Methodologic Differences Across Studies of Patients With Atrial Fibrillation Lead to Varying Estimates of Stroke Risk

Quinn, Gene R.; Severdija, Olivia N.; Chang, Yuchiao; Dallalzadeh, Liane O.; Singer, Daniel E.

doi:10.1161/jaha.117.007537

Cited by 5 publications

(4 citation statements)

References 38 publications

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“…It is, to our knowledge one of the first studies to compare baseline use of DOACs by race/ethnicity as well as the quality of DOAC use. The data were obtained from a prospectively assembled registry with detailed clinical information and close follow-up, thereby avoiding pitfalls of alternative designs, such as administrative database analyses …”

Section: Discussionmentioning

confidence: 99%

Association of Race/Ethnicity With Oral Anticoagulant Use in Patients With Atrial Fibrillation

et al. 2018

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IMPORTANCE Black and Hispanic patients are less likely than white patients to use oral anticoagulants for atrial fibrillation. Little is known about racial/ethnic differences in use of direct-acting oral anticoagulants (DOACs) for atrial fibrillation. OBJECTIVE To assess racial/ethnic differences in the use of oral anticoagulants, particularly DOACs, in patients with atrial fibrillation. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II, a prospective, US-based registry of outpatients with nontransient atrial fibrillation 21 years and older who were followed up from February 2013 to July 2016. Data were analyzed from February 2017 to February 2018. EXPOSURES Self-reported race/ethnicity as white, black, or Hispanic. MAIN OUTCOMES AND MEASURES The primary outcome was use of any oral anticoagulant, particularly DOACs. Secondary outcomes included the quality of anticoagulation received and oral anticoagulant discontinuation at 1 year. RESULTS Of 12 417 patients, 11 100 were white individuals (88.6%), 646 were black individuals (5.2%), and 671 were Hispanic individuals (5.4%) with atrial fibrillation. After adjusting for clinical features, black individuals were less likely to receive any oral anticoagulant than white individuals (adjusted odds ratio [aOR], 0.75 [95% CI, 0.56, 0.99]) and less likely to receive DOACs if an anticoagulant was prescribed (aOR, 0.63 [95% CI, 0.49-0.83]). After further controlling for socioeconomic factors, oral anticoagulant use was no longer significantly different in black individuals (aOR, 0.78 [95% CI, 0.59-1.04]); among patients using oral anticoagulants, DOAC use remained significantly lower in black individuals (aOR, 0.73 [95% CI, 0.55-0.95]). There was no significant difference between white and Hispanic groups in use of oral anticoagulants. Among patients receiving warfarin, the median time in therapeutic range was lower in black individuals (57.1% [IQR, 39.9%-72.5%]) and Hispanic individuals (51.7% [interquartile range {IQR}, 39.1%-66.7%]) than white individuals (67.1% [IQR, 51.8%-80.6%]; P < .001). Black and Hispanic individuals treated with DOACs were more likely to receive inappropriate dosing than white individuals (black patients, 61 of 394 [15.5%]; Hispanic patients, 74 of 409 [18.1%]; white patients, 1003 of 7988 [12.6%]; P = .01). One-year persistence on oral anticoagulants was the same across groups. CONCLUSIONS AND RELEVANCE After controlling for clinical and socioeconomic factors, black individuals were less likely than white individuals to receive DOACs for atrial fibrillation, with no difference between white and Hispanic groups. When atrial fibrillation was treated, the quality of anticoagulant use was lower in black and Hispanic individuals. Identifying modifiable causes of these disparities could improve the quality of care in atrial fibrillation.

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Section: Discussionmentioning

confidence: 99%

Association of Race/Ethnicity With Oral Anticoagulant Use in Patients With Atrial Fibrillation

et al. 2018

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“…A BP is a time period immediately after an inception event (here index ICH), during which outcome events (here possible admissions for re-ICH) are ignored (Figure 2). 23,24 The underlying assumption when using a BP is that misclassification of recurrent events is to a certain degree time-dependent, ie, more distant admissions are more likely to represent true recurrent events compared with admissions immediately after the index event.…”

Section: The Algorithmsmentioning

confidence: 99%

Validity of Simple Algorithms to Identify Recurrence of Intracerebral Hemorrhage in Two Danish Nationwide Registries

