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Published on: October 12, 2012
Evaluating the Initiation of Novel Oral Anticoagulants in Medicare Beneficiaries
Seo Hyon Baik1, Inmaculada Hernandez2, Yuting Zhang3
11 Staff Scientist, Lister Hill National Center for Biomedical Communications, National Library of Medicine, Bethesda, Maryland.
Background:
As alternatives to warfarin, 2 novel oral anticoagulants (NOACs), dabigatran and rivaroxaban, were approved in 2010 and 2011 to prevent stroke and other thromboembolic events in patients with atrial fibrillation. It is unclear how patient characteristics are associated with the initiation of anticoagulants.
Objective:
To evaluate how patient demographics, clinical characteristics, types of insurance, and patient out-of-pocket spending affect the initiation of warfarin and 2 NOACs--dabigatran and rivaroxaban.
Methods:
We used pharmacy claims data from a 5% random sample of Medicare beneficiaries to identify patients who were newly diagnosed with atrial fibrillation between October 1, 2010, and October 31, 2012, and who were prescribed an oral anticoagulant within 60 days of diagnosis. We identified key predictors of initiation of NOACs using a multinomial logistic regression model with generalized logit link.
Results:
Patients who were black and who had a history of acute myocardial infarction, stroke or transient ischemic attack, chronic kidney disease, or congestive heart failure were significantly associated with lower odds of receiving NOACs compared with warfarin. Age greater than 65 years, a history of hypertension, and use of nonsteroidal anti-inflammatory drugs were positively associated with the initiation of NOACs. Rivaroxaban was most likely to be initiated among women, followed by warfarin and dabigatran. Individuals receiving a low-income subsidy were more likely to initiate warfarin than NOACs, even though they paid little copayment. Individuals with supplemental Part D drug coverage, such as national Programs for All-Inclusive Care for the Elderly or employer-sponsored plans, were more likely to initiate NOACs compared with warfarin.
Conclusions:
We found that race, sex, type of Part D plans, and some clinical conditions were associated with the initiation of NOACs relative to warfarin. But patient demographic and clinical characteristics did not appear to affect which particular NOAC patients initiated.
Insights
Patient characteristics like race and clinical conditions influence the choice between novel oral anticoagulants (NOACs) and warfarin for atrial fibrillation. However, specific NOAC choice was not affected by these factors.
Area of Science:
- Pharmacoeconomics and Health Services Research
- Cardiovascular Medicine
- Health Outcomes Research
Background:
- Novel oral anticoagulants (NOACs), including dabigatran and rivaroxaban, emerged as alternatives to warfarin for preventing thromboembolic events in atrial fibrillation patients.
- Understanding the factors influencing the initiation of these anticoagulants is crucial for optimizing patient care and resource allocation.
Purpose of the Study:
- To investigate the impact of patient demographics, clinical characteristics, insurance types, and out-of-pocket spending on the initiation of warfarin versus NOACs.
- To identify predictors associated with the choice between warfarin and NOACs in a Medicare population.
Main Methods:
- Analysis of pharmacy claims data from a 5% random sample of Medicare beneficiaries diagnosed with atrial fibrillation.
- Identification of patients newly prescribed an oral anticoagulant within 60 days of diagnosis.
- Application of multinomial logistic regression with a generalized logit link to determine key predictors of NOAC initiation.
Main Results:
- Black patients and those with a history of myocardial infarction, stroke/TIA, chronic kidney disease, or heart failure showed lower odds of receiving NOACs compared to warfarin.
- Older age (>65), hypertension history, and NSAID use were positively associated with NOAC initiation.
- Women were most likely to initiate rivaroxaban, followed by warfarin and dabigatran. Low-income subsidy recipients favored warfarin, while those with supplemental Part D coverage favored NOACs.
Conclusions:
- Race, sex, Part D plan type, and specific clinical conditions significantly influence the choice between NOACs and warfarin.
- Patient demographic and clinical factors did not appear to affect the selection of a specific NOAC (dabigatran vs. rivaroxaban).
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