Utilization of anticoagulants and predictors of treatment among hospitalized patients with atrial fibrillation in the USA

Abstract

Objective: To evaluate utilization of anticoagulants (ACs) and the predictors of treatment of patients with a diagnosis of atrial fibrillation (AF) during a hospital stay in the USA. Methods: Patients (!18 years of age) who had a primary or secondary discharge diagnosis code of AF during a hospitalization (without a diagnosis of venous thromboembolism) were identified from the Premier Hospital database (1 January 2016-30 September 2017). AC treatments were examined during hospitalizations to assign AF patients into 3 study cohorts: those who received an oral AC (OAC), those who received parenteral AC only, and those who did not receive AC therapy. Multivariable logistic regression analyses were carried out to evaluate potential predictors of receiving parenteral AC only vs. OAC therapy, no AC therapy vs. OAC therapy, as well as the specific OAC drug choices. Results: Of the patients hospitalized with an AF diagnosis (n ¼ 482,729; mean age: 74.7 years; 46.8% female; 82.9% White; 79.4% with Medicare), 42.6% received OAC therapy (most commonly, warfarin or apixaban), 35.3% parenteral AC only, and 22.2% no AC therapy. A key predictor of not receiving OAC therapy was having an AF diagnosis in the second position (applicable to 87.4% of study population). Greater comorbidity level and prior baseline bleeding were strong predictors of receiving parenteral AC only or not receiving any AC therapy vs. receiving OAC therapy. Predictors of receiving warfarin vs. apixaban included higher stroke risk and prior baseline bleeding. Limitations: OAC utilization may have been underestimated since outpatient OAC utilization was not included in the analysis. Conclusions: A substantial portion of hospitalized AF patients did not receive any AC therapy, particularly those patients with an AF diagnosis in the second position on hospital records. The predictors of inpatient AC treatment that were identified may be helpful in the clinical decision-making process for patients who are hospitalized with AF.

Adherence to anticoagulant guideline for atrial fibrillation: A large care gap among stroke patients in a rural population

“…The proportion of highrisk patients who did not receive any therapy in our study was slightly higher, around 31%, compared to 21% previously reported in the U.S [12]. Likewise, other studies have shown that overall, between 22% to 25% of AF patients do not receive treatment [7,13]. Contrasted with 48% of high-risk patients (CHA 2 DS 2 -VASc ≥2) receiving anticoagulants in our study, the National Anticoagulation Benchmark Outcomes Report established that from 86% of the patients identified as high-risk, only 55% received warfarin in a 2002 study [12].…”

“…As the patients with undertreated AF are at higher risk of a stroke, our study by default recruited a higher proportion of undertreated patients than what we would have had in a population study. Nevertheless, compared to previous reports in the United States (U.S.), the population demographics and comorbidities are similar despite our predominantly rural population [7,13]. Contrasted to our study, Aronis et al combined data from the GHS, the University of Alabama, and the Boston Medical Center [7].…”

“…This comprehensive data collection allowed us to take a closer look at specific comorbidities, such as other thromboembolism, chronic kidney disease, and neoplasm. While our cohort contained patients from different centers, the demographics of these patients lacked racial and socioeconomic diversity compared to previous studies [7,13,28]. The use of ICD-9-CM and ICD-10-CM codes also provided several limitations.…”

“…The AF undertreatment is a long-established healthcare concern [7,[9][10][11][12]. Despite multiple studies investigating the prevalence of AF undertreatment among stroke patients, reports worldwide differ on the proportion of patients who did not receive OAC treatment, ranging from around 20% to 60% [7,[10][11][12][13][14][15]. Furthermore, it remains unclear what factors affect an individual's risk of undertreatment as prior studies have shown diverse associations with increasing age, heart failure, ischemic stroke, and TIA [7,[10][11][12][16][17][18].…”

Influence of Prior Major Bleeding on the Safety and Effectiveness of Left Atrial Appendage Closure in Non-Valvular Atrial Fibrillation Patients: A Single-Center Study

“…On the other hand, such patients are usually not treated properly with anticoagulation, and are therefore also at high risk for thromboembolic events in clinical practice. Deitelzweig et al reported that prior baseline bleeding was a strong predictor of not receiving any anticoagulation therapy [25]. For patients with a contraindication to OAC who were on oral anticoagulants, use of OAC could signi cantly decrease the incidence of mortality, stroke and all-cause hospitalization during long-term follow-up, compared with those not receiving anticoagulation [24].…”