Warfarin tablets

NEW ORLEANS—Many US patients who are candidates for treatment with oral anticoagulants (OACs) are not actually receiving these drugs, a large study suggests.

Investigators analyzed information on nearly 1.6 million hospital admissions of patients with atrial fibrillation who were candidates for OAC treatment according to guideline recommendations.

The data showed that only 46% of these patients actually received an OAC at discharge.

“This low rate of OAC use in hospitalized patients highlights an important opportunity to improve care in atrial fibrillation patients,” said Sean Pokorney, MD, of Duke University School of Medicine in Durham, North Carolina.

Dr Pokorney and his colleagues presented this research at the American Heart Association Scientific Sessions (abstract 17636).

The study was supported by Janssen Scientific Affairs, and some of the study’s investigators reported financial relationships with Janssen.

The investigators analyzed data on 1,579,456 hospital admissions across the US, occurring between January 2010 and June 2015, in which patients were treated for atrial fibrillation. The information was taken from the Premier Healthcare Database, which includes data for 1 in 5 hospital discharges in the US.

The patients analyzed were at least 40 years old and stayed in the hospital for at least 1 day. They also had a CHA₂DS₂-VASc stroke risk score of 2 or higher and were therefore candidates for treatment with an OAC, according to guideline recommendations from the American Heart Association and American College of Cardiology.

The CHA₂DS₂-VASc stroke risk score considers several factors, including age, sex, and history of congestive heart failure, stroke, diabetes, hypertension, and vascular disease.

“[I]n certain cases, it may not be safe for patients with a high stroke risk score to take blood thinners because of complications that could arise,” Dr Pokorney noted. “Still, we think 50% is too low and that there are thousands of preventable strokes happening in the United States each year because of the low rates of OAC usage.”

Dr Pokorney noted that use of OACs hovered just below 50% across several subgroups in the study.

OAC use by subgroup

The proportion of OAC use was:

46% overall

47% for patients with prior stroke

45% for females

46% for non-whites

47% for patients with hypertension

49% for those with diabetes

45% for patients with chronic kidney disease

35% for those with dementia

38% for patients with a history of falls

47% for those younger than 55

50% for ages 55-64 and 65-74

49% for ages 75-84

38% for patients 85 and older.

“This study identified a gap in care and is a critical first step in raising questions about how we can optimize the OAC decision-making process that atrial fibrillation patients and their providers are engaging in during a hospital stay and at the point of discharge,” Dr Pokorney said.

Barriers to OAC use

Dr Pokorney and his colleagues hope to conduct further research to determine what barriers to OAC use might exist. Dr Pokorney said possible barriers could include:

A lack of understanding about atrial fibrillation and the risk of stroke or fear of using OACs among patients

Knowledge deficits about stroke prevention or overemphasis of the risks of OACs among healthcare providers

A view that OAC use is an outpatient issue, rather than an inpatient issue, among healthcare providers and systems.

Study limitations

The data showed whether patients were provided an OAC during their hospital stays. For the purposes of the study, the investigators assumed that those inpatients who were on an OAC within 24 hours of hospital discharge were also prescribed an OAC upon discharge.

However, there was no way to verify that a prescription was indeed made or filled after discharge. Additionally, although the investigators tried to exclude patients who were not candidates for OACs because of the risk of complications, there is the possibility that some remained in the study’s sample.

Eligible patients aren’t receiving anticoagulants