For instance, before , OAC treatment was recommended for patients at moderate to high stroke risk, and aspirin was widely used for patients at low stroke risk Camm et al. However, the guidelines used for this analysis were in use for most of the study period and are appropriate to evaluate the trends. Over the 10 years, overall OAC prescribing increased by one-third. By , There remains scope to improve OAC prescribing for AF in the primary care setting, and the reasons for withholding OAC therapy in eligible patients need to be investigated.
The datasets presented in this article are not readily available because the data analyzed in this study was obtained from MedicineInsight with the restriction of not sharing the data publicly.
Requests to access these datasets should be directed to MedicineInsight, DataGovernance nps. Requests to access the datasets should be directed to DataGovernance nps.
Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. WB participated in the study design, data preparation and manipulation, analysis and interpretation of the data and drafting and revising of the manuscript.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. We are grateful to the general practices and general practitioners that participate in MedicineInsight, and their patients who allow the use of de-identified information for MedicineInsight.
Adderley, N. Prevalence and treatment of atrial fibrillation in UK general practice from to Heart , 27— Admassie, E. Changes in oral anticoagulant prescribing for stroke prevention in patients with atrial fibrillation. Aguilar, M. Oral anticoagulants for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks. Cochrane Database Syst. Alamneh, E. The Tasmanian atrial fibrillation study: transition to direct oral anticoagulants Australian Bureau of Statistics Belconnen, Canberra: Australian Bureau of Statistics.
Significant urban areas, urban centres and localities, section of state , Belconnen, Canberra: Australian Bureau of Statistics.
Busingye, D. Camm, A. Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European society of Cardiology. Heart J. Europace 14 10 , — Connolly, S. Dabigatran versus warfarin in patients with atrial fibrillation. Novel oral anticoagulant: predicted vs actual analysis, Public release document. Google Scholar. Increased use of oral anticoagulants in patients with atrial fibrillation: temporal trends from to in Denmark.
Epidemiology of arthritis, chronic back pain, gout, osteoporosis, spondyloarthropathies and rheumatoid arthritis among 1. If you're going to have surgery or a test such as an endoscopy , make sure your doctor or surgeon is aware that you're taking anticoagulants, as you may have to stop taking them for a short time.
Speak to your GP, anticoagulant clinic or pharmacist before taking any other medicines, including prescription and over-the-counter medicines, as some medicines can affect how your anticoagulant works.
If you're taking warfarin, you'll also need to avoid making significant changes to what you normally eat and drink, as this can affect your medicine. Most anticoagulant medicines aren't suitable for pregnant women. Speak to your GP or anticoagulant clinic if you become pregnant or are planning to try for a baby while taking anticoagulants. Read more about things to consider when taking anticoagulants. Like all medicines, there's a risk of experiencing side effects while taking anticoagulants.
The main side effect is that you can bleed too easily, which can cause problems such as:. For most people, the benefits of taking anticoagulants will outweigh the risk of excessive bleeding. Read more about the side effects of anticoagulants. Page last reviewed: 26 July Next review due: 26 July Single Accounts Corporate Solutions Universities. This statistic displays the leading ten dispensed antiocoagulants and protamine in England in , by number of prescription items dispensed.
In that year, warfarin sodium was the most popular prescribed anticoagulant at approximately 6. Loading statistic Show source. Download for free You need to log in to download this statistic Register for free Already a member? Log in. Show detailed source information? Register for free Already a member?
More information. Supplementary notes. Other statistics on the topic. Matej Mikulic. For rivaroxaban, apixaban, and edoxaban, we obtained 0. This denoted a moderate association between policy and prescribing when looking at individual DOAC choice, with the highest association found for edoxaban.
Stroke is costly for both individuals and societies. In , 5. In the U. Encouraging proper anticoagulation therapy is thus an essential cornerstone of preventive strategy.
Given the importance of anticoagulation in public health, this study attempted to characterize and investigate trends in prescribing at both a local and national level. This trend could suggest a substitution effect wherein patients on warfarin are switched to DOACs.
However, there was also near-doubling of total anticoagulant prescriptions from to This suggests that the increase in DOACs could also be driven by an initiation of new patients on the medication, not just switching of existing patients. This is consistent with findings that rate of DOAC initiation has increased in recent years compared to a drop in initiation of VKAs [ 17 ].
