In the cohort study of 136,551 Medicare beneficiaries with AF, apixaban was associated with increased home time and fewer clinical events when compared with rivaroxaban and warfarin, with greater differences among those with frailty. The researchers from Brigham and Women’s Hospital and Harvard Medical School also found that apixaban was associated with a lower cost than rivaroxaban but a higher cost than warfarin because of a higher anticoagulant cost.
The Journal of the American Medical Association Network Open article pointed out the lack of data on patient-centered outcomes and healthcare costs by frailty in patients with AF who take OACs. That led the study team to compare home time, clinical events, and healthcare costs associated with OACs by frailty levels in older adults with AF.
The community-based cohort study assessed Medicare fee-for-service beneficiaries aged 65 years or older with AF from January 1, 2013, to December 31, 2019, with data analysis performed from January 2022 to December 2022.
Prescription claims were used to measure apixaban, rivaroxaban, and warfarin use. Frailty was determined using a validated claim–based frailty index. Outcome measures were:
• Home time (days alive out of the hospital and skilled nursing facility) loss greater than 14 days
• A composite end point of ischemic stroke, systemic embolism, major bleeding, or death
• Total cost per member per year after propensity score–overlap weighting.
The study included 136,551 beneficiaries, including 45,950 taking apixaban (mean [SD] age, 77.6 [7.3] years; 51.3% female), 45,320 taking rivaroxaban (mean [SD] age, 77.6 [7.3] years; 51.9% female), and 45,281 taking warfarin (mean [SD] age, 77.6 [7.3] years; 52.0% female).
“Compared with apixaban, rivaroxaban was associated with increased risk of home time lost greater than 14 days (risk difference per 100 persons, 1.8 [95% CI, 1.5-2.1]), composite end point (rate difference per 1,000 person-years, 21.3 [95% CI, 16.4-26.2]), and total cost (mean difference, $890 [95% CI, $652-$1,127]), with greater differences among the beneficiaries with frailty,” the authors wrote.
“Use of warfarin relative to apixaban was associated with increased home time lost (risk difference per 100 persons, 3.2 [95% CI, 2.9-3.5]) and composite endpoint (rate difference per 1,000 person-years, 29.4 [95% CI, 24.5-34.3]), with greater differences among the beneficiaries with frailty,” the researchers added. “Compared with apixaban, warfarin was associated with lower total cost (mean difference, –$1,166 [95% CI, –$1,396 to –$937]) but higher cost when excluding OAC cost (mean difference, $1,409 [95% CI, $1,177 to $1,642]) regardless of frailty levels.”
Background information in the study noted that the use of OACs remains suboptimal in older adults with AF. One of the main concerns is frailty, which complicates prescribing decisions, the authors suggested, because the condition is “highly associated with the risk of bleeding, falls, and drug-related adverse events.”
The authors added, “Although the prevalence of frailty in older adults with AF ranges from 17% in the community to 62% in the hospital, patients with frailty are severely underrepresented in clinical trials, leading to limited data to inform OAC prescribing and suboptimal use in older adults with AF and with frailty. In a recent US nationwide trend analysis, frailty was associated with 26% lower odds of OAC prescribing among older adults. However, the evidence generated based on routine care on OACs in patients with frailty remains limited, and no prior studies have investigated the use of OACs with a focus on patient-centered outcomes and health care costs among patients with AF and with frailty.”
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