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Can J Cardiol. 2014 Oct;30(10):1245-8. doi: 10.1016/j.cjca.2014.08.002.

Aligning health care policy with evidence-based medicine: the case for funding direct oral anticoagulants in atrial fibrillation.

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Department of Cardiac Sciences, Faculty of Medicine, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada.
EBM Consulting, Inc, Oakville, Ontario, Canada. Electronic address:
Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.
Department of Medicine (Neurology), McMaster University / Population Health Research Institute, Hamilton, Ontario, Canada.
Division of Cardiology, McGill Health University Center, McGill University, Montreal, Québec, Canada.
Center for Innovation in Complex Care and Department of Pharmacy, University Health Network and Department of Pharmacy, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.
Sauder Family and Heart and Stroke Foundation, Department of Stroke Neurology, University of British Columbia, Vancouver, British Columbia, Canada.
Departments of Cardiovascular Outcomes Research, Medicine, and Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.


Misalignment between evidence-informed clinical care guideline recommendations and reimbursement policy has created care gaps that lead to suboptimal outcomes for patients denied access to guideline-based therapies. The purpose of this article is to make the case for addressing this growing access barrier to optimal care. Stroke prevention in atrial fibrillation (AF) is discussed as an example. Stroke is an extremely costly disease, imposing a significant human, societal, and economic burden. Stroke in the setting of AF carries an 80% probability of death or disability. Although two-thirds of these strokes are preventable with appropriate anticoagulation, this has historically been underprescribed and poorly managed. National and international guidelines endorse the direct oral anticoagulants as first-line therapy for this indication. However, no Canadian province has provided these agents with an unrestricted listing. These decisions appear to be founded on silo-based cost assessment-the drug costs rather than the total system costs-and thus overlook several important cost-drivers in stroke. The discordance between best scientific evidence and public policy requires health care providers to use a potentially suboptimal therapy in contravention of guideline recommendations. It represents a significant obstacle for knowledge translation efforts that aim to increase the appropriate anticoagulation of Canadians with AF. As health care professionals, we have a responsibility to our patients to engage with policy-makers in addressing and resolving this barrier to optimal patient care.

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