Anticoagulant Prescribing for Non‐Valvular Atrial Fibrillation in the Veterans Health Administration

Abstract

Background Direct acting oral anticoagulants ( DOAC s) theoretically could contribute to addressing underuse of anticoagulation in non‐valvular atrial fibrillation ( NVAF ). Few studies have examined this prospect, however. The potential of DOAC s to address underuse of anticoagulation in NVAF could be magnified within a healthcare system that sharply limits patients’ exposure to out‐of‐pocket copayments, such as the Veterans Health Administration ( VA ). Methods and Results We used a clinical data set of all patients with NVAF treated within VA from 2007 to 2016 (n=987 373). We examined how the proportion of patients receiving any anticoagulation, and which agent was prescribed, changed over time. When first approved for VA use in 2011, DOAC s constituted a tiny proportion of all prescriptions for anticoagulants (2%); by 2016, this proportion had increased to 45% of all prescriptions and 67% of new prescriptions. Patient characteristics associated with receiving a DOAC , rather than warfarin, included white race, better kidney function, fewer comorbid conditions overall, and no history of stroke or bleeding. In 2007, before the introduction of DOAC s, 56% of VA patients with NVAF were receiving anticoagulation; this dipped to 44% in 2012 just after the introduction of DOAC s and had risen back to 51% by 2016. Conclusions These results do not suggest that the availability of DOAC s has led to an increased proportion of patients with NVAF receiving anticoagulation, even in the context of a healthcare system that sharply limits patients’ exposure to out‐of‐pocket copayments.