Dissonance Between Clinicians and Patients Could Prevent Optimal Prescription of Oral Anticoagulants

Patrick Campbell

An analysis of patient and clinician responses to surveys within BOAT-AF suggests many were willing to consider DOACs but were never prescribed anticoagulation and also provides insight into how trends in this cohort compared to those in the ACC's PINNACLE registry.

With anticoagulation rates lagging behind, new research from the BOAT-AF study is offering clinicians insight into the prescribing patterns related to direct oral anticoagulants (DOACs) among patients with nonvalvular atrial fibrillation (AF).

While results indicate prescribing rates improved of reviewing patient and clinician preferences, they suggest 1-in-3 clinicians and 2-in-3 patients were willing to consider a DOAC but only 1-in-6 ultimately received a prescription.

BOAT-AF was designed with the intent of establishing a benchmark for rate of oral anticoagulant prescribing in patients with nonvalvular AF and an indication. The current analysis, which was presented at the American College of Cardiology’s 70th Annual Scientific Session (ACC.21), focused on reasons for not using anticoagulation, changes in prescribing rates over time, and comparing these patterns versus those in the ACC’s PINNACLE registry.

Designed as an observational cohort study, BOAT-AF enrolled 817 participants who were followed for 12 months. Patients were enrolled between January 2017 and May 2018 from 19 medical centers. As part of the study design, patients and their physicians underwent surveys regarding their oral anticoagulation preferences.

The BOAT-AF cohort had a mean age of 76 years, 45% were women, 61% were White, and 53% had private insurance. Among the 817 patients included in the study, all of whom had an indication for anticoagulation, 119 (14.6%) were prescribed a DOAC at follow-up, which occurred at a mean of 14.4 months after enrollment. Among a matched patient population from the PINNACLE Registry, investigators noted similar rates of prescription, with a rate of 14.4% after a mean follow-up of 13 months.

Based on physician survey responses, investigators concluded the most common reasons for not prescribing a DOAC were a low burden of stroke or successful rhythm control and patient refusal. However, results of patient surveys indicated 66.6% of patients would consider oral anticoagulation. Additionally, investigators identified 385 (46.5%) cases where a patient said they were willing to consider oral anticoagulation, but their clinicians deemed it inappropriate.

Among a subgroup of 647 patients an external committee adjudicated as being appropriate or may be appropriate for anticoagulation, 30.3% of clinicians and 36.5% of patients agreed while another 27.3% of patients considered themselves neutral. Upon analysis at follow-up, only 14.2% (n=96) of those patients were prescribed oral anticoagulation.

For more on this study and insight on current trends in DOAC prescribing, Practical Cardiology reached out to Christopher Cannon, MD, and that conversation is the subject of this ACC.21 House Call.

This study, “Is Appropriate Use of Oral Anticoagulants Improving Among Atrial Fibrillation Patients? Results from the Benchmarking an Oral Anticoagulant Treatment Rate in Patients with Nonvalvular Atrial Fibrillation (BOAT-AF) Study and Comparison to 387,975 Participants in the Pinnacle Registry,” was presented at ACC.21.