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Huge variation in use of new anticoagulants “completely unacceptable”

There is huge variation across England in the use of non-vitamin K antagonist oral anticoagulants (NOACs) to reduce stroke risk in patients with atrial fibrillation (AF), according to a recent statement from the Atrial Fibrillation Association (AF Association) which condemns the new data as “completely unacceptable”.1

The data, from NHS England, show prescribing rates for the newer therapies differing by 44-fold between Clinical Commissioning Groups (CCGs). The figures reveal that in one part of the country more than one in two AF patients are prescribed the modern drugs while in another area they are prescribed to just one AF patient in 71.

The data on the variation in prescribing rates for the non-Vitamin K antagonist oral anticoagulants (NOACs) for AF comes from a project called the Medicines Optimisation Dashboard (MOD). It has looked at NOAC prescribing rates compared to warfarin use for AF in all 211 CCGs in England over the period October to December 2014. The range stretched from an NOAC prescribing rate of 62.1% in South Kent Coast CCG to 1.4% in Thurrock CCG, Essex.

Trudie Lobban MBE, Founder and Trustee of AF Association said: “This variation is completely unacceptable. Kent and Essex are separated by the width of the River Thames, but in terms of modern medicines to reduce AF-related strokes they appear worlds apart. It makes a mockery of the concept of a National Health Service that patients with the same condition living just miles apart receive such dramatically different rates of the newer therapies.”

The MOD data shows that around two-thirds (63%) of CCGs had NOAC prescribing rates below the national average of 11.5% and of these some one in eight (12.8%) had prescribing rates below 5%.

Mrs Lobban continued: “In the West Country there are four CCGs where more than a quarter of patients receive the modern therapies. By contrast, in East Anglia there are four CCGs where fewer than 5% – one in 20 patients – receive the newer therapies. The physiology of the human heart doesn’t change between Bristol and Ipswich, but the therapies vary dramatically. This has nothing to do with medicine and everything to do with money.”

Mrs Lobban added: “Some of the local contrasts are shocking. In Havering, East London, 30% of patients receive the new drugs – in the next door CCG of Basildon and Brentwood, Essex, the proportion is 3.7%…If you look at Leeds South and East CCG and Leeds West CCG around 3% of patients (3.2%) are prescribed NOACs. Some 12 miles away in Bradford City CCG 27.9% of patients receive them, and this drops to 25.3% in Bradford Districts CCG. How can anyone say that this is fair?”

Mrs Lobban pointed out that the National Institute for Health and Care Excellence (NICE) published reports in 2013 and 2014 looking at services for AF patients, including the use of NOACs. Part of the 2013 advice stated: “We are committed to ensuring that NHS patients have access to clinically and cost effective drugs and technologies and that NICE appraisal guidance is promptly delivered throughout the NHS. There should be no local barriers in accessing technologies recommended in NICE appraisals beyond a clinical decision relating to an individual patient.”2

The guidance states that: “Commissioners should note that the choice of anticoagulation therapy should be a clinical decision made by a competent healthcare professional in consultation with the individual patient.”

Mrs Lobban said: “These local decisions to ration the modern therapies are in flagrant breach of the guidelines issued by NICE. NICE has said specifically that local barriers should not exist and price considerations should not be used to restrict the newer medicines.”

“We are grateful that NHS England has compiled this data, but for most ordinary people its existence is a state secret. AF patients have the right to know the policies of their local CCGs with regard to stroke prevention, and it is high time CCGs spoke openly about why they choose to restrict the newer therapies,” she concluded.

Use of NOACs across Clinical Commissioning Groups in England (data from Medicines Optimisation Dashboard)

Use of NOACs across Clinical Commissioning Groups in England (data from Medicines Optimisation Dashboard)


1. Medicines optimisation dashboard. NHS England 2015. Available from (Accessed June 2015)

2. NICE Commissioning Guide 49. Support for commissioning anticoagulant therapy. National Institute for Health and Care Excellence 2013. Available from (Accessed July 2015)

Published on: July 30, 2015

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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