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Observational Study
. 2021 Nov 8;23(11):1722-1730.
doi: 10.1093/europace/euab091.

Persistence and adherence to non-vitamin K antagonist oral anticoagulant treatment in patients with atrial fibrillation across five Western European countries

Joris J Komen  1   2 , Anton Pottegård  3 , Aukje K Mantel-Teeuwisse  1 , Tomas Forslund  2   4 , Paul Hjemdahl  4 , Björn Wettermark  5 , Maja Hellfritzsch  3   6 , Jesper Hallas  3 , Morten Olesen  3 , Marion Bennie  7   8 , Tanja Mueller  7 , Annemarie Voss  9 , Tania Schink  9 , Ulrike Haug  9   10 , Bianca Kollhorst  11 , Øystein Karlstad  12 , Lars J Kjerpeseth  12 , Olaf H Klungel  1   3
Affiliations
Observational Study

Persistence and adherence to non-vitamin K antagonist oral anticoagulant treatment in patients with atrial fibrillation across five Western European countries

Joris J Komen et al. Europace. .

Abstract

Aims: To assess persistence and adherence to non-vitamin K antagonist oral anticoagulant (NOAC) treatment in patients with atrial fibrillation (AF) in five Western European healthcare settings.

Methods and results: We conducted a multi-country observational cohort study, including 559 445 AF patients initiating NOAC therapy from Stockholm (Sweden), Denmark, Scotland, Norway, and Germany between 2011 and 2018. Patients were followed from their first prescription until they switched to a vitamin K antagonist, emigrated, died, or the end of follow-up. We measured persistence and adherence over time and defined adequate adherence as medication possession rate ≥90% among persistent patients only.

Results: Overall, persistence declined to 82% after 1 year and to 63% after 5 years. When including restarters of NOAC treatment, 85% of the patients were treated with NOACs after 5 years. The proportion of patients with adequate adherence remained above 80% throughout follow-up. Persistence and adherence were similar between countries and was higher in patients starting treatment in later years. Both first year persistence and adherence were lower with dabigatran (persistence: 77%, adherence: 65%) compared with apixaban (86% and 75%) and rivaroxaban (83% and 75%) and were statistically lower after adjusting for patient characteristics. Adherence and persistence with dabigatran remained lower throughout follow-up.

Conclusion: Persistence and adherence were high among NOAC users in five Western European healthcare settings and increased in later years. Dabigatran use was associated with slightly lower persistence and adherence compared with apixaban and rivaroxaban.

Keywords: Adherence; Atrial fibrillation; Oral anticoagulants; Persistence; Stroke.

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Figures

Figure 1
Figure 1
(A) Proportion of persistent patients during follow-up overall and per country. The line is the average persistence in the five countries. The values on the x-axis represent the start of an interval. (B) Proportion of patients with an adequate adherence (i.e. MPR ≥ 90%) during follow-up overall and per country. The line is the average proportion in the five countries. The values on the x-axis represent the start of an interval.  (C) Proportion of patients on NOAC treatment, including restarts, during follow-up overall and per country. The line is the average proportion of the five countries. The values on the x-axis represent the start of an interval. MPR, medication possession rate; NOAC, non-vitamin K antagonist oral anticoagulant.
Figure 2
Figure 2
(A) Proportion of patients with at least 1 year of follow-up who were persistent after 1 year of follow-up per calendar year per country. The line is the average proportion in the five countries. (B) Proportion of patients with at least 1 year of follow-up who had a medication possession rate > 90% in their first year of follow-up per calendar year per country. The line is the average proportion from the five countries.
Figure 3
Figure 3
(A) Proportion of persistent patients during follow-up per NOAC. Patients initiated on edoxaban were excluded given the limited sample size. (B) Proportion of patients with a medication possession rate > 90% during follow-up per NOAC. Patients initiated on edoxaban were excluded given the limited sample size. NOAC, non-vitamin K antagonist oral anticoagulant.
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