Background: 2014 AHA/ACC/HRS guidelines recommend anticoagulation for NVAF patients with a CHA2DS2-VASc≥2, but do not endorse a specific therapy. Several published indirect treatment comparisons demonstrate similar stroke risk reduction but distinct differences for bleeding risk among novel oral anticoagulants (NOACs) in NVAF patients.
Objectives: Survey physicians to determine how their preferences over antithrombotic therapies compare with current treatment guidelines and indirect treatment comparisons.
Methods: An online survey was completed by 200 physicians who regularly treat patients with NVAF. Respondents answered 12 questions comparing two hypothetical antithrombotic treatments that varied across five attributes: stroke risk, major bleeding risk, inconvenience (i.e., regular INR blood-testing/dietary restrictions), dosing frequency and patient out-of-pocket (OOP) cost. Physician willingness to trade higher OOP cost for improvements in other attributes was estimated using a logistic regression. Based on these results, we calculated the share of prescriptions that would be written for apixaban, aspirin, dabigatran, rivaroxaban and warfarin using real-world US patient OOP costs.
Results: Physicians were willing to trade an increase in monthly OOP cost of $38.21 (95% CI: $22.07-$54.34) for a 1 percentage point (absolute) decrease in annual stroke risk. Physicians also placed a positive value on less inconvenience ($34.46, 95% CI: $8.50-$60.41), and a 1 percentage point reduction in the risk of a major bleed ($14.44, 95% CI: $8.01-$20.88). Physicians did not have a significant willingness to pay to reduce dosing frequency from twice to once per day ($17.16; 95% CI: -0.08-$34.40). Cardiologists and cardiac electrophysiologists had higher willingness to pay for stroke risk reduction than general practitioners ($54.32 vs. $24.74, p<0.001). Based on these preferences, physicians would recommend NOACs to 77% of patients, with apixaban (32%) being the preferred NOAC.
Conclusions: Similar to findings from indirect treatment comparison studies, physicians largely prefer NOACs_particularly apixaban_compared to warfarin or aspirin for stroke risk reduction in NVAF patients. Additional research is needed to determine why NOACs are underused in practice.