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- Title
Frailty, Home Time, and Health Care Costs in Older Adults With Atrial Fibrillation Receiving Oral Anticoagulants.
- Authors
Lin, Kueiyu Joshua; Singer, Daniel E.; Ko, Darae; Glynn, Robert; Najafzadeh, Mehdi; Lee, Su Been; Bessette, Lily Gui; Cervone, Alexander; DiCesare, Elyse; Kim, Dae Hyun
- Abstract
Key Points: Question: What is the association of frailty level with oral anticoagulant outcomes in terms of home time, clinical events, and total health care costs in patients with atrial fibrillation (AF)? Findings: In this cohort study of 136 551 Medicare beneficiaries with AF, apixaban was associated with increased home time and fewer clinical events than rivaroxaban and warfarin, with greater differences among those with frailty. Apixaban was associated with a lower cost than rivaroxaban but a higher cost than warfarin because of a higher anticoagulant cost. Meaning: These results suggest that apixaban may be preferred for older adults with AF, particularly for patients with frailty. This cohort study of Medicare beneficiaries with arial fibrillation compares home time, health care cost, and clinical events associated with commonly prescribed oral anticoagulants by frailty level. Importance: There are no data on patient-centered outcomes and health care costs by frailty in patients with atrial fibrillation (AF) taking oral anticoagulants (OACs). Objective: To compare home time, clinical events, and health care costs associated with OACs by frailty levels in older adults with AF. Design, Setting, and Participants: This community-based cohort study assessed Medicare fee-for-service beneficiaries 65 years or older with AF from January 1, 2013, to December 31, 2019. Data analysis was performed from January to December 2022. Exposures: Apixaban, rivaroxaban, and warfarin use were measured from prescription claims. Frailty was measured using a validated claims-based frailty index. Main outcomes and measures: Outcome measures were (1) home time (days alive out of the hospital and skilled nursing facility) loss greater than 14 days; (2) a composite end point of ischemic stroke, systemic embolism, major bleeding, or death; and (3) total cost per member per year after propensity score overlap weighting. Results: The weighted population comprised 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 1000 person-years, 21.3 [95% CI, 16.4-26.2]), and total cost (mean difference, $890 [95% CI, $652-$1127]), with greater differences among the beneficiaries with frailty. 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 end point (rate difference per 1000 person-years, 29.4 [95% CI, 24.5-34.3]), with greater differences among the beneficiaries with frailty. Compared with apixaban, warfarin was associated with lower total cost (mean difference, −$1166 [95% CI, −$1396 to −$937]) but higher cost when excluding OAC cost (mean difference, $1409 [95% CI, $1177 to $1642]) regardless of frailty levels. Conclusions and Relevance: In older adults with AF, apixaban was associated with increased home time and lower rates of clinical events than rivaroxaban and warfarin, especially for those with frailty. Apixaban was associated with lower total cost compared with rivaroxaban but higher cost compared with warfarin due to higher OAC cost. These findings suggest that apixaban may be preferred for older adults with AF, particularly those with frailty.
- Subjects
WARFARIN; FRAIL elderly; CONFIDENCE intervals; ATRIAL fibrillation; ANTICOAGULANTS; MEDICAL care costs; TREATMENT effectiveness; RIVAROXABAN; EMPLOYMENT; DESCRIPTIVE statistics; COST analysis; CHI-squared test; RESEARCH funding; LOGISTIC regression analysis; LONGITUDINAL method; PROBABILITY theory; OLD age
- Publication
JAMA Network Open, 2023, Vol 6, Issue 11, pe2342264
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2023.42264