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Development and Application of an Attribute-Based Taxonomy on the Benefits of Oral Anticoagulant Switching in Atrial Fibrillation: A Delphi Study

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Abstract

Introduction

Patients with atrial fibrillation (AF) often switch between oral anticoagulants (OACs). It can be hard to know why a patient has switched outside of a clinical setting. Medication attribute comparisons can suggest benefits. Consensus on terms and definitions is required for inferring OAC switch benefits. The objectives of the study were to generate consensus on a taxonomy of the potential benefits of OAC switching in patients with AF and apply the taxonomy to real-world data.

Methods

Nine expert clinicians (seven clinical pharmacists, two cardiologists) with at least 3 years of clinical and research experience in AF participated in a Delphi process. The experts rated and commented on a proposed taxonomy on the potential benefits of OAC switching. After each Delphi round, ratings were analyzed with the RAND Corporation/University of California, Los Angeles (RAND/UCLA) appropriateness method. Median ratings, disagreement index, and comments were used to modify the taxonomy. The resulting taxonomy from the Delphi process was applied to a cohort of patients with AF who switched OACs in a population-based administrative health dataset from 1996 to 2019 in British Columbia, Canada.

Results

The taxonomy was finalized in two Delphi rounds, reaching consensus on five switch benefit categories: safety, effectiveness, convenience, economic considerations, and drug interactions. Safety benefit (a switch that could lower the risk of adverse drug events) had three subcategories: major bleeding, intracranial hemorrhage (ICH), and gastrointestinal (GI) bleeding. Effectiveness benefit had four subcategories: stroke and systemic embolism (SSE), ischemic stroke, myocardial infarction (MI), and all-cause mortality. Real-world OAC switches revealed that more OAC switches had convenience (72.6%) and drug interaction (63.0%) benefits compared to effectiveness (SSE 22.0%, ischemic stroke 11.1%, MI 3.1%, all-cause mortality 10.1%), safety (major bleeding 24.3%, GI bleeding 10.6%, ICH 48.5%), and economic benefits (12.1%).

Conclusions

The Delphi-based taxonomy identified five criteria for the beneficial effects of OAC switching, aiding in characterizing real-world OAC switching.

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Data Availability

Access to data provided by the Data Stewards is subject to approval but can be requested for research projects through the Data Stewards or their designated service providers. The following databases were used in this study: Consolidation File, Discharge Abstract Database, Vital Statistics, Medical Services Plan, and PharmaNet. Further information regarding these data sets is available at https://my.popdata.bc.ca/project_listings/17-149/collection_approval_dates. All inferences, opinions, and conclusions drawn in this publication are those of the authors, and do not reflect the opinions or policies of the Data Steward(s). The other datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We appreciate the contributions of our patient partners and experts to this study. The experts were not compensated for their time. We are grateful to Dr. Anita Kapanen for proofreading the manuscript.

Funding

This work was supported by the Canadian Institutes of Health Research (CIHR grant number FRN 168896), and the UBC David H MacDonald Professorship in Clinical Pharmacy. The study sponsor is also funding the journal’s Rapid Service Fee.

Author information

Authors and Affiliations

  1. Faculty of Pharmaceutical Sciences, University of British Columbia (UBC), Vancouver, Canada

    Adenike R. Adelakun, Mary A. De Vera, Ricky D. Turgeon, Arden R. Barry & Peter Loewen

  2. UBC Collaboration for Outcomes Research and Evaluation, Vancouver, Canada

    Adenike R. Adelakun, Mary A. De Vera, Ricky D. Turgeon & Peter Loewen

  3. UBC School of Population and Public Health, Vancouver, Canada

    Kim McGrail

  4. UBC Centre for Health Services and Policy Research, Vancouver, Canada

    Kim McGrail

  5. Jim Pattison Outpatient Care and Surgery Centre, Surrey, Canada

    Arden R. Barry

  6. Vancouver General Hospital, Vancouver, Canada

    Jason G. Andrade, Jenny MacGillivray & Elaine Lum

  7. Department of Medicine, The University of British Columbia, Vancouver, Canada

    Jason G. Andrade & Marc W. Deyell

  8. Centre for Cardiovascular Innovation, Vancouver, Canada

    Jason G. Andrade, Marc W. Deyell & Peter Loewen

  9. St. Paul’s Hospital, Vancouver, Canada

    Marc W. Deyell & Doson Chua

  10. Royal Columbian Hospital, New Westminster, Canada

    Leanne Kwan

  11. Vancouver Island Health Authority, Vancouver, Canada

    Reginald Smith

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  1. Adenike R. Adelakun
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Contributions

Adenike R. Adelakun: conceptualization, data curation, formal analysis, investigation, methodology, validation, visualization, manuscript writing and reviewing; Peter Loewen: conceptualization, data curation, funding acquisition, investigation, methodology, project administration, supervision, validation, visualization, manuscript writing and reviewing; Ricky D. Turgeon: conceptualization, data curation, methodology, supervision, validation, manuscript writing and reviewing; Kim McGrail and Mary A. De Vera: conceptualization, data curation, methodology, supervision, validation, manuscript writing and reviewing; other authors (Arden R. Barry, Jason G. Andrade, Jenny MacGillivray, Marc W. Deyell, Leanne Kwan, Doson Chua, Elaine Lum, Reginald Smith): data curation, investigation, validation, visualization, manuscript writing and reviewing. Adenike Adelakun and Peter Loewen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Corresponding author

Correspondence to Peter Loewen.

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Conflict of Interest

Adenike R. Adelakun, Kim McGrail, Mary A. De Vera, Ricky D. Turgeon, Arden R. Barry, Jenny McGillivray, Leanne Kwan, Doson Chua, Elaine Lum, Reginald Smith, and Peter Loewen have nothing to disclose. Jason G. Andrade has received honoraria from Bayer, Biosense-Webster, BMS Pfizer, Medtronic, and Servier, and research grants from Medtronic. Marc W. Deyell has received honoraria from Pfizer, Servier, and Bayer. Adenike Adelakun’s affiliation changed after this work was completed to Health Outcomes Scientist, GSK, Toronto, Ontario, Canada.

Ethics Approval

Approval was obtained from the University of British Columbia Behavioral Research Ethics Board (certificate numbers H21-03045 and H17-02420). Written informed consent was obtained from all Delphi participants to participate and publish the results of the Delphi process.

Additional information

Prior Presentation: Part of this study has been presented as a poster at the 2022 ISPOR Conference (Vienna, Austria), and the 2022 Canadian Cardiovascular Congress (Ottawa, Canada).

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Adelakun, A.R., De Vera, M.A., McGrail, K. et al. Development and Application of an Attribute-Based Taxonomy on the Benefits of Oral Anticoagulant Switching in Atrial Fibrillation: A Delphi Study. Adv Ther (2024). https://doi.org/10.1007/s12325-024-02859-0

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