A systematic review of economic aspects of service interventions to increase anticoagulation use in atrial fibrillation

Objective: To systematically identify and appraise existing evidence surrounding economic aspects of anticoagulation service interventions for patients with atrial fibrillation. Methods: We searched the published and grey literature up to October 2019 to identify relevant economic evidence in any healthcare setting. A narrative synthesis approach was taken to summarise evidence by economic design and type of service intervention, with costs expressed in pound sterling and valued at 2017-2018 prices. Results: 13 studies met our inclusion criteria from 1,168 papers originally identified. Categories of interventions included anticoagulation clinics (n=4), complex interventions (n=4), decision support tools (n=3) and patient-centred approaches (n=2). Anticoagulation clinics were cost saving compared to usual care (range for mean cost difference: £188-£691 per-patient per-year) with equivalent health outcomes. Only one economic evaluation of a complex intervention was conducted; case management was more expensive than usual care (mean cost difference: £255 per-patient per-year) and the probability of its cost-effectiveness never exceeded 70%. There was limited economic evidence surrounding decision support tools or patient-centred approaches. Targeting service interventions at high-risk groups and those with suboptimal treatment was most likely to result in cost savings. Conclusion: This review revealed some evidence to support the cost-effectiveness of anticoagulation clinics. However, summative conclusions are constrained by a paucity of economic evidence, a lack of direct comparisons between interventions, and study heterogeneity in terms of intervention, comparator and study year. Further research is urgently needed to inform commissioning and service development. Data from this review can inform future economic evaluations of anticoagulation service interventions

The impact of the introduction of direct oral anticoagulants into a general practice and hospital anticoagulant services: two local service evaluations

Background/Aims Anticoagulants are indicated for stroke prevention in nonvalvular atrial fibrillation, and treatment and prevention of venous thromboembolism. The aim of this study was to describe the impact of introducing direct oral anticoagulants on anticoagulation services. Methods One primary and one secondary care anticoagulation service evaluation compared pre-direct oral anticoagulant (2012) and post-direct oral anticoagulant introduction (2015). Findings In the secondary care service, anticoagulant monitoring clinics decreased by 20% and service capacity increased by 38.5% post-direct oral anticoagulant introduction. Direct oral anticoagulants comprised 87.6% of newly-initiated anticoagulants post-direct oral anticoagulant introduction. In patients newly initiated on anticoagulation, a total of 62 anticoagulation-related inpatient admissions were recorded in 12.6% of patients in the pre-direct oral anticoagulant period, compared with a total of 21 anticoagulation-related admissions in 3.6% of patients in the post-direct oral anticoagulant period. In the primary care service, warfarin comprised 62.9% of all anticoagulants prescribed post-direct oral anticoagulant introduction. Overall, patients attended a mean of 14.2 anticoagulation service visits in 6 months pre-direct oral anticoagulant and 13.3 visits in 6 months post-direct oral anticoagulant introduction (non-direct oral anticoagulant-treated: 16.1/patient; direct oral anticoagulant treated: 0.8/patient). Few patients were offered a choice of anticoagulant; however, overall patient satisfaction was high in both services. Conclusions Direct oral anticoagulant introduction in secondary care was associated with increased service capacity and decreased patient visits. Patient choice was limited; however, satisfaction was high in both services.