However, to translate any research findings into real-world implementation, it is crucial to understand the variety of factors that drive local decision-making. There was wide variation in trends at the local level, with DOAC uptake ranging from Although patient demographics must play a role in this discrepancy, countless other factors could be at play. For example, knowledge of favorable clinical trial results involving DOACs could sway physician preferences.
There may be local financial incentives for either DOAC prescription [ 19 ] or warfarin monitoring [ 20 ], and pharmaceutical companies may provide local rebates that make certain anticoagulants much more cost-effective [ 21 ]. There may be carryover from secondary care. Since NICE does not recommend any anticoagulant as first-line, local recommendations may influence prescribers.
We characterized this last correlation between local policies and local prescribing practices. There were significant p values for all comparisons. However, a large number of observations—DDD values in the millions—mean even very small differences will yield p values suggesting statistical significance.
For example, warfarin interacts with a number of foods and medications, including cranberries, alcohol, many antibiotics, and ibuprofen. DOACs have few interactions. Warfarin requires routine blood monitoring, while DOACs do not. Only warfarin is recommended for the treatment of patients with valvular atrial fibrillation, defined as the presence of moderate-to-severe mitral stenosis or a mechanical heart valve [ 23 , 24 ]. The upfront cost of the two drugs is vastly different.
These differences between DOACs and VKAs impact financing, patient choice, and medical considerations, which may be the main determinants in prescribing choices rather than local policy recommendations. However, local recommendations that differentiate between the less-distinguishable DOACs may be perceived as more helpful by prescribers. This may be especially true in cases where the recommendations provide genuine insight into unique local conditions, such as a rebate received by the CCG that makes one DOAC comparatively cheaper.
Although there were relatively strong associations between anticoagulant prescribing and certain policies where they existed, our review of these policies on public formularies revealed that This—along with the negligible association found between policies and prescribing of warfarin vs DOACs—suggests that local policies cannot fully explain the geographical variation in prescribing shown by Fig.
Although existing studies have explored national trends and local variation in anticoagulation for patients with atrial fibrillation [ 7 , 17 , 26 , 27 , 28 ], this study represents the first comprehensive review of local anticoagulation policies in England.
Other studies use dedicated primary care databanks that contain more patient-level data, while we use national NHS prescribing data aggregated by CCG. The ePACT2 database does not include indications. Still, previous studies in U. Patients on anticoagulation for AF typically have a longer median treatment time than those with VTE [ 7 ], which means more doses.
It is reasonable to assume that the main driver of anticoagulant doses in our data is AF. This lack of granular patient-level data represents a trade-off with the wide coverage of the data. Our review of policies was comprehensive, classifying However, a limitation is that our review of local policies only captured a snapshot at one point in time. Although we used prescribing data from July and August that roughly coincided with data collection on policies during the same period, we could not ensure that these policies remained in effect during the entire two-month period.
Another limitation is that the study is purely observational. We can draw conclusions about correlation but not causation.
Moreover, we could not differentiate between existing patients and new patients. Perhaps the association between policy and prescribing practice is driven by initiating many new patients on the recommended DOAC, but existing patients are not being switched. In this case, our results may simply be reflective of local AF screening campaigns that recruit large numbers of new patients. The finding that local policy correlates with DOAC choice may only translate over to cases where the number of new patients shows robust growth.
This represents a barrier to uptake that policymakers should consider. Our results indicate that in the majority of CCGs, local policies as they are currently implemented do not drive choice of anticoagulant for atrial fibrillation. Future research should aim to characterize the complex influence of other possible factors, including financial and structural features of local healthcare economies.
In order to effectively encourage adoption of clinically robust, cost-efficient therapeutics, it is worthwhile for national policymakers and researchers to understand the complex factors driving local prescribing choices. This study investigates one such factor in the case of anticoagulation for atrial fibrillation: local policies. A review of policies in England and analysis of corresponding prescribing data revealed that local recommendations are indeed moderately correlated with choices between individual DOACs.
Our study provides insight into the implementation of national healthcare initiatives in local systems. CDA W. The impact of stroke. Br Med Bull. Available from. Article Google Scholar. Cost of stroke: a controlled national study evaluating societal effects on patients and their partners. Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. N Engl J Med.
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