Guideline‐concordant initiation of oral anticoagulant therapy for stroke prevention in older veterans with atrial fibrillation eligible for Medicare Part D

Done, Nicolae; Roy, Amanda M.; Yuan, Yingzhe; Pizer, Steven D.; Rose, Adam J.; Prentice, Julia C.

doi:10.1111/1475-6773.13079

Cited by 6 publications

(19 citation statements)

References 44 publications

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“…This is comparable to other recent studies showing AC use of 8%‐22% among patients with AF with cirrhosis, ( 9,38 ) in contrast to ~50%‐60% in patients without cirrhosis. ( 39,40 ) Our study used high‐dimensional, longitudinal data and advanced causal‐inference methods to account for time‐updated factors that are likely to influence decisions around AC use as well as patient outcomes and address, to the extent possible, confounding by indication in a retrospective cohort.…”

Section: Discussionmentioning

confidence: 99%

Mortality and Hepatic Decompensation in Patients With Cirrhosis and Atrial Fibrillation Treated With Anticoagulation

et al. 2020

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Background and Aims Outcomes with anticoagulation (AC) are understudied in advanced liver disease. We investigated effects of AC with warfarin and direct oral anticoagulants (DOACs) on all‐cause mortality and hepatic decompensation as well as ischemic stroke, major adverse cardiovascular events, splanchnic vein thrombosis, and bleeding in a cohort with cirrhosis and atrial fibrillation (AF). Approach and Results This was a retrospective, longitudinal study using national data of U.S. veterans with cirrhosis at 128 medical centers, including patients with cirrhosis with incident AF, from January 1, 2012 to December 31, 2017 followed through December 31, 2018. To assess the effects of AC on outcomes, we applied propensity score (PS) matching and marginal structural models (MSMs) to account for confounding by indication and time‐dependent confounding. The final cohort included 2,694 veterans with cirrhosis with AF (n = 1,694 and n = 704 in the warfarin and DOAC cohorts after PS matching, respectively) with a median of 4.6 years of follow‐up. All‐cause mortality was lower with warfarin versus no AC (PS matched: hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.55‐0.76; MSM models: HR, 0.54; 95% CI, 0.40‐0.73) and DOACs versus no AC (PS matched: HR, 0.68; 95% CI, 0.50‐0.93; MSM models: HR, 0.50; 95% CI, 0.31‐0.81). In MSM models, warfarin (HR, 0.29; 95% CI, 0.09‐0.90) and DOACs (HR, 0.23; 95% CI, 0.07‐0.79) were associated with reduced ischemic stroke. In secondary analyses, bleeding was lower with DOACs compared to warfarin (HR, 0.49; 95% CI, 0.26‐0.94). Conclusions Warfarin and DOACs were associated with reduced all‐cause mortality. Warfarin was associated with more bleeding compared to no AC. DOACs had a lower incidence of bleeding compared to warfarin in exploratory analyses. Future studies should prospectively investigate these observed associations.

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Section: Discussionmentioning

confidence: 99%

Mortality and Hepatic Decompensation in Patients With Cirrhosis and Atrial Fibrillation Treated With Anticoagulation

et al. 2020

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Section: Methodsmentioning

confidence: 99%

“…We used established International Classification of Diseases, Ninth Revision (ICD-9) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis codes for AF from VA outpatient clinical encounters to identify unique patients with an initial diagnosis of AF from January 1, 2010, to December 31, 2018. 3,32 We used the date of the first detected AF diagnosis code to represent the index (initial) diagnosis. To restrict the cohort to patients with incident AF treated in the VA system, we excluded those with any prior outpatient diagnosis of AF or who were not enrolled in the VA system in the 2 years prior to their index diagnosis.…”

Section: Cohort Eligibility Criteriamentioning

confidence: 99%

“…We required all patients to have 1 or more outpatient confirmatory diagnoses of AF within 7 to 180 days of their index diagnosis (Figure 1). 32,33 Among 827 502 patients in the REACH-AF cohort with an index AF diagnosis between 2010 and 2018, 255 000 had continuous VA enrollment, no AF diagnosis in the 2 years prior, and a confirmatory AF diagnosis between 7 and 180 days after the index AF event.…”

Section: Cohort Eligibility Criteriamentioning

confidence: 99%

“…33 Consistent with prior studies, we excluded patients who died or were enrolled in hospice care within 90 days after their index AF diagnosis. 32,33 We excluded those missing race/ethnicity (0.6% [633 of 113 340 patients]) and multiracial individuals (0.9% [1041 of 113 340 patients]) given the small number and heterogeneity of these patients. Finally, we restricted our assessment to individuals with an index AF diagnosis between January 1, 2014, and December 31, 2018, when all 3 of the most commonly prescribed DOACs (apixaban, dabigatran, and rivaroxaban) were available on the national VA drug formulary.…”

Section: Cohort Eligibility Criteriamentioning

confidence: 99%

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Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System

et al. 2021

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IMPORTANCE Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups.Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients.OBJECTIVE To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation.

