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In Europe, decitabine is not approved due to lack of survival advantage in randomized trials. The two drugs have not been compared in clinical trials. We identified patients diagnosed with <jats:styled-content style=\"fixed-case\">MDS<\/jats:styled-content> between 2004 and 2011 from the Surveillance, Epidemiology, and End Results (<jats:styled-content style=\"fixed-case\">SEER<\/jats:styled-content>)\u2010Medicare linked database in <jats:styled-content style=\"fixed-case\">the USA<\/jats:styled-content> who received \u2265 10 doses of either <jats:styled-content style=\"fixed-case\">HMA<\/jats:styled-content>. We estimated survival from <jats:styled-content style=\"fixed-case\">HMA<\/jats:styled-content> initiation with Kaplan\u2013Meier methods and used multivariate Cox proportional hazards models to adjust for covariates. Analyses controlled for histological subtype and we conducted a subset analysis limited to patients with refractory anaemia with excess blasts (<jats:styled-content style=\"fixed-case\">RAEB<\/jats:styled-content>). In 2025 <jats:styled-content style=\"fixed-case\">HMA<\/jats:styled-content>\u2010treated patients, median survival was 15\u00a0months with no difference in survival based on the <jats:styled-content style=\"fixed-case\">HMA<\/jats:styled-content> received in adjusted analysis (decitabine <jats:italic>versus<\/jats:italic> azacitidine, hazard ratio\u00a0=\u00a01\u00b706, 95% confidence interval: 0\u00b794\u20131\u00b719, <jats:italic>P<\/jats:italic>\u00a0=\u00a00\u00b737). For <jats:styled-content style=\"fixed-case\">RAEB<\/jats:styled-content> patients (<jats:italic>n<\/jats:italic>\u00a0=\u00a0523), median survival was 12\u00a0months, with no significant difference based on <jats:styled-content style=\"fixed-case\">HMA<\/jats:styled-content> received. No significant survival difference was found between azacitidine and decitabine in patients with <jats:styled-content style=\"fixed-case\">MDS<\/jats:styled-content>, including <jats:styled-content style=\"fixed-case\">RAEB<\/jats:styled-content>. Importantly, population\u2010based survival of azacitidine\u2010treated <jats:styled-content style=\"fixed-case\">RAEB<\/jats:styled-content> patients was substantially shorter than in the <jats:styled-content style=\"fixed-case\">AZA<\/jats:styled-content>\u2010001 clinical trial (11 versus 24\u00b75\u00a0months).<\/jats:p>","DOI":"10.1111\/bjh.14305","type":"journal-article","created":{"date-parts":[[2016,9,21]],"date-time":"2016-09-21T09:46:38Z","timestamp":1474451198000},"page":"829-840","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":69,"title":["Comparative clinical effectiveness of azacitidine <i>versus<\/i> decitabine in older patients with myelodysplastic syndromes"],"prefix":"10.1111","volume":"175","author":[{"given":"Amer M.","family":"Zeidan","sequence":"first","affiliation":[{"name":"Department of Internal Medicine School of Medicine Yale University New Haven CT USA"},{"name":"Cancer Outcomes, Public Policy, and 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USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rong","family":"Wang","sequence":"additional","affiliation":[{"name":"Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center Yale University New Haven CT USA"},{"name":"Department of Chronic Disease Epidemiology School of Public Health Yale University New Haven CT USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaomei","family":"Ma","sequence":"additional","affiliation":[{"name":"Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center Yale University New Haven CT USA"},{"name":"Department of Chronic Disease Epidemiology School of Public Health Yale University New Haven CT USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cary P.","family":"Gross","sequence":"additional","affiliation":[{"name":"Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center Yale University New Haven CT 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