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Original research
Trends in direct oral anticoagulant (DOAC) prescribing in English primary care (2014–2019)
  1. Mark Joy1,
  2. John Williams1,
  3. Subo Emanuel2,
  4. Debasish Kar1,
  5. Xuejuan Fan1,
  6. Gayathri Delanerolle1,
  7. Benjamin CT Field2,3,
  8. Christian Heiss3,
  9. Kevin G Pollock4,
  10. Belinda Sandler4,
  11. Jasleen Arora4,
  12. James P Sheppard1,
  13. Michael Feher1,
  14. FD Richard Hobbs1,
  15. Simon de Lusignan1
  1. 1Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  2. 2Department of Clinical & Experimental Medicine, University of Surrey, Guildford, UK
  3. 3Diabetes & Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
  4. 4Innovative Medicines, Bristol-Myers Squibb Pharmaceuticals Ltd, London, UK
  1. Correspondence to Prof Simon de Lusignan, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK; simon.delusignan{at}phc.ox.ac.uk

Abstract

Background In England, most prescribing of direct-acting oral anticoagulants for atrial fibrillation (AF) is in primary care. However, there remain gaps in our understanding of dosage and disparities in use. We aimed to describe trends in direct oral anticoagulant (DOAC) prescribing, including dose reduction in people with renal impairment and other criteria, and adherence.

Methods Using English primary care sentinel network data from 2014 to 2019, we assessed appropriate DOAC dose adjustment with creatinine clearance (CrCl). Our primary care sentinel cohort was a subset of 722 general practices, with 6.46 million currently registered patients at the time of this study.

Results Of 6 464 129 people in the cohort, 2.3% were aged ≥18 years with a diagnosis of AF, and 30.8% of these were prescribed vitamin K antagonist and 69.1% DOACs. Appropriate DOAC prescribing following CrCl measures improved between 2014 and 2019; dabigatran from 21.3% (95% CI 15.1% to 28.8%) to 48.7% (95% CI 45.0% to 52.4%); rivaroxaban from 22.1% (95% CI 16.7% to 28.4%) to 49.9% (95% CI 48.5% to 53.3%); edoxaban from 10.0% (95% CI 0.3% to 44.5%) in 2016 to 57.6% (95% CI 54.5% to 60.7%) in 2019; apixaban from 30.8% (95% CI 9.1% to 61.4%) in 2015 to 60.5% (95% CI 57.8% to 63.2%) in 2019.

Adherence was highest for factor Xa inhibitors, increasing from 50.1% (95% CI 47.7% to 52.4%) in 2014 to 57.8% (95% CI 57.4% to 58.2%) in 2019. Asian and black/mixed ethnicity was associated with non-adherence (OR 1.81, 95% CI 1.56 to 2.09) as was male gender (OR 1.19, 95% CI 1.15 to 1.22), higher socioeconomic status (OR 1.60, 95% CI 1.52 to 1.68), being an ex-smoker (OR 1.12, 95% CI 1.06 to 1.19) and hypertension (OR 1.07, 95% CI 1.03 to 1.17).

Conclusions The volume and quality of DOAC prescribing has increased yearly. Future interventions to augment quality of anticoagulant management should target disparities in adherence.

  • atrial fibrillation
  • medication adherence
  • general practice

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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Footnotes

  • Twitter @jamessheppard48

  • Contributors SdeL, KGP, BS, JA, SE and MJ created the study concept. GD provided study oversight. MJ, SE and XF performed statistical analysis of the data. All other coauthors were responsible for clinical discussion relating to the analysis and iterative drafting of the manuscript. SdeL and KGP are responsible for the overall content as guarantors.

  • Funding The study was supported by Bristol Myers Squibb and Pfizer.

  • Competing interests MJ, XF, JS, GD, FDRH and SdeL are employees of, and JW and MF honorary appointment at University of Oxford, which received funding from Bristol Myers Squibb and Pfizer to undertake this study. KGP, BS and JA are employees of Bristol Myers Squibb Pharmaceuticals. SE is a postgraduate doctoral student with SdeL at University of Surrey. SdeL is director of the Oxford Royal College of General Practitioners Research and Surveillance Centre and has also received funding through his university from Daiichi Sankyo for AF research. JS receives funding from the Wellcome Trust/Royal Society via a Sir Henry Dale Fellowship (ref: 211182/Z/18/Z) and an NIHR Oxford Biomedical Research Centre (BRC) Senior Fellowship. BCTF has acted as a consultant, speaker or received grants from Abbott Diabetes, AstraZeneca, Boehringer Ingelheim, Eli Lilly, GSK, Janssen, Medtronic, MSD, Napp, Novo Nordisk and Sanofi. This research was funded in part, by the Wellcome Trust (211182/Z/18/Z). For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission. FDRH acknowledges part support as director of the NIHR Applied Research Collaboration (ARC) Oxford Thames Valley, and Theme Lead of the NIHR OUH BRC. FDRH has also received occasional fees or expenses for speaking or consultancy from AZ, BI, Bayer, BMS/Pfizer and Novartis.

  • Patient and public involvement Patients and/or the public were involved in the design, conduct, reporting or dissemination plans of this research. Refer to the Methods section for further details.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.