gms | German Medical Science

Background and state of research: Atrial fibrillation is the most common sustained cardiac arrhythmia in adults and increases the risk of stroke five-fold. Therefore, prevention of stroke and systemic embolism is a core tenet of patient treatment. In Germany, there is little real-world evidence on physicians’ choice of oral anticoagulants (OACs).

Research question and objectives, hypothesis: Our study aimed at assessing preferences for and prescribing patterns of treatment options for stroke prevention in atrial fibrillation in clinical practice in Germany.

Method: We conducted a nationwide quantitative online survey among office-based physicians in Germany. Physicians were asked about their preference for and use of treatment options as well as factors influencing their choice of a specific OAC

Results: A total of n=953 physicians was surveyed in September and October 2020 (general physicians: 36.0%; internists: 37.3%; cardiologists: 23.7%; neurologists: 10.5%; multiple specialties possible). Preference and use were highest for non-vitamin K oral anticoagulants (NOACs); followed by vitamin K antagonists (VKAs). Most preferred OACs were apixaban (39.3%), rivaroxaban (28.5%) and edoxaban (14.7%). Most used OACs were apixaban (24.3%), rivaroxaban (21.2%) and phenprocoumon (21.4%). NOACs were preferred more often than used (85.6% > 68.6%). VKAs were preferred less often than used (9.6% < 23.5%). OAC attributes and patient characteristics related to efficacy and safety, as well as patients’ kidney function were most important when selecting a specific OAC. Federal and regional governance instruments likely influenced treatment decision-making.

Discussion: We found a high divergence between preferences for and use of available OAC treatment options among relevant office-based specialist groups. The favorable efficacy and safety profile of NOACs presumably affected physicians’ high preference for this treatment option, as OAC attributes and patient characteristics related to efficacy and safety played the most important role in the physicians’ choice of a specific OAC. More exploration of the importance of OAC attributes, patient characteristics as well as federal and regional governance instruments for physicians’ choice of a specific OAC may help to further optimize the healthcare of patients with atrial fibrillation in the long-term.

Implication for care: In clinical practice, vitamin K antagonists were used more often than preferred whereas non-vitamin K oral anticoagulants, on average, were used less often than preferred. Oral anticoagulant attributes and patient characteristics related to efficacy and safety, as well as patients’ kidney function were most important when selecting a specific oral anticoagulant. Federal and regional governance instruments likely influenced treatment decision-making process. To our knowledge, our study is the first large-scale survey on preferences for and prescribing patterns of treatment for stroke prevention in atrial fibrillation among physicians under real-world conditions in Germany, thus, providing relevant insights into physicians’ decision-making process.