valvular atrial fibrillation (NVAF). However, challenges persist in Iraq’s private pharmaceutical sector. DOACs have been sold at high and inconsistent retail prices and lack insurance coverage, leading to significant out-of-pocket (OOP) costs. The objective of this study is to investigate the impact of OOP costs on oral anticoagulants (OAC) adherence among NVAF patients.

Research design and methods

This multicenter cross-sectional study interviewed 359 eligible patients attending three private cardiology clinics within Iraq’s southern region from December 2022 to February 2023. The 8-item Morisky Adherence Scale evaluated patient adherence. Statistical analyses, including descriptive analysis, ANOVA, and chi-square. p < 0.05 was considered statistically significant.

Results

The most frequently prescribed OAC were DOACs (62.8%). Patient adherence level to OAC was chiefly medium (54.6%) with no significant difference in adherence based on OAC type. Patient adherence was significantly associated with monthly income (p = 0.001), number of daily pills (p = 0.006), and OACs’ average monthly cost (p = 0.011).

Conclusion

Addressing the issue of cost-related non-adherence to OACs requires multiple actions. These include ensuring comprehensive health insurance coverage for OACs, increasing the use of affordable generic alternatives, and establishing effective cost-related discussions between healthcare providers and patients.

KEYWORDS:

• Atrial fibrillation
• direct oral anticoagulants
• warfarin
• out-of-pocket cost
• adherence
• Morisky Adherence Scale (MMAS-8)

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Acknowledgments

We would like to thank Dr. Maha Almohamad for her assistance in proofreading this paper. Her valuable feedback significantly improved the clarity of the manuscript.

Author contributions

S Al-Obaidi and I Alabbadi conceived the idea of the study and designed the initial proposal. R Ηijazeen and R Arabyat helped in refining the idea. S Al-Obaidi performed the interviews and collected the data. S Al-Obaidi performed data analysis and interpretation. I Alabbadi, R Ηijazeen and R Arabyat provided critical feedback on statistical analysis and interpretation of results. R Ηijazeen wrote the manuscript with input from all other authors. R Arabyat, I Alabbadi. and S Al-Obaidi substantially revised and critically reviewed the article. All authors agreed on the journal selection and submission. All authors reviewed and approved the final version of the manuscript. All authors agreed to take responsibility and be accountable for the content of the article and to share responsibility to resolve any questions raised about the accuracy or integrity of the published work.

Data availability statement

The data that was used to generate the results of this study are available upon request from the corresponding author R Arabyat.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.