Jensen

Hald

Kristensen

et al. 2021

CLEP

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Purpose: Danish registries could be an attractive resource for studies of recurrent intracerebral hemorrhage (re-ICH). We developed and validated algorithms to identify re-ICH in the Danish Stroke Registry (DSR) and the Danish National Patient Registry (DNPR). Patients and Methods: Using multiple sources, we followed-up an inception cohort with verified first-ever spontaneous ICH (n = 2528) for their first re-ICH in 2009-2018 (study period). We used verified cases of re-ICH (n = 124) as the gold standard to assess the performance of register-based algorithms for identifying re-ICH. For each cohort member, we traced events of re-ICH (ICD-10-code I61) in the study period according to DSR and DNPR, respectively. For each registry, we tested algorithms with a blanking period (BP) -ie, a period immediately following the index ICH during which outcome events were ignoredof varying length (7 days-360 days). The algorithm with the shortest BP that returned a positive predictive value (PPV) of ≥80% was considered optimal. We also calculated negative predictive value (NPV), sensitivity, and specificity of each algorithm and [95% confidence intervals] for all proportions. Results: The optimal algorithm for DSR (BP 30 days) had a PPV of 89.

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“…Claims databases often carry information for relatively short periods, corresponding to the time a person has a certain employment. Limiting lookback to 6 or 12 months is therefore often necessary in order to have sufficient time left over for follow‐up …”

Section: Introductionmentioning

confidence: 99%

“…Limiting lookback to 6 or 12 months is therefore often necessary in order to have sufficient time left over for follow-up. 17,18 Hospital databases are generally linked to a certain area, which puts constraints on observation periods as patients move out or in an area. In nationwide administrative registers, whole populations can be followed over prolonged periods of time, with left censoring when the register started or immigration and right censoring at Other large databases such as the CPRD in the UK have been operational about as long, but without full national coverage.…”

Section: Introductionmentioning

confidence: 99%

Short lookback periods causing exaggerated stroke risk estimates in atrial fibrillation may expose patients to unnecessary anticoagulant treatment

Friberg

2019

Pharmacoepidemiology and Drug

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Purpose The purpose was to investigate how different lookback periods in observational registry studies affect estimates of stroke risk in patients with atrial fibrillation and stroke risk score CHA2DS2‐VASc 1, a level where the appreciated risk is likely to affect decisions about oral anticoagulation. Methods All 354 854 individuals in Sweden with a hospital diagnosis of atrial fibrillation during 2010‐2016 were included. At least 13 years of observational data prior to inclusion was available for all patients. The prevalence of hypertension, heart failure, diabetes, previous thromboembolism, and vascular disease was estimated from data with different lookback periods. The incident stroke rates at CHA2DS2‐VASc score 1 was then assessed using data with successively longer lookback periods. Results Depending on duration of lookback period, the proportion of patients with heart failure varied 2.7 times, thromboembolism 3.7 times, hypertension 4.0 times, and diabetes and vascular disease both approximately 4.5 times. During follow‐up, 22 237 patients suffered an ischaemic stroke. The estimated risk without anticoagulant treatment at CHA2DS2‐VASc score 1 was 51% higher if the scores had been calculated with the shortest lookback period than if all information had been used. Conclusions Short lookback periods underestimate comorbidity, cause high‐risk patients to be misclassified as low risk, and overestimate stroke risk at CHA2DS2‐VASc 1. This may lead to unnecessary anticoagulant treatment of true low‐risk patients. Transparency regarding lookback periods is essential for interpretation and comparison of registry studies.

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Methodologic Differences Across Studies of Patients With Atrial Fibrillation Lead to Varying Estimates of Stroke Risk

Cited by 5 publications

References 38 publications

Association of Race/Ethnicity With Oral Anticoagulant Use in Patients With Atrial Fibrillation

Association of Race/Ethnicity With Oral Anticoagulant Use in Patients With Atrial Fibrillation

Validity of Simple Algorithms to Identify Recurrence of Intracerebral Hemorrhage in Two Danish Nationwide Registries

Short lookback periods causing exaggerated stroke risk estimates in atrial fibrillation may expose patients to unnecessary anticoagulant treatment

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