Cost of warfarin versus direct oral anticoagulants

In Dr Wohlgemut’s commentary “The ‘direct’ dilemma. Oral anticoagulants and the parameters of public prescribing,” published in the November issue of Canadian Family Physician, his point about being fiscally responsible and recognizing the responsibility of physicians to help politicians be good stewards of the public purse is well taken¹; however, we as physicians and as a society have to be very careful about not being penny-wise and pound-foolish. The Canadian Agency for Drugs and Technologies in Health report cited in Wohlgemut’s article showed that outpatient treatment of atrial fibrillation with warfarin is cheaper than use of direct oral anticoagulants (DOACs).² This is not surprising given that DOACs are many times more expensive. However, we do have to recognize that effective primary care, as well as interventions that potentially improve outcomes in chronic diseases such as atrial fibrillation, ultimately save the health care system money in the long run by reducing use of acute care. The Canadian Institute for Health Information reported that in 2019, 26.6% of health spending would go toward hospitals, which is also the single biggest cost.³ In fact, the combined cost of physicians and drugs is 30.4% of health care spending, while hospitals account for 26.6% alone. It is also worth noting that the cost of physician services increases for hospitalized patients versus patients seen on an outpatient basis. It is a complicated scenario, but others have more recently attempted to answer this question vis-à-vis DOACs: Ortiz-Cartagena and colleagues⁴ conducted a study of patients enrolled in anticoagulation clinics who had hospital admissions related to anticoagulation treatment. Their findings reflected those of the earlier mentioned Canadian Institute for Health Information review,³ in that for outpatient care alone, cost was less for warfarin, but when inpatient treatment was factored in as well, warfarin was actually less cost effective, as length of stay for the warfarin patients was substantially longer.

While the results of one study are by no means conclusive proof of superior cost efficacy in the Canadian system, it is worth noting these results. Ultimately it also raises another problem with these discussions: our health care system tends to be “siloed” in Canada. We talk about costs of primary care, or costs of acute care, but we don’t always look at those systems together and the way they interact with each other. In order to provide the best care to our patients and be the best possible stewards of health care resources, we can no longer continue to do that.