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CC BY-NC-ND 4.0 · Avicenna J Med 2021; 11(02): 93-102
DOI: 10.4103/ajm.ajm_228_20
Original Article

Patient characteristics, adherence, and costs of oral anticoagulation therapy in non-valvular atrial fibrillation using the Dubai Real-World Claims Database

Moutaz El Kadri
Sheikh Khalifa Medical City, Abu Dhabi, UAE
,
Ahmed Ghorab
Pfizer Gulf, Dubai, UAE
,
Jean Joury
Pfizer Gulf, Dubai, UAE
,
Mohamed Farghaly
Dubai Health Authority, Dubai, UAE
,
Nancy Awad
IQVIA, Dubai, UAE
,
Badarinath Chickballapur Ramachandrachar
IQVIA, Dubai, UAE
,
Ashok Natarajan
IQVIA, Dubai, UAE
› Author Affiliations
Subject Editor: Financial support and sponsorship This research was sponsored by Pfizer Gulf FZ LLC.
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Abstract

Background: Non-vitamin K antagonist oral anticoagulants (NOACs) reduce the risk of stroke in patients with non-valvular atrial fibrillation (NVAF) and have better safety profile than vitamin K antagonists (VKAs). However, there is a dearth of quality, real-world, patient data on the use of these drugs to guide healthcare policies in United Arab Emirates (UAE). Aims and Objectives: The aim is to address the knowledge gap in demographic and clinical profiles of NVAF patients on NOACs (apixaban, rivaroxaban, and dabigatran) and warfarin in UAE. Materials and Methods: This retrospective cohort analysis utilized the Dubai Real-World Claims Database to extract anonymized longitudinal data on NVAF patients with at least one NOAC or warfarin claim between January 2015 and March 2019. Data examined included comorbidities, healthcare resource utilization (HCRU), treatment adherence, and clinical events. Results: From 11,086 NVAF patients in the database, 940 patients on oral anticoagulant treatment were selected with mean age of 58.6 ± 14.7 years and 73.7% men. At baseline, the mean CHA2DS2-VASc risk score was 2.4, and the mean Deyo–Charlson comorbidity index (CCI) score was 1.6. Most patients (71%) started oral anticoagulation treatment on a standard index dose. High medication possession ratio (MPR) and proportion of days covered (PDC) were observed in 86.8% and 43.1% of the overall cohort. The mean number of HCRU claims and cost during the 180-day follow-up period was 18.5 and 9,747 USD, respectively. Warfarin users accounted for both the highest number of claims and cost, whereas apixaban accounted for the lowest figures. Time to first major bleeding was shorter for warfarin users compared with patients on NOACs. Longer times to first stroke/systemic embolism (SE) were observed for rivaroxaban and warfarin. Conclusion: This study provides important comparative insights about comorbidities, adherence, HCRU, and outcome events among NOAC and warfarin users from real-world clinical practice settings.

Keywords

Anticoagulants - atrial fibrillation - claims - healthcare resource utilization - NOAC - real-world study


Publication History

Article published online:
06 August 2021

© 2021. Syrian American Medical Society. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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  • References

