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Published on: February 26, 2013
Atrial fibrillation decision support tool: Population perspective
Mark H Eckman1, Alexandru Costea2, Mehran Attari2
1Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH; Center for Health Informatics, University of Cincinnati, Cincinnati, OH.
Insights
Direct oral anticoagulants (DOACs) increase oral anticoagulant therapy (OAT) recommendations for atrial fibrillation (AF) patients. This shift to DOACs in AF management offers substantial gains in quality-adjusted life-years (QALYs).
Area of Science:
- Cardiology
- Pharmacology
- Health Economics
Background:
- Atrial fibrillation (AF) management poses challenges in appropriate thromboprophylaxis.
- Direct oral anticoagulants (DOACs) offer improved safety and comparable efficacy to warfarin.
- Assessing the net benefit of DOACs versus warfarin in real-world AF populations is crucial.
Purpose of the Study:
- To evaluate the impact of DOACs as an alternative to warfarin on the net clinical benefit of oral anticoagulant therapy (OAT).
- To analyze treatment recommendations using an updated Atrial Fibrillation Decision Support Tool (AFDST) incorporating DOACs.
- To quantify potential gains in quality-adjusted life-years (QALYs) with DOAC-guided OAT in AF patients.
Main Methods:
- Retrospective cohort study of 5,121 adult patients with nonvalvular AF.
- Utilized an updated AFDST with a decision analytic model to calculate patient-specific QALYs for different treatment strategies.
- Included inpatient and ambulatory data from an academic health center over a 1-year period (2016).
Main Results:
- DOACs as an option led to OAT recommendations for 81% of AF patients, compared to 63% with warfarin alone.
- A significant increase in OAT recommendations was observed when DOACs were available.
- Potential gain of 1,508 QALYs if all patients received AFDST-recommended thromboprophylaxis.
Conclusions:
- DOAC availability increases the proportion of AF patients recommended for OAT.
- Implementing DOACs as recommended by the AFDST can significantly improve projected QALYs in AF patients.
- DOACs represent a valuable advancement in optimizing thromboprophylaxis and net clinical benefit for AF patients.
Background:
Appropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. The recent availability of direct oral anticoagulants (DOACs) with comparable efficacy and improved safety compared with warfarin alters the balance between risk factors for stroke and benefit of anticoagulation. Our objective was to examine the impact of DOACs as an alternative to warfarin on the net benefit of oral anticoagulant therapy (OAT) in a real-world population of AF patients.
Methods:
This is a retrospective cohort study of patients with paroxysmal or persistent nonvalvular AF. We updated an Atrial Fibrillation Decision Support Tool (AFDST) to include DOACs as treatment options. The tool generates patient-specific recommendations based upon individual patient risk factor profiles for stroke and major bleeding using quality-adjusted life-years (QALYs) calculated for each treatment strategy by a decision analytic model. The setting included inpatient and ambulatory sites in an academic health center in the midwestern United States. The study involved 5,121 adults with nonvalvular AF seen for any ambulatory visit or inpatient hospitalization over the 1-year period (January through December 2016). Outcome measure was net clinical benefit in QALYs.
Results:
When DOACs are a therapeutic option, the AFDST recommends OAT for 4,134 (81%) patients and no antithrombotic therapy or aspirin for 489 (9%). A strong recommendation for OAT could not be made in 498 (10%) patients. When warfarin is the only option, OAT is recommended for 3,228 (63%) patients and no antithrombotic therapy or aspirin for 973 (19%). A strong recommendation for OAT could not be made in 920 (18%) patients. In total, 1,508 QALYs could be gained if treatment were changed to that recommended by the AFDST.
Conclusions:
Availability of DOACs increases the proportion of patients for whom oral anticoagulation therapy is recommended in a real-world cohort of AF patients and increased projected QALYs by more than 1,500 when all patients are receiving thromboprophylaxis as recommended by the AFDST compared with current treatment.
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