Abstract
Atrial fibrillation has a high disease burden—both in prevalence and associated consequences.
Despite anticoagulation being an effective treatment in atrial fibrillation, stroke
prevention is slow to reflect evidence-based practice. Real-world data reveal a substantial
portion of patients who would benefit from anticoagulation, yet do not receive it
adequately or at all. A large part of this suboptimal treatment is due to the underutilization
of direct oral anticoagulants (DOACs). In response to abundant evidence published
over a short timeframe, international guidelines have adopted DOAC usage ahead of
policy and fund holders. This paper reviews the evidence and values that influence
published guidelines, patient-physician decision making, and policy framework on DOAC
usage. An important factor is the access gap between patients who qualify for DOAC
according to evidence-based guidelines and the subset of this cohort who are eligible
for DOAC based on government funded policy. We analyse the Canadian health system
in detail—including drug approval and funding process. Health care systems in other
countries are explored, with emphasis on similar universal health care systems that
may help overcome barriers common to Canada. We will discuss strategies to: (1) improve
awareness of the risk and preventability of stroke; (2) enable physicians to provide
evidence-based DOAC usage; (3) empower patients to improve adherence and persistence;
(4) collect real-life data that encourages patient self-monitoring, physician outcomes
auditing, and building evidence that is useful for policy makers; and (5) use postmarketing
data in negotiating shared risk management between pharmaceuticals and government
to improve access to DOACs.
Résumé
La fibrillation auriculaire (FA) impose un fardeau très lourd, sur le plan tant de
sa prévalence que de ses conséquences. Malgré l’efficacité de l’anticoagulation contre
la FA, la prévention des accidents vasculaires cérébraux (AVC) tarde à suivre la pratique
fondée sur les données probantes. Les données obtenues en situation réelle montrent
qu’une fraction appréciable de patients chez lesquels l’anticoagulation serait bénéfique
ne reçoivent pas ce traitement, ou le reçoivent selon des modalités inappropriées.
Ce traitement sous-optimal s’explique en grande partie par la sous-utilisation des
anticoagulants oraux directs (AOD). En réponse à l’abondance des données probantes
publiées en peu de temps, les lignes directrices internationales ont devancé les décideurs
et les bailleurs de fonds en préconisant l’utilisation des AOD. Cet article présente
une recension des données probantes et des valeurs qui influencent les lignes directrices
publiées, la prise de décision patient-médecin et le cadre politique relativement
à l’utilisation des AOD. L’écart en matière d’accès au traitement entre les patients
admissibles aux AOD selon les lignes directrices fondées sur des données probantes
et le sous-ensemble de cette cohorte qui y est admissible en fonction des politiques
gouvernementales constitue un facteur important. Nous analysons en profondeur le système
de santé canadien, y compris le processus d’homologation et de financement des médicaments.
Nous explorons aussi les systèmes de santé d’autres pays, en nous arrêtant plus particulièrement
aux systèmes de soins de santé universels semblables au nôtre qui pourraient aider
à surmonter les obstacles rencontrés au Canada. Nous discutons des stratégies permettant
d’atteindre les objectifs suivants : 1) améliorer la sensibilisation au risque et
au caractère évitable de l'AVC 2) permettre aux médecins d’offrir l’utilisation des
AOD selon les pratiques fondées sur des données probantes; 3) habiliter les patients
à améliorer leur observance et leur persévérance; 4) recueillir des données en situation
réelle afin d’encourage l’autosurveillance du patient et la vérification des résultats
par le médecin et de constituer un corpus de données probantes susceptibles d’être
utiles aux décideurs; 5) utiliser les données post-commercialisation dans la négociation
de la gestion partagée des risques entre les sociétés pharmaceutiques et le gouvernement
afin d’améliorer l’accès aux AOD.
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Article info
Publication history
Accepted:
July 9,
2018
Received:
May 25,
2018
Footnotes
See page 1421 for disclosure information.
Identification
Copyright
© 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