  • 1 January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland Jr JC. et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons. Circulation 2019; 140: e125-51
    CrossrefPubMedGoogle Scholar
  • 2 Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W. et al ROCKET AF Investigators. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365: 883-91
    CrossrefPubMedGoogle Scholar
  • 3 Agarwal S, Hachamovitch R, Menon V. Current trial-associated outcomes with warfarin in prevention of stroke in patients with nonvalvular atrial fibrillation: A meta-analysis. Arch Intern Med 2012; 172: 623-31 discussion 631-3
    CrossrefPubMedGoogle Scholar
  • 4 Sulzgruber P, Wassmann S, Semb AG, Doehner W, Widimsky P, Gremmel T. et al. Oral anticoagulation in patients with non-valvular atrial fibrillation and a CHA2DS2-VASc score of 1: A current opinion of the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy and European Society of Cardiology Council on Stroke. Eur Heart J Cardiovasc Pharmacother 2019; 5: 171-80
    CrossrefPubMedGoogle Scholar
  • 5 Tomaselli GF, Mahaffey KW, Cuker A, Dobesh PP, Doherty JU, Eikelboom JW. et al. 2020 ACC Expert Consensus Decision Pathway on management of bleeding in patients on oral anticoagulants: A report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2020; 76: 594-622
    CrossrefPubMedGoogle Scholar
  • 6 Giugliano RP, Ruff CT, Braunwald E, Murphy SA, Wiviott SD, Halperin JL. et al ENGAGE AF-TIMI 48 Investigators. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013; 369: 2093-104
    CrossrefPubMedGoogle Scholar
  • 7 Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M. et al ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011; 365: 981-92
    CrossrefPubMedGoogle Scholar
  • 8 Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A. et al RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361: 1139-51
    CrossrefPubMedGoogle Scholar
  • 9 May GS, DeMets DL, Friedman LM, Furberg C, Passamani E. The randomized clinical trial: Bias in analysis. Circulation 1981; 64: 669-73
    CrossrefPubMedGoogle Scholar
  • 10 Viera AJ, Bangdiwala SI. Eliminating bias in randomized controlled trials: Importance of allocation concealment and masking. Fam Med 2007; 39: 132-7
    PubMedGoogle Scholar
  • 11 Kim HS, Lee S, Kim JH. Real-world evidence versus randomized controlled trial: Clinical research based on electronic medical records. J Korean Med Sci 2018; 33: e213
    CrossrefPubMedGoogle Scholar
  • 12 Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: The Euro Heart Survey on Atrial Fibrillation. Chest 2010; 137: 263-72
    CrossrefPubMedGoogle Scholar
  • 13 Mahagaonkar SB. Drug safety assessment using Dubai Real World Claims Database (DRWD), in Joint International Conference and Expo on Industrial Pharmacy & 5th Global Pharmacovigilance Summit. J Develop Drugs. 2016. April 28–29, 2016 Dubai, UAE:
    Google Scholar
  • 14 El Kadri M, Bazargani N, Farghaly M, Mohamed R, Awad N, Natarajan A. et al. Profiling clinical characteristics and treatment patterns among non-valvular atrial fibrillation patients: A real-world analysis in Dubai, United Arab Emirates. Open Med J 2019; 6: 33-41
    CrossrefGoogle Scholar
  • 15 Dubai Drug code. Dubai Health Authority [cited February 14 and 15, 2020]. Available from: https://www.eclaimlink.ae/. [Last accessed on 2019 Dec 10]
    Google Scholar
  • 16 Pisters R, Lane DA, Nieuwlaat R, De Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: The Euro Heart Survey. Chest 2010; 138: 1093-100
    CrossrefPubMedGoogle Scholar
  • 17 Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45: 613-9
    CrossrefPubMedGoogle Scholar
  • 18 Brämer GR. International Statistical Classification of Diseases and related health problems. Tenth revision. World Health Stat Q 1988; 41: 32-6
    PubMedGoogle Scholar
  • 19 Thorwarth Jr WT. CPT: An open system that describes all that you do. J Am Coll Radiol 2008; 5: 555-60
    CrossrefPubMedGoogle Scholar
  • 20 Cramer JA, Roy A, Burrell A, Fairchild CJ, Fuldeore MJ, Ollendorf DA. et al. Medication compliance and persistence: Terminology and definitions. Value Health 2008; 11: 44-7
    CrossrefPubMedGoogle Scholar
  • 21 Andrade SE, Raebel MA, Morse AN, Davis RL, Chan KA, Finkelstein JA. et al. Use of prescription medications with a potential for fetal harm among pregnant women. Pharmacoepidemiol Drug Saf 2006; 15: 546-54
