OBJECTIVES: Direct oral anticoagulants (DOACs) reimbursement under Israeli health basket has been merely partial over the years. We wanted to describe DOACs use under public funding in Israel and as compared to different healthcare systems.

METHODS: Descriptive study from Meuhedet, Israel. We retrospectively identified patients who had purchased one of the anticoagulants (DOACs, warfarin or enoxaparin) at least once between 2013 and 2020 under the Israeli health basket indications: atrial fibrillation (AF), venous thromboembolism (VTE) and/or hip/knee replacement. Demographic and clinical characteristics were described. The primary outcome was the distribution of anticoagulants' use in DDDs and prescriptions. Secondary outcomes included comparison of DOACs growth rate at Meuhedet (representing Israel) to other countries (Norway, England, and Canada) adjusted per population; and annual proportion of AF/VTE patients not meeting health basket's criteria to DOACs despite being clinically eligible. Logistic regression was performed to identify predictive factors for prescribing DOACs in naïve AF patients. Finally, we evaluated Meuhedet's cumulative expenditure versus budget for DOACs.

RESULTS: 31,326 patients purchased at least one anticoagulant during study period, half of whom were AF patients. Warfarin's use dropped from 76% in 2013 to 13% in 2020. By 2020, DOACs accounted for 80% of total anticoagulants purchased. The growth rate of DOACs in Norway and England was significantly higher than in Israel (54% and 78%, respectively). No comparative data were available for Canada. In 2014, 82.1% of patients were eligible to DOACs according to clinical guidelines but did not meet the basket criteria, hence were treated with warfarin. This rate decreased over the years following the basket criteria's expansion. Reimbursement's eligibility status was the strongest predictor for DOACs initiation (OR=12.1, p<0.001). In 2020, Meuhedet's expenditure on DOACs exceeded the cumulative basket's budget.

CONCLUSIONS: DOACs uptake was considerably slower in Israel compared to other countries, with discordance between reimbursement decisions and clinical recommendations.