Evidence‐Practice Gaps in Postdischarge Initiation With Oral Anticoagulants in Patients With Atrial Fibrillation

Abstract

Background Oral anticoagulant ( OAC ) therapy reduces the risk of stroke in people with atrial fibrillation ( AF ), and is considered best practice; however, there is little Australian evidence around the uptake of OAC s in this population. Methods and Results We used linked hospital admissions, pharmaceutical dispensing claims, medical services, and mortality data for people in Australia's 2 most populous states (July 2010 to June 2015). Among OAC ‐naïve people hospitalized with AF , we estimated initiation of OAC therapy within 30 days of discharge, and persistence with therapy in the first year. We analyzed both outcomes using multivariable Cox regression. In 71 184 people with AF (median age 78 years, 49% female), 22.7% initiated OAC therapy. Initiation was lowest in July to December 2011 (17.0%) and highest in July to December 2014 (30.1%) after subsidy of the direct OAC s. In adjusted analyses, initiation was most likely in people with a CHA 2 DS 2 ‐ VA score ≥7 (versus 0) (hazard ratio=6.25, 95% CI 5.08–7.69), and a history of venous thromboembolism (hazard ratio=2.65, 95% CI 2.49–2.83). Of the people who initiated OAC therapy, 39.9% discontinued within 1 year; a lower risk of discontinuation was associated with a CHA 2 DS 2 ‐ VA score ≥7 (versus 0) (hazard ratio=0.22, 95% CI 0.14–0.35), or initiation on a direct OAC (versus warfarin) (hazard ratio=0.55, 95% CI 0.50–0.60). Conclusions We found that OAC therapy was severely underutilized in people hospitalized with AF , even among high‐risk individuals. Reasons for this underuse, whether patient, prescriber, or hospital related, should be identified and addressed to reduce stroke‐related morbidity and mortality in people with AF .

Ten-Year Trends in the Use of Oral Anticoagulants in Australian General Practice Patients With Atrial Fibrillation

“…Recent studies on the utilization of OAC have highlighted both underuse and overuse in patients with AF in Australia ( Admassie et al, 2017 ; Alamneh et al, 2017 ; Schaffer et al, 2019 ). The Tasmanian AF Study observed prescribing practice from 2011 to 2015, and reported that 55 and 63% of eligible AF patients with a high stroke risk were prescribed an OAC before and after DOACs were listed on the PBS, respectively ( Admassie et al, 2017 ).…”

The changing face of Australian data reforms: Impact on pharmacoepidemiology research

“…With respect to undertaking exposure-outcomes studies, the Australian Institute of Health and Welfare’s development of multi-source enduring linked data assets (MELDAs) comprising continuing cross-jurisdictional, person-level linkages of medicines exposure with hospitalisation and mortality data show strong potential to further accelerate national population-based research capacity [ 25 , 26 ]. At the time of writing, there were no formal policies around third-party access (including to academic researchers) to the current suite of MELDAs; this should be considered an immediate priority to realise this significant investment in public money [ 27 ].…”

Missed Opportunities to Initiate Oral Anticoagulant in Atrial Fibrillation: Insights from Australian Acute Coronary Syndrome Registries

“…In the absence of funded clinical audits the most promising avenue may be jurisdictional and national information sets linking clinical diagnoses to prescribing data. Although there is a time lag between prescription and availability of this information, recent demonstration projects have shown the power of these datasets [35].…”