Estimating the Impact of Adherence to Direct Oral Anticoagulants on Health Outcomes Among Patients with Atrial Fibrillation



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Suboptimal adherence to direct oral anticoagulants (DOACs) among patients with atrial fibrillation can result in worsening clinical outcomes and increased mortality risk. A critical gap in evidence showed that studies did not (1) Evaluate the adherence to DOACs using group-based trajectory modeling (GBTM); (2) Used the traditional models to evaluate the association between adherence to DOACs and clinical outcomes without addressing the time-varying confounder affected by prior exposure; (3) No economic models have compared the cost-effectiveness of DOACs by incorporating adherence. This study was developed based on the evidence gap to address the shortcomings. The primary objective was to identify the adherence trajectories of DOAC adherence. The secondary objective was to evaluate the impact of adherence to DOACs on the composite events/bleeding events using a marginal structural model. Finally, this study compared the cost-effectiveness of apixaban and rivaroxaban by incorporating real-world evidence. The study was comprised of 1,969 patients with AF. The adherence to DOACs was suboptimal among Medicare Advantage Plan beneficiaries. Only 36.8% were adherent during the follow-up. Adherence to DOACs was not significantly associated with composite events/bleeding events. After incorporating adherence to the economic model, apixaban was a cost-effective alternative to rivaroxaban from a US payers' perspective. This study gives a piece of comprehensive information regarding the importance of being adherent over a longer period of time.



Direct oral anticoagulants, Atrial fibrillation, Elderly, Adherence, Composite events, Bleeding events, Cost-effectiveness