Acceso a los anticoagulantes de acción directa en España

Abstract

In Spain, new oral anticoagulants are used in fewer than 20% of patients with nonvalvular atrial fibrillation. This is lower than the rate observed in comparable countries and lower than that expected given current official recommendations and given the number of patients known to lie outside the therapeutic range while taking vitamin-K antagonists. This article provides an overview of the possible causes of the apparently low use of new oral anticoagulants in Spain. A number of distinct barriers have been documented that affect individuals involved in treatment decision-making (i.e. patients and health-care professionals and payers). The most relevant explanatory factors appear to be resistance to change by patients and health-care professionals, prescription being restricted to particular specialists, and the variation in policies affecting access to drugs between different Spanish autonomous regions. The causative factor that appears to best explain differing access to new oral anticoagulants in the Spanish National Health System is the impact of these drugs on the health budget. In particular, difficulties have been created by the absence of a coherent common management framework that takes responsibility for both the decision to fund an innovative treatment and the budgetary implications of its use. The effectiveness of a particular type of therapy does not imply that it will be “possible” to fund it at any given time, given that it is always legitimate to limit its use if decision-making is transparent and based on clear criteria. However, keeping alive, mostly nonexistent, technical uncertainties does not help solve the problem and casts doubt on the credibility of the evaluation process.