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首页> 外文期刊>The American Journal of Cardiology >Factors Driving Anticoagulant Selection in Patients With Atrial Fibrillation in the United States
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Factors Driving Anticoagulant Selection in Patients With Atrial Fibrillation in the United States

机译：美国房颤患者抗凝选择的驱动因素

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With the introduction of novel oral anticoagulants (NOACs), the factors driving anticoagulant selection in atrial fibrillation (AF) in real-world practice are unclear. The goal was to examine whether and to what extent utilization has been driven by predictions of stroke risk (treatment benefit), bleeding risk (treatment harm), or prescription benefits' coverage. We extracted a cohort of patients with nonvalvular AF initiating anticoagulation from October 2010 to December 2012 from a large US database of commercial and Medicare supplement claims. Multivariable regression examined associations between ischemic stroke (CHA(2)DS(2)-VASc) and bleeding (Anticoagulation and Risk Factors in Atrial Fibrillation [ATRIA]) risk scores and benefits' generosity (proportion of costs covered by patients relative to total) with warfarin and novel oral anticoagulant (NOAC) selection and also between dabigatran and rivaroxaban. C-statistics and partial chi-square statistics were used to assess the variation explained. Of 70,498 patients initiating anticoagulation, 29.9% and 7.9% used dabigatran and rivaroxaban, respectively. Compared with warfarin, patients were less likely to receive an NOAC with high ischemic stroke risk (CHA(2)DS(2)-VASc >= 2; adjusted relative risk [aRR] 0.75, 95% confidence interval [CI] 0.72 to 0.77) and high bleeding risk (ATRIA >= 5; aRR 0.66, 95% CI 0.64 to 0.69) but more likely with good benefits' generosity (<= 20% of costs borne by patient; aRR 2.03, 95% CI 1.92 to 2.16). Prescription generosity explained almost twice the model variation as either risk score. Compared with dabigatran, patients were more likely to fill rivaroxaban with high bleeding risk (aRR 1.16, 95% CI 1.09 to 1.24). In conclusion, patients with greater bleeding and ischemic stroke risk were more likely to initiate warfarin, but generous benefits more strongly predicted NOAC usage and drove more selection. (C) 2015 Elsevier Inc. All rights reserved.
机译：随着新型口服抗凝剂（NOACs）的引入，在实际操作中驱动房颤（AF）中抗凝剂选择的因素尚不清楚。目的是检查中风风险（治疗获益），出血风险（治疗危害）或处方受益范围的预测是否以及在多大程度上推动了利用率。我们从大型的美国商业和Medicare补充声明数据库中提取了从2010年10月至2012年12月开始抗凝的非瓣膜性房颤患者队列。多变量回归检验了缺血性中风（CHA（2）DS（2）-VASc）与出血（抗凝和房颤的危险因素[ATRIA]）风险评分和获益的慷慨程度（患者所占总费用相对于总费用的比例）之间的关联使用华法令和新型口服抗凝剂（NOAC）以及达比加群和利伐沙班之间。使用C统计量和部分卡方统计量来评估所解释的差异。在70,498例开始抗凝治疗的患者中，分别有29.9％和7.9％的患者使用了达比加群和利伐沙班。与华法林相比，患者接受缺血性卒中风险较高的NOAC的可能性较小（CHA（2）DS（2）-VASc> = 2;调整后相对风险[aRR] 0.75，95％置信区间[CI] 0.72至0.77 ）和高出血风险（ATRIA> = 5; aRR 0.66，95％CI 0.64至0.69），但更有可能具有良好获益的慷慨（<=患者负担的费用的20％; aRR 2.03，95％CI 1.92至2.16） 。处方的慷慨几乎解释了模型变化的两倍，即任一风险得分。与达比加群相比，患者更容易将利伐沙班充满出血风险高（aRR 1.16，95％CI 1.09至1.24）。总之，出血和缺血性卒中风险更大的患者更可能开始使用华法林，但慷慨的益处更能强烈预测NOAC的使用并推动更多的选择。 （C）2015 Elsevier Inc.保留所有权利。

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