ATRIAL FIBRILLATION PATIENTS' REAL-WORLD PERSISTENCE WITH ORAL ANTICOAGULANTS: A RETROSPECTIVE CANADIAN COHORT
CCC ePoster Library. Loewen P. 10/26/19; 280507; 242
Dr. Peter Loewen
Dr. Peter Loewen
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Abstract
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BACKGROUND: Oral anticoagulants (OACs) can prevent debilitating and fatal strokes in patients with atrial fibrillation (AF). International evidence, however, suggests that more than half of AF patients prescribed OACs stop taking them within the first three years of therapy. Our objective was to compare Canadian AF patients' real-world persistence between OACs.

METHODS AND RESULTS: Using linked, population-based administrative data containing physician billings, hospitalization and prescription records of 4.8 million British Columbians, incident adult cases of AF between 1996 and 2016 were identified. Incident nonpersistence was defined as a patient exceeding a permissible gap of 100 days in their OAC supply, where the last day of supply was calculated as the date of the previous prescription fill plus the number of days of medication supplied. Because the daily dose of warfarin users was unknown, we developed and validated a novel method to accurately estimate the number of days of supplied from patient-specific fill history. Kaplan‐Meier curves were used to plot the probability of persistence over time, stratified by first OAC. Cox regression models were used to estimate the hazard ratio (HR) of discontinuation, while adjusting for sex, socioeconomic status (SES), stroke risk, age at first qualifying prescription, and calendar time. OAC type was included as a time-varying covariate to account for those who switched between OACs. Analyses were restricted to individuals with index date after 2013, the year when all four OAC options became available. We identified 39,078 [mean age: 69.25 (SD11.4), 55% male] eligible patients. A majority of the cohort was initiated on warfarin (75%), had SES score of < 3 (56%), and CHA2DS2-VASc score of >2 (95%). A total of 3,014 nonpersistence events were detected from 2013-16. Nonpersistence events were observed most frequently among those initiated on rivaroxaban (36% of total initiated on rivaroxaban), followed by dabigatran (36%) and apixaban (21%). Compared to warfarin, patients on dabigatran or rivaroxaban were more likely to be nonpersistent (adjusted HR [aHR]:1.28, 95% CI: 1.13-1.46 and 1.29, 95% CI: 1.19-1.41, respectively; p < 0.0001 for both), while those on apixaban were less likely to be nonpersistent (aHR: 0.89, 95% CI: 0.79-1.00; p=0.05).

CONCLUSION: Compared with warfarin, patients on apixaban were more likely to be persistent, and patients on rivaroxaban and dabigatran were less likely to be persistent, after adjustment for significant patient characteristics.
BACKGROUND: Oral anticoagulants (OACs) can prevent debilitating and fatal strokes in patients with atrial fibrillation (AF). International evidence, however, suggests that more than half of AF patients prescribed OACs stop taking them within the first three years of therapy. Our objective was to compare Canadian AF patients' real-world persistence between OACs.

METHODS AND RESULTS: Using linked, population-based administrative data containing physician billings, hospitalization and prescription records of 4.8 million British Columbians, incident adult cases of AF between 1996 and 2016 were identified. Incident nonpersistence was defined as a patient exceeding a permissible gap of 100 days in their OAC supply, where the last day of supply was calculated as the date of the previous prescription fill plus the number of days of medication supplied. Because the daily dose of warfarin users was unknown, we developed and validated a novel method to accurately estimate the number of days of supplied from patient-specific fill history. Kaplan‐Meier curves were used to plot the probability of persistence over time, stratified by first OAC. Cox regression models were used to estimate the hazard ratio (HR) of discontinuation, while adjusting for sex, socioeconomic status (SES), stroke risk, age at first qualifying prescription, and calendar time. OAC type was included as a time-varying covariate to account for those who switched between OACs. Analyses were restricted to individuals with index date after 2013, the year when all four OAC options became available. We identified 39,078 [mean age: 69.25 (SD11.4), 55% male] eligible patients. A majority of the cohort was initiated on warfarin (75%), had SES score of < 3 (56%), and CHA2DS2-VASc score of >2 (95%). A total of 3,014 nonpersistence events were detected from 2013-16. Nonpersistence events were observed most frequently among those initiated on rivaroxaban (36% of total initiated on rivaroxaban), followed by dabigatran (36%) and apixaban (21%). Compared to warfarin, patients on dabigatran or rivaroxaban were more likely to be nonpersistent (adjusted HR [aHR]:1.28, 95% CI: 1.13-1.46 and 1.29, 95% CI: 1.19-1.41, respectively; p < 0.0001 for both), while those on apixaban were less likely to be nonpersistent (aHR: 0.89, 95% CI: 0.79-1.00; p=0.05).

CONCLUSION: Compared with warfarin, patients on apixaban were more likely to be persistent, and patients on rivaroxaban and dabigatran were less likely to be persistent, after adjustment for significant patient characteristics.
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