OBJECTIVES : A difference-in-differences analysis showed a that prescription of direct oral anticoagulants (DOACs) increased substantially in the periods 2011–2013 and 2015–2017 and, meanwhile, that the incidence of atrial fibrillation (AF)-related stroke decreased. This budget impact analysis was performed to estimate the impact of these changes on the costs associated with AF-related stroke prevention and care.

METHODS : Data on AF-related stroke cases (stroke as primary diagnosis, AF as secondary diagnosis) for all clinical commissioning groups in England were obtained from Hospital Episode Statistics data (copyright NHS Digital 2018), prescribing data from the electronic Prescribing and Costing Tool, and AF detection and treatment data from the Quality and Outcomes Framework data, in the periods 2011–2013 and 2015–2017. The per-patient health-care cost for the first year after a stroke (transport, scans, treatment, care, and rehabilitation) was set at £13,452. The estimated mean drug price for warfarin was £41.32 (excluding the costs of monitoring international normalisation ratio, as these data are not available in England), and for DOACs was £49.00–53.20 per pack.

RESULTS : With the increase in DOAC prescribing, the total drug prescription costs for oral anticoagulants overall increased by £683,946,537 (983%). At the same time, the total number of AF-adjusted strokes was reduced by 9,737 (13%), leading to a reduction in stroke-associated health-care costs of £130,982,124 (13%). The combined cost for oral anticoagulant prescribing and care after stroke increased by £552,964,413 (151%).

CONCLUSIONS : Although associated with a 13% decrease in AF-related stroke incidence, increased DOAC prescribing led to nearly a tenfold rise in oral anticoagulant prescribing expenditure. With the likely rise in incidence of AF and AF-related stroke among England’s ageing population, these budget impact findings suggest that action is needed to achieve the most efficient use of NHS resources without compromising patient outcomes.