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Original article
Adherence and persistence to direct oral anticoagulants in atrial fibrillation: a population-based study
  1. Amitava Banerjee1,2,
  2. Valerio Benedetto3,
  3. Philip Gichuru4,
  4. Jane Burnell2,
  5. Sotiris Antoniou5,
  6. Richard J Schilling6,
  7. William David Strain7,
  8. Ronan Ryan8,
  9. Caroline Watkins3,
  10. Tom Marshall8,
  11. Chris J Sutton9
  1. 1 Institute of Health Informatics, University College London, London, UK
  2. 2 School of Health Sciences, University of Central Lancashire, Preston, UK
  3. 3 Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom
  4. 4 Edge Hill University, Ormskirk, UK
  5. 5 Barts Health NHS Trust, London, UK
  6. 6 Department of Cardiology, Barts and The London NIHR Cardiovascular Biomedical Research Unit and The William Harvey Research Institute, London, UK
  7. 7 Diabetes and Vascular Medicine Research, University of Exeter, Exeter, UK
  8. 8 Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
  9. 9 Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
  1. Correspondence to Dr Amitava Banerjee, Institute of Health Informatics, University College London, London WC1E 6BT, UK; ami.banerjee{at}ucl.ac.uk

Abstract

Background Despite simpler regimens than vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF), adherence (taking drugs as prescribed) and persistence (continuation of drugs) to direct oral anticoagulants are suboptimal, yet understudied in electronic health records (EHRs).

Objective We investigated (1) time trends at individual and system levels, and (2) the risk factors for and associations between adherence and persistence.

Methods In UK primary care EHR (The Health Information Network 2011–2016), we investigated adherence and persistence at 1 year for oral anticoagulants (OACs) in adults with incident AF. Baseline characteristics were analysed by OAC and adherence/persistence status. Risk factors for non-adherence and non-persistence were assessed using Cox and logistic regression. Patterns of adherence and persistence were analysed.

Results Among 36 652 individuals with incident AF, cardiovascular comorbidities (median CHA2DS2VASc[Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category] 3) and polypharmacy (median number of drugs 6) were common. Adherence was 55.2% (95% CI 54.6 to 55.7), 51.2% (95% CI 50.6 to 51.8), 66.5% (95% CI 63.7 to 69.2), 63.1% (95% CI 61.8 to 64.4) and 64.7% (95% CI 63.2 to 66.1) for all OACs, VKA, dabigatran, rivaroxaban and apixaban. One-year persistence was 65.9% (95% CI 65.4 to 66.5), 63.4% (95% CI 62.8 to 64.0), 61.4% (95% CI 58.3 to 64.2), 72.3% (95% CI 70.9 to 73.7) and 78.7% (95% CI 77.1 to 80.1) for all OACs, VKA, dabigatran, rivaroxaban and apixaban. Risk of non-adherence and non-persistence increased over time at individual and system levels. Increasing comorbidity was associated with reduced risk of non-adherence and non-persistence across all OACs. Overall rates of ‘primary non-adherence’ (stopping after first prescription), ‘non-adherent non-persistence’ and ‘persistent adherence’ were 3.5%, 26.5% and 40.2%, differing across OACs.

Conclusions Adherence and persistence to OACs are low at 1 year with heterogeneity across drugs and over time at individual and system levels. Better understanding of contributory factors will inform interventions to improve adherence and persistence across OACs in individuals and populations.

  • atrial fibrillation
  • anticoagulant
  • adherence
  • persistence
  • stroke
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Footnotes

  • Contributors The study was conceived by AB. VB, PG, JB, AB and CJS wrote the statistical analysis plan, carried out the analysis, collected the data and produced the initial draft of the manuscript. AB was guarantor. All authors contributed to the revision of the manuscript and have accepted the final version.

  • Funding The research leading to these results has received funding from the European Research Council under the European Union’s Seventh Framework Programme (FP/2007-2013)/ERC Grant Agreement no. 339239. WDS was supported by the NIHR Exeter Clinical Research Facility and the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula. CW and VB were supported by the NIHR CLAHRC North West Coast. TM is supported by the NIHR CLAHRC West Midlands.

  • Competing interests AB reports personal fees from AstraZeneca, Boehringer Ingelheim, Pfizer and Novo Nordisk. SA reports personal fees from Bayer, Boehringer Ingelheim, Pfizer/BMS and Daiichi Sankyo. RJS reports grants and personal fees from Boehringer Ingelheim; grants and personal fees from Daiichi Sankyo; grants, personal fees and non-financial support from Medtronic; grants, personal fees and non-financial support from Boston Scientific; grants, personal fees and non-financial support from Abbott Medical; and grants, personal fees and non-financial support from Biosense Webster. WDS reports grants and personal fees from Boehringer Ingelheim; grants and personal fees from Daiichi Sankyo; grants, personal fees and non-financial support from Medtronic; grants, personal fees and non-financial support from Boston Scientific; grants, personal fees and non-financial support from Abbott Medical; and grants, personal fees and non-financial support from Biosense Webster. The remaining authors have no competing interests.

  • Patient consent for publication Not required.

  • Ethics approval Research carried out using The Health Improvement Network data was approved by the NHS South-East Multicentre Research Ethics Committee (MREC) in 2003, subject to independent scientific approval. Approval for this analysis was obtained in 2015 (SRC reference number 15THIN002).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement THIN data are available upon application after Scientific Review Committee (SRC) approval through a licenced organisation. Data are not publicly available.

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