title: National Trends in Ambulatory Oral Anticoagulant Use.
abstract: BACKGROUND
  Four direct oral anticoagulants (DOACs) have been brought to market for the treatment of nonvalvular atrial fibrillation and venous thromboembolism. Many forces, including numerous positive trial results, emerging safety concerns, marketing, and promotion, may shape DOAC adoption by providers. However, relatively little is known regarding their ambulatory utilization compared with warfarin, as well as the degree to which they have decreased under-treatment of atrial fibrillation.
  
  
  METHODS
  We used the IMS Health National Disease and Therapeutic Index, a nationally representative audit of outpatient office visits, to estimate the use of warfarin and DOACs between 2009 and 2014.
  
  
  RESULTS
  Overall, visits with anticoagulation use increased from 2.05 (95% confidence interval [CI], 1.82-2.27) to 2.83 (95% CI, 2.49-3.17) million (M) quarterly visits (P < .001). Of these, DOAC use has grown to 4.21M (95% CI, 3.63M-4.79M; 38.2% of total) treatment visits in 2014 since their introduction in 2010. Use of all oral anticoagulants in treatment visits for atrial fibrillation has increased from 0.88M (95% CI, 0.74M-1.02M) to 1.72M (95% CI, 1.47M-1.97M; P < .001), with similar DOAC and warfarin use in 2014. Atrial fibrillation visits with anticoagulant use increased from 51.9% (95% CI, 50.4%-53.8%) to 66.9% (95% CI, 65.0%-69.3%) between 2009 and 2014 (P < .001). In 2014, rivaroxaban was the most commonly prescribed DOAC for atrial fibrillation (47.9% of office visits), followed by apixaban (26.5%) and dabigatran (25.5%).
  
  
  CONCLUSIONS
  Direct oral anticoagulants have been adopted rapidly, matching the use of warfarin, and are associated with increased use of oral anticoagulation for patients with atrial fibrillation.
authors.affiliation: Frankel Cardiovascular Center and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor. Electronic address: gbarnes@umich.edu.
authors.forename: Geoffrey D
authors.initials: GD
authors.lastname: Barnes
authors.affiliation: Department of Epidemiology and the Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.
authors.forename: Eleanor
authors.initials: E
authors.lastname: Lucas
authors.affiliation: Department of Epidemiology and the Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.
authors.forename: G Caleb
authors.initials: GC
authors.lastname: Alexander
authors.affiliation: Division of Cardiology, University of Washington, Seattle.
authors.forename: Zachary D
authors.initials: ZD
authors.lastname: Goldberger
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000367:Age Factors; D000368:Aged; D000553:Ambulatory Care / Q000379:methods / Q000706:statistics & numerical data; D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy; D000069604:Dabigatran / Q000008:administration & dosage / Q000627:therapeutic use; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011720:Pyrazoles / Q000008:administration & dosage / Q000627:therapeutic use; D011728:Pyridones / Q000008:administration & dosage / Q000627:therapeutic use; D000069552:Rivaroxaban / Q000008:administration & dosage / Q000627:therapeutic use; D014481:United States / Q000453:epidemiology; D054556:Venous Thromboembolism / Q000517:prevention & control; D014859:Warfarin / Q000008:administration & dosage / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D011720:Pyrazoles; D011728:Pyridones; C522181:apixaban; D014859:Warfarin; D000069552:Rivaroxaban; D000069604:Dabigatran
keywords: Anticoagulants; Atrial Fibrillation; Venous Thromboembolism; Warfarin