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Effects of policy interventions on the introduction of novel oral anticoagulants in Stockholm: an interrupted time series analysis


To assess the effect of policy interventions, i.e. reimbursement decisions, guidelines, and regional recommendations, on the prescribing of oral anticoagulant treatment in patients with atrial fibrillation (AF).


Interrupted time series analyses using monthly data on all patients with a recorded diagnosis of AF newly initiated (both switchers and anticoagulant naïve patients) on either warfarin, dabigatran, rivaroxaban or apixaban in the Stockholm region from April 2011 until February 2016.


A total of 34 165 initiations in 27 942 patients were included. The publication of the European Guidelines was associated with an increase in Novel Oral Anticoagulant (NOAC) initiations of 12.5% (95% confidence interval (CI): 7.3;17.7) after 5 months. The choice between the different NOACs was mainly associated with changes in the regional recommendations with apixaban initiations increasing by 19.5% (95% CI: 16.3;22.7) 5 months after the drug was recommended as a first‐line alternative to warfarin. Dabigatran received a second‐line recommendation but decreased by ‐9.5% (95% CI: ‐12.6;‐6.4) and rivaroxaban which had no specific recommendation decreased by ‐9.2% (95% CI: ‐12.7;‐5.7%). A steady decrease in warfarin and increase in NOAC initiations was seen throughout the study period and from November 2015, AF patients were more likely to receive apixaban than any other anticoagulant, while less than 20% of the initiations were with warfarin.


After reimbursement and inclusion in the European guidelines the NOACs started gaining popularity, while changes in regional recommendations were associated with the biggest change in the prescriber's choice between the different NOACs. This article is protected by copyright. All rights reserved.

Authors:   Joris Komen, Tomas Forslund, Paul Hjemdahl, Morten Andersen, Björn Wettermark
Journal:   British Journal of Clinical Pharmacology
Year:   2016
Pages:   n/a
DOI:   10.1111/bcp.13150
Publication date:   12-Oct-2016
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