Korean Circ J.  2020 Mar;50(3):267-277. 10.4070/kcj.2019.0207.

Social Inequalities of Oral Anticoagulation after the Introduction of Non-Vitamin K Antagonists in Patients with Atrial Fibrillation

• Yu HT
• Yang PS
• Hwang J
• Ryu S
• Jang E
• Kim TH
• Uhm JS
• Kim JY
• Pak HN
• Lee MH
• Lip GY
• Joung B

• KMID: 2470912
• DOI: http://doi.org/10.4070/kcj.2019.0207

Abstract

BACKGROUND AND OBJECTIVES
Nationwide social inequalities of oral anticoagulation (OAC) usage after the introduction of non-vitamin K antagonist oral anticoagulants (NOACs) have not been well identified in patients with atrial fibrillation (AF). This study assessed overall rate and social inequalities of OAC usage after the introduction of NOAC in Korea.
METHODS
Between January 2002 and December 2016, we identified 888,540 patients with AF in the Korea National Health Insurance system database. The change of OAC rate in different medical systems after the introduction of NOAC were evaluated.
RESULTS
In all population, overall OAC use increased from 13.2% to 23.4% (p for trend <0.001), and NOAC use increased from 0% to 14.6% (p for trend <0.001). Compared with pre-reimbursement (0.48%), the annual increase of OAC use was significantly higher after partial (1.16%, p<0.001), and full reimbursement of OAC (3.72%, p<0.001). Full reimbursement of NOAC (adjusted odds ratio, 2.10; 95% confidence interval, 2.04-2.15) was independently associated with higher OAC use. However, the difference of overall OAC usage between tertiary referral hospitals and nursing or public health centers increased from 17.9% in 2010 to 36.8% in 2016. Moreover, usage rate of NOAC was significantly different among different medical systems from 37.2% at the tertiary referral hospital and 5.5% at nursing or public health centers.
CONCLUSIONS
Introduction of NOACs in routine practice for stroke prevention in AF was associated with improved rates of overall OAC use. However, significant practice-level variations in OAC and NOAC use remain producing social inequalities of OAC despite full reimbursement.

Keyword

Atrial fibrillation; Insurance; Anticoagulation; NOAC

MeSH Terms

Anticoagulants
Atrial Fibrillation*
Humans
Insurance
Korea
National Health Programs
Nursing
Odds Ratio
Public Health
Socioeconomic Factors*
Stroke
Tertiary Care Centers
Anticoagulants

Figure

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  Figure 1 Flowchart of study cohort enrollment. AF = atrial fibrillation; NHIS = National Health Insurance Service.

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  Figure 2 Temporal trends in overall oral anticoagulation prescription in total atrial fibrillation population (A) and patients with CHA2DS2-VASc score ≥2 (B). NOAC = non-vitamin K antagonist oral anticoagulant; CHA2DS2-VASc = congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism, vascular disease, age 65–74 years, sex category (female).

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  Figure 3 Adjusted patient factors associated with overall OAC use within 1 year from AF diagnosis in total AF population (A) and patients with CHA2DS2-VASc score ≥2 (B). CKD = chronic kidney disease; ESRD = end-stage renal disease; COPD = chronic obstructive pulmonary disease; TIA = transient ischemic attack; NOAC = non-vitamin K antagonist oral anticoagulant; OAC = oral anticoagulant; CI = confidence interval; AF = atrial fibrillation; CHA2DS2-VASc = congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism, vascular disease, age 65–74 years, sex category (female).

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  Figure 4 Practice level variation in total OAC (A), warfarin (B), and NOAC (C) use for AF patients with CHA2DS2-VASc score ≥2. OAC = oral anticoagulant; NOAC = non-vitamin K antagonist oral anticoagulant; AF = atrial fibrillation; CHA2DS2-VASc = congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism, vascular disease, age 65–74 years, sex category (female). *Others include nursing hospital, public health centers, etc.

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  Figure 5 OAC usage according to the patients' economic status with total OAC (A), warfarin (B), and NOAC (C). OAC = oral anticoagulant; NOAC = non-vitamin K antagonist oral anticoagulant.

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