Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Dec 1;4(12):e2137288.
doi: 10.1001/jamanetworkopen.2021.37288.

Clinician Trends in Prescribing Direct Oral Anticoagulants for US Medicare Beneficiaries

Kevin M Wheelock  1 , Joseph S Ross  2   3   4 , Karthik Murugiah  2   5 , Zhenqiu Lin  2   5 , Harlan M Krumholz  2   4   5 , Rohan Khera  2   5
Affiliations

Clinician Trends in Prescribing Direct Oral Anticoagulants for US Medicare Beneficiaries

Kevin M Wheelock et al. JAMA Netw Open. .

Abstract

Importance: Contemporary national clinical practice guidelines recommend direct-acting oral anticoagulants (DOACs) as the first-line anticoagulant strategy over warfarin for most indications, especially among older individuals with an elevated bleeding risk.

Objective: To evaluate anticoagulant prescribing and DOAC uptake by US clinicians in the Medicare population.

Design, setting, and participants: This retrospective cohort study included all US clinicians with more than 10 Medicare oral anticoagulant prescription claims, who were included in the national Medicare Provider Utilization and Payment Data (2013-2018). Data analyses were conducted between October 2020 and October 2021.

Exposures: DOAC prescription in 2013.

Main outcomes and measures: Clinicians were categorized based on 2013 prescribing as solely prescribing warfarin, DOAC, or both, and their temporal trajectories of proportionate DOAC use were examined.

Results: The analysis included 325 666 unique clinicians with more than 10 oral anticoagulant prescriptions between 2013 and 2018 (26 620 [8.2%] cardiologists, 85 563 [26.3%] internal medicine physicians, 84 369 [25.9%] family medicine physicians, and 81 161 [24.9%] advanced practice clinicians, including nurse practitioners and physician assistants). In 2013, among 91 837 prescribers, 54 501 (59.3%) prescribed only warfarin, 1918 (2.1%) prescribed only a DOAC, and 35 418 (38.6%) prescribed both. During the study period, the number of clinicians prescribing DOACs increased, but 19% continued to prescribe only warfarin in 2018. While 359 cardiologists prescribing anticoagulants (1.6%) were warfarin-only prescribers, 10 414 (20.0%) and 6296 (12.6%) of family and internal medicine physicians also prescribed only warfarin, respectively. Clinicians prescribing only warfarin in 2013 had lower proportionate DOAC use throughout the study compared with 2013 DOAC prescribers, which represents a median (IQR) of 41.9% (20.3%-61.9%) of their anticoagulant prescriptions in 2018 vs 67.0% (49.9%-82.8%) for DOAC prescribers.

Conclusions and relevance: Despite the increase in DOAC use among Medicare beneficiaries, many clinicians in this study continued to use warfarin as their predominant or only anticoagulant instead of DOACs. There is a need to address barriers to the uptake of these medications to realize their potential benefits for patients.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Ross reported receiving grants from the US Food and Drug Administration, Johnson and Johnson, Medical Devices Innovation Consortium, Agency for Healthcare Research and Quality, the National Institutes for Health National Heart, Lung, and Blood Institute, and the Laura and John Arnold Foundation outside the submitted work. Dr Lin reported working under contract for the US Centers for Medicare & Medicaid Services. Dr Krumholz reported receiving personal fees from the UnitedHealth, IBM Watson Health, Element Science, Aetna, Facebook, Siegfried and Jensen Law Firm, Arnold and Porter Law Firm, Martin and Baughman Law Firm, F-Prime, the Beijing National Center for Cardiovascular Diseases; being a cofounder of HugoHealth and Refactor Health; receiving grants from the Shenzhen Center for Health Information, Medtronic and the US Food and Drug Administration, Medtronic and Johnson and Johnson, Foundation for a Smoke-Free World, the State of Connecticut Department of Public Health; working with the Centers of Medicare & Medicaid Services; and being a member of the advisory board of Element Science, Facebook, and Aetna outside the submitted work. Dr Khera reported receiving honorarium from the New England Journal of Medicine Journal Watch; being the coinventor of the US Provisional Patent Application No. 63/177,177; and being the founder of Evidence2Health. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Oral Anticoagulant Claims by Year
All available claims for an oral anticoagulant stratified by year. In panel A, all claims included in the study are shown in aggregate. In panels B-E, claims data for cardiologists (B), internal medicine physicians (C), family medicine physicians (D), and advanced practice clinicians (E) are shown.
Figure 2.
Figure 2.. Prescribers in Anticoagulant Category by Year and Specialty
Clinicians were divided into prescriber categories each year; individuals who only prescribed warfarin, individuals who prescribed only a direct oral anticoagulant (DOAC), or individuals who prescribed both. For each specialty, the number of clinicians who fell into each category are shown.
Figure 3.
Figure 3.. Annual Oral Anticoagulant Prescriber Groups by 2013 Prescribing Behavior
In panel A, all clinicians who prescribed an oral anticoagulant from 2013 to 2018 were divided into 3 categories based on 2013 prescriptions: clinicians who only prescribed warfarin, clinicians who prescribed only a DOAC, or clinicians who prescribed both. The proportion of all oral anticoagulants that were DOACs were calculated for each clinician for each subsequent study year. The median (IQR) of the proportion of DOAC scripts for clinicians in each baseline prescriber category are shown. In panel B, the annualized rate of change of DOAC usage and number of beneficiaries is shown for individual clinicians. Panel C shows the 2018 DOAC percentage according to decile of change in beneficiary counts. DOAC indicates direct oral anticoagulants; error bars, interquartile range.
See this image and copyright information in PMC

References

    1. Wardrop D, Keeling D. The story of the discovery of heparin and warfarin. Br J Haematol. 2008;141(6):757-763. doi:10.1111/j.1365-2141.2008.07119.x - DOI - PubMed
    1. Connolly SJ, Ezekowitz MD, Yusuf S, et al. ; RE-LY Steering Committee and Investigators . Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139-1151. doi:10.1056/NEJMoa0905561 - DOI - PubMed
    1. Patel MR, Mahaffey KW, Garg J, et al. ; ROCKET AF Investigators . Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883-891. doi:10.1056/NEJMoa1009638 - DOI - PubMed
    1. Granger CB, Hylek EM, Avezum A, et al. . Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981-992. doi:10.1056/NEJMoa1107039 - DOI - PubMed
    1. Agnelli G, Buller HR, Cohen A, et al. ; AMPLIFY Investigators . Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med. 2013;369(9):799-808. doi:10.1056/NEJMoa1302507 - DOI - PubMed

Publication types