Oral Anticoagulation Use in High-Risk Patients Is Improved by Elimination of False-Positive and Inactive Atrial Fibrillation Cases

Abstract

BACKGROUND: Multiple registries have reported that >40% of high-risk atrial fibrillation patients are not taking oral anticoagulants. The purpose of our study was to determine the presence or absence of active atrial fibrillation and CHA 2 DS 2 -VASc (Congestive heart failure, Hypertension, Age ≥75 y, Diabetes mellitus, prior Stroke [or transient ischemic attack or thromboembolism], Vascular disease, Age 65-74 y, Sex category) risk factors to accurately identify high-risk atrial fibrillation (CHA 2 DS 2 -VASc ≥2) patients requiring oral anticoagulants and the magnitude of the anticoagulant treatment gap. METHODS: We retrospectively adjudicated 6514 patients with atrial fibrillation documented by at least one of: billing diagnosis, electronic medical record encounter diagnosis, electronic medical record problem list, or electrocardiogram interpretation. RESULTS: After review, 4555/6514 (69.9%) had active atrial fibrillation, while 1201 had no documented history of atrial fibrillation and 758 had a history of atrial fibrillation that was no longer active. After removing the 1201 patients without a confirmed atrial fibrillation diagnosis, oral anticoagulant use in high-risk patients increased to 71.1% (P < .0001 compared with 62.9% at baseline). Oral anticoagulant use increased to 79.7% when the 758 inactive atrial fibrillation patients were also eliminated from the analysis (P < .0001 compared with baseline). In the active high-risk atrial fibrillation group, there was no significant difference in the use of oral anticoagulants between men (80.7%) and women (78.8%) with a CHA 2 DS 2 -VASc ≥2, or in women with a CHA 2 DS 2 -VASc ≥3 (79.9%). CONCLUSIONS: Current registries and health system health records with unadjudicated diagnoses overreport the number of high-risk atrial fibrillation patients not taking oral anticoagulants. Expert adjudication identifies a smaller treatment gap than previously described.

A targeted educational intervention increases oral anticoagulation rates in high-risk atrial fibrillation patients

“…A recent study eliminated falsely labeled AF and inactive AF patients in their review and found that OAC rates increased from 62.9% to 79.7%. 17 Although this had less of an effect on our study as a random sample of 50 patients was manually checked for AF to confirm the accuracy of the dashboard data, manual adjudication would be the most accurate way to assess for AF.…”

Oral anticoagulant underutilization among elderly patients with atrial fibrillation: insights from the United States Medicare database

“…As such, coding errors and lack of clinical accuracy may have introduced bias in the study. In fact, early studies have reported up to 30% false positive and inactive AF patients when extracted from large scale registries and elimination of such cases have shown to improve the OAC utilization [ 27 ]. Additionally, differential follow-up of AF patients in our cohort may have introduced selection bias, as patients with longer follow-ups were more likely to be treated with an OAC.…”