A four-year Italian study of direct oral anticoagulant (DOAC) use in patients with atrial fibrillation (AF) has shown that as prescription rates increased healthcare costs per patient decreased. Prescription rates for antiplatelet agents fell during the same time period. Other trends observed in the study were that the rate of admissions for ischaemic stroke decreased, while those for intracerebral haemorrhages or major bleeds did not substantially change.
Aldo Pietro Maggioni (Mario Negri Institute for Pharmacological Research, Milan, Italy) presented the findings today on behalf the investigators at the European Society of Cardiology Congress (ESC 2019; 31 August–4 September, Paris, France). He explained: “Guidelines recommend strongly the use of oral anticoagulants, while antiplatelet agents are not recommended. However, there is some data showing relatively low prescription of oral anticoagulants while antiplatelet [agents] are prescribed very frequently.”
Researchers used the longitudinal Ricerca e Salute (ReS) database of more than 12 million individuals to assess the prescription rates for antithrombotic agents, and hospitalisation rates for AF, ischaemic stroke, and major haemorrhage.
The retrospective study was conducted between January 2012 and December 2015, and looked at patients who were discharged alive with a diagnosis of primary secondary AF; 194,030 participants were followed for one year after the index date (discharge) to assess medication use and further hospitalisations. Costs to the Italian National Health Service were assessed using drug prescription reimbursements, and national tariffs for outpatient specialist services and hospitalisations.
Investigators found that approximately four out of every 1000 people in Italy are hospitalised yearly with AF, a figure that remained stable over the study period (3.98% in 2012 and 4.35% in 2015). Age and gender were also similar across 2012–2015, with mean age 77 years, and half of those studied were male.
The main causes of re-admission in the AF patients at one year were ischaemic stroke (21.3% in 2012 vs. 14.7% in 2015), acute coronary syndrome (13.9% in 2012 vs. 11.2% in 2015), and heart failure (9.6% in 2012 vs. 9.2% in 2015). The rate of haemorrhagic stroke fell from 6.5% to 4.1% during the study period, and major bleeds increased from 1.5% to 2.3%. The use of oral anticoagulants increased during that time, and by 2015 was prescribed to one-third of those with AF, and there was a marked decrease in prescriptions for antiplatelet drugs, in line with guidelines.
Maggioni said: “There was a decrease in the rate of hospitalisation for ischaemic stroke; there was a slight decrease in the rate of hospitalisation for intracranial haemorrhage; there was an increase of hospitalisation for major haemorrhages. There was a clear decrease in the use of antiplatelet [agents]; there was a clear decrease in the use of vitamin K antagonists, and a very important increase in the use of direct oral anticoagulants. The major driver of the costs is hospitalisation, both for cardiovascular and non-cardiovascular reasons. In 2015, there was a clear decrease in the costs per patient, per year for patients admitted for atrial fibrillation.”
However, Maggioni pointed out that the patient cohort was “sufficiently ill to require hospitalisation, and sufficiently strong to survive discharge”, and stressed that the study was descriptive. “This is just an association that cannot demonstrate causality,” he said.