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Veterans Affairs Medical Center Racial and Ethnic Composition and Initiation of Anticoagulation for Atrial Fibrillation

Essien,

Kim,

Hausmann

et al. 2024

JAMA Netw Open

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ImportanceRacial and ethnic disparities exist in anticoagulation therapy for atrial fibrillation (AF). Whether medical center racial and ethnic composition is associated with these disparities is unclear.ObjectiveTo determine whether medical center racial and ethnic composition is associated with overall anticoagulation and disparities in anticoagulation for AF.Design, Setting, and ParticipantsRetrospective cohort study of Black, White, and Hispanic patients with incident AF from 2018 to 2021 at 140 Veterans Health Administration medical centers (VAMCs). Data were analyzed from March to November 2023.ExposureVAMC racial and ethnic composition, defined as the proportion of patients from minoritized racial and ethnic groups treated at a VAMC, categorized into quartiles. VAMCs in quartile 1 (Q1) had the lowest percentage of patients from minoritized groups (ie, the reference group).Main Outcomes and MeasuresThe odds of initiating any anticoagulant, direct-acting oral anticoagulant (DOAC), or warfarin therapy within 90 days of an index AF diagnosis, adjusting for sociodemographics, medical comorbidities, and facility factors.ResultsThe cohort comprised 89 791 patients with a mean (SD) age of 73.0 (10.1) years; 87 647 (97.6%) were male, 9063 (10.1%) were Black, 3355 (3.7%) were Hispanic, and 77 373 (86.2%) were White. Overall, 64 770 individuals (72.1%) initiated any anticoagulant, 60 362 (67.2%) initiated DOAC therapy, and 4408 (4.9%) initiated warfarin. Compared with White patients, Black and Hispanic patients had lower rates of any anticoagulant and DOAC therapy initiation but higher rates of warfarin initiation across all quartiles of VAMC racial and ethnic composition. Any anticoagulant therapy initiation was lower in Q4 than Q1 (69.8% vs 74.9%; adjusted odds ratio [aOR], 0.80; 95% CI, 0.69-0.92; P &lt; .001). DOAC and warfarin initiation were also lower in Q4 than in Q1 (DOAC, 69.4% vs 65.3%; aOR, 0.85; 95% CI, 0.74-0.97; P &lt; .001; warfarin, 5.4% vs 4.5%; aOR, 0.82; 95% CI, 0.67-1.00; P &lt; .001). In adjusted models, patients in Q4 were significantly less likely to initiate any anticoagulant therapy than those in Q1 (aOR, 0.88; 95% CI, 0.78-0.99). Patients in Q3 (aOR, 0.75; 95% CI, 0.60-0.93) and Q4 (aOR, 0.69; 95% CI, 0.55-0.87) were significantly less likely to initiate warfarin therapy than those in Q1. There was no significant difference in the adjusted odds of initiating DOAC therapy across racial and ethnic composition quartiles. Although significant Black-White and Hispanic-White differences in initiation of any anticoagulant, DOAC, and warfarin therapy were observed, interactions between patient race and ethnicity and VAMC racial composition were not significant.Conclusions and RelevanceIn a national cohort of VA patients with AF, initiation of any anticoagulant and warfarin, but not DOAC therapy, was lower in VAMCs serving more minoritized patients.

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Guideline‐concordant initiation of oral anticoagulant therapy for stroke prevention in older veterans with atrial fibrillation eligible for Medicare Part D

Cited by 6 publications

References 44 publications

Mortality and Hepatic Decompensation in Patients With Cirrhosis and Atrial Fibrillation Treated With Anticoagulation

Mortality and Hepatic Decompensation in Patients With Cirrhosis and Atrial Fibrillation Treated With Anticoagulation

Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System

Veterans Affairs Medical Center Racial and Ethnic Composition and Initiation of Anticoagulation for Atrial Fibrillation

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