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Impact of cost on use of non-vitamin K antagonists in atrial fibrillation patients in Ontario, Canada


Canadian guidelines recommend non vitamin K antagonists (NOACs) in preference to vitamin K antagonists (VKAs) for stroke prevention in patients with atrial fibrillation (AF), but NOACs are more expensive than VKAs. Canada has a universal healthcare system that covers the cost of NOACs for select patient groups. Ability to pay for NOACs may influence their use. We reviewed medical charts of Hamilton General Hospital outpatients under the age of 65 with a new diagnosis of AF who were referred for initiation of OAC therapy. We contacted these patients by phone and asked them to complete a questionnaire regarding their OAC choice, economic factors that may have influenced this choice (income, insurance) and the financial burden of OAC therapy. We included 110 patients, mean age 56 years, and 26.4% females. NOAC users had a higher median neighborhood income than VKA users (p = 0.0144, n = 110). 73 patients responded to the questionnaire. NOAC users reported higher annual household income (p = 0.0038, n = 73). Patients with private insurance were more likely to use NOACs than those without insurance (p = 0.0496, n = 73). The cost of NOACs and ability to pay is a determinant of their use Ontario patients under the age of 65. This two tiered provision of care appears to contradict the values of Canada’s universal healthcare system.

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Correspondence to Sarah R. Monagle.

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Conflict of interest

PK is the recipient of an educational grant from the Haematology Society of Australia and New Zealand. JE is the recipient of a mid-career award from the Heart and Stroke Foundation and holds the Jack Hirsh/Population Health Research Institute Chair in Thrombosis and Atherosclerosis, and has received honoraria from Astra-Zeneca, Bayer, Boehringer-Ingelheim, Bristol-Myer-Squibb, Daiichi-Sankyo, Eli-Lilly, Glaxo Smith-Kline, Janssen and Sanofi-Aventis. JE has received grants and/or in-kind support from Astra-Zeneca, Bayer, Boehringer-Ingelheim, Bristol-Myer-Squibb, Glaxo-Smith-Kline, Pfizer, Janssen and Sanofi Aventis. The rest of the authors declare that they have no conflict of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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This article does not contain any studies with animals performed by any of the authors.

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Monagle, S.R., Hirsh, J., Bhagirath, V.C. et al. Impact of cost on use of non-vitamin K antagonists in atrial fibrillation patients in Ontario, Canada. J Thromb Thrombolysis 46, 310–315 (2018). https://doi.org/10.1007/s11239-018-1692-4

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  • Non vitamin K antagonists (NOACs)
  • Vitamin K antagonists (VKAs)
  • Cost
  • Atrial fibrillation