    CrossrefPubMedGoogle Scholar
  • 22 Sikka R, Xia F, Aubert RE. Estimating medication persistency using administrative claims data. Am J Manag Care 2005; 11: 449-57
    PubMedGoogle Scholar
  • 23 Zubaid M, Rashed WA, Alsheikh-Ali AA, Almahmeed W, Shehab A, Sulaiman K. et al Gulf Survey of Atrial Fibrillation Events (Gulf SAFE) Investigators. Gulf Survey of Atrial Fibrillation Events (gulf SAFE): Design and baseline characteristics of patients with atrial fibrillation in the Arab Middle East. Circ Cardiovasc Qual Outcomes 2011; 4: 477-82
    CrossrefPubMedGoogle Scholar
  • 24 Martinez C, Katholing A, Wallenhorst C, Granziera S, Cohen AT, Freedman SB. Increasing incidence of non-valvular atrial fibrillation in the UK from 2001 to 2013. Heart 2015; 101: 1748-54
    CrossrefPubMedGoogle Scholar
  • 25 Proietti M, Marzona I, Vannini T, Tettamanti M, Fortino I, Merlino L. et al. Long-term relationship between atrial fibrillation, multimorbidity and oral anticoagulant drug use. Mayo Clin Proc 2019; 94: 2427-36
    CrossrefPubMedGoogle Scholar
  • 26 Saheb Sharif-Askari N, Sulaiman SA, Saheb Sharif-Askari F, Al Sayed Hussain A, Tabatabai S, Al-Mulla AA. Hospitalized heart failure patients with preserved vs. reduced ejection fraction in Dubai, United Arab Emirates: A prospective study. Eur J Heart Fail 2014; 16: 454-60
    CrossrefPubMedGoogle Scholar
  • 27 Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: Results from the National Registry of Atrial Fibrillation. JAMA 2001; 285: 2864-70
    CrossrefPubMedGoogle Scholar
  • 28 Kirchhof P, Radaideh G, Kim YH, Lanas F, Haas S, Amarenco P. et al Global XANTUS Program Investigators. Global prospective safety analysis of rivaroxaban. J Am Coll Cardiol 2018; 72: 141-53
    CrossrefPubMedGoogle Scholar
  • 29 García Rodríguez LA, Martín-Pérez M, Vora P, Roberts L, Balabanova Y, Brobert G. et al. Appropriateness of initial dose of non-vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation in the UK. BMJ Open 2019; 9: e031341
    CrossrefPubMedGoogle Scholar
  • 30 Lackner TE, Battis GN. Use of warfarin for nonvalvular atrial fibrillation in nursing home patients. Arch Fam Med 1995; 4: 1017-26
    CrossrefPubMedGoogle Scholar
  • 31 Rodríguez-Bernal CL, García-Sempere A, Hurtado I, Santa-Ana Y, Peiró S, Sanfélix-Gimeno G. Real-world adherence to oral anticoagulants in atrial fibrillation patients: A study protocol for a systematic review and meta-analysis. BMJ Open 2018; 8: e025102
    CrossrefPubMedGoogle Scholar
  • 32 Kim H, Lee YS, Kim TH, Cha MJ, Lee JM, Park J. et al. A prospective survey of the persistence of warfarin or NOAC in nonvalvular atrial fibrillation: A Comparison Study of Drugs for Symptom Control and Complication Prevention of Atrial Fibrillation (CODE-AF). Korean J Intern Med 2020; 35: 99-108
    CrossrefPubMedGoogle Scholar
  • 33 Collings SL, Lefèvre C, Johnson ME, Evans D, Hack G, Stynes G. et al. Oral anticoagulant persistence in patients with non-valvular atrial fibrillation: A cohort study using primary care data in Germany. PLoS One 2017; 12: e0185642
    CrossrefPubMedGoogle Scholar
  • 34 Franchino-Elder J, Gilligan A, Song X, Hartaigh BO, Henriques C, Sainski-Nguyen A. et al. Healthcare resource utilization among non-valvular atrial fibrillation patients who switched from warfarin to a novel oral anti-coagulant. J Cardiol Cardiovasc Sci 2019; 3: 36-46
    CrossrefGoogle Scholar
  • 35 Coleman CI, Peacock WF, Bunz TJ, Alberts MJ. Effectiveness and safety of apixaban, dabigatran, and rivaroxaban versus warfarin in patients with nonvalvular atrial fibrillation and previous stroke or transient ischemic attack. Stroke 2017; 48: 2142-9
    CrossrefPubMedGoogle Scholar
  • 36 Hylek EM, Held C, Alexander JH, Lopes RD, De Caterina R, Wojdyla DM. et al. Major bleeding in patients with atrial fibrillation receiving apixaban or warfarin: The ARISTOTLE trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation): Predictors, characteristics, and clinical outcomes. J Am Coll Cardiol 2014; 63: 2141-7
    CrossrefPubMedGoogle Scholar
  • 37 Gandhi SK, Salmon JW, Kong SX, Zhao SZ. Administrative databases and outcomes assessment: An overview of issues and potential utility. J Manag Care Spec Pharm 1999; 5: 215-22
    Google Scholar