Background Direct oral anticoagulants (DOACs) are widely used in patients with nonvalvular atrial fibrillation for stroke prevention. However, long‐term adherence to DOACs and clinical outcomes in real‐world clinical practice is not well understood. This study evaluated long‐term medication adherence patterns to DOAC therapy and clinical outcomes in a large US integrated health care system. Methods and Results We included adult patients with nonvalvular atrial fibrillation who newly initiated DOACs between 2012 and 2018 in Kaiser Permanente Southern California. Long‐term (3.5 years) adherence trajectories to DOAC were investigated using monthly proportion of days covered and group‐based trajectory models. Factors associated with long‐term adherence trajectories were investigated. Multivariable Poisson regression analyses were used to investigate thromboembolism and major bleeding events associated with long‐term adherence trajectories. Of 18 920 patients newly initiating DOACs, we identified 3 DOAC adherence trajectories: consistently adherent (85.2%), early discontinuation within 6 months (10.6%), and gradually declining adherence (4.2%). Predictors such as lower CHA 2 DS 2 ‐VASc (0–1 versus ≥5) and previous injurious falls were associated with both early discontinuation and gradually declining adherence trajectories. Early discontinuation of DOAC therapy was associated with a higher risk of thromboembolism (rate ratio, 1.40; 95% CI, 1.05–1.86) especially after 12 months from DOAC initiation but a lower risk of major bleed compared with consistent adherence (rate ratio, 0.48; 95% CI, 0.30–0.75), specifically during the first 12 months following DOAC initiation. A gradual decline in adherence to DOACs was not statistically significantly associated with thromboembolism outcomes compared with consistent adherence. Conclusions Although a large proportion of patients with nonvalvular atrial fibrillation were adherent to DOAC therapy over 3.5 years, early discontinuation of DOAC was associated a higher risk of thromboembolic events. Future tailored interventions for early discontinuers may improve clinical outcomes.

We observed that increased LOS was the only clinically relevant measure negatively impacted by resident physician involvement during RAPN.

IntroductionStudies of hypertension in pregnancy that use electronic health care data generally identify hypertension using hospital diagnosis codes alone. We sought to compare results from this approach to an approach that included diagnosis codes, antihypertensive medications and blood pressure (BP) values.Materials and methodsWe conducted a retrospective cohort study of 1,45,739 pregnancies from 2009 to 2014 within an integrated healthcare system. Hypertensive pregnancies were identified using the “BP-Inclusive Definition” if at least one of three criteria were met: (1) two elevated outpatient BPs, (2) antihypertensive medication fill plus an outpatient hypertension diagnosis, or (3) hospital discharge diagnosis for preeclampsia or eclampsia. The “Traditional Definition” considered only delivery hospitalization discharge diagnoses. Outcome event analyses compared rates of preterm delivery and small for gestational age (SGA) between the two definitions.ResultsThe BP-Inclusive Definition identified 14,225 (9.8%) hypertensive pregnancies while the Traditional Definition identified 13,637 (9.4%); 10,809 women met both definitions. Preterm delivery occurred in 20.9% of BP-Inclusive Definition pregnancies, 21.8% of Traditional Definition pregnancies and 6.6% of non-hypertensive pregnancies; for SGA the numbers were 15.6, 16.3, and 8.6%, respectively (p < 0.001 for all events compared to non-hypertensive pregnancies). Analyses in women meeting only one hypertension definition (21–24% of positive cases) found much lower rates of both preterm delivery and SGA.ConclusionPrevalence of hypertension in pregnancy was similar between the two study definitions. However, a substantial number of women met only one of the study definitions. Women who met only one of the hypertension definitions had much lower rates of adverse neonatal events than women meeting both definitions.

BackgroundSerological markers have been investigated for the identification of RA. Current diagnostic criteria recommend conducting tests for anti-citrullinated peptide antibodies (ACPA) and rheumatoid factor (RF) prior to reaching the RA diagnosis. However, there is a lack of information about how these tests are utilized in a managed care setting.ObjectivesTo describe the frequency of ACPA/RF tests at the time of RA diagnosis and at follow-up, as well as to compare baseline characteristics between patients who received ACPA/RF tests and those who did not.MethodsA cohort study was conducted using adult patients newly diagnosed with RA within a US integrated healthcare delivery system from 1 January 2007 to 31 December 2014. Individuals were followed from their first RA diagnosis (index date) until 30 June 2015. Patients were required to have two ICD-9 codes of 714.x, treatment with a DMARD, and continuous eligibility for 12 months prior to the index date (baseline period). At baseline, data were collected on co-morbid conditions, laboratory test results and dispensed medications. Descriptive statistics and multivariable logistic regression analyses were conducted to describe ACPA/RF testing patterns and to investigate baseline patient characteristics associated with ACPA/RF testing.ResultsA total of 7444 patients with newly diagnosed RA were identified. Mean (SD) age was 55.6 (15.0) years, 75% were female, 69% of patients received corticosteroid treatment and 22% had other autoimmune diseases at baseline. Overall, 83% had both ACPA and RF tests at baseline while 10% and 2% had only an RF or an ACPA test, respectively. Baseline ACPA and RF testing rates were increased over time (p<0.001) and both ACPA and RF testing rates were >90% from 2012 onwards (Table). At baseline, 34% of patients had positive ACPA and RF test results, 30% had negative ACPA and RF results, 6% had only ACPA-positive and 21% had only RF-positive results. During follow-up, 20% of patients repeated their ACPA tests; 11% had a repeat test within 1 year of baseline. Patients with a higher Elixhauser index (odds ratio [OR]=0.72, 95% CI 0.62, 0.95) were less likely to receive ACPA tests at baseline, whereas patients receiving NSAIDs (OR=1.45, 95% CI 1.25, 1.69) or corticosteroids (OR=1.23, 95% CI 1.07, 1.43) were more likely to receive baseline ACPA tests. Patients who had other autoimmune conditions were more likely to repeat their ACPA tests during follow-up.Table 1.Baseline ACPA and RF testing rates by index yearIndex yearNew RA patients, total NBaseline ACPA test, N (%)Baseline RF test, N (%)20071095740 (67.6)919 (83.9)2008926703 (75.9)856 (92.4)2009921782 (84.9)870 (94.4)2010914796 (87.1)870 (95.2)2011885812 (91.8)856 (96.7)2012921847 (92.0)880 (95.5)2013919841 (91.5)876 (95.3)2014863829 (96.1)833 (96.5)Total74446350 (85.3)6960 (93.5)ConclusionsACPA and RF testing rates in patients with RA have increased over time, with 96% of patients with newly diagnosed RA receiving both tests at the time of RA diagnosis in 2014. However, there may be still ...

Off-label reduced dosing of direct oral anticoagulants is common among patients at high bleeding risk with atrial fibrillation (AF), however, outcomes data of reduced dosing are limited. We evaluated the effectiveness and safety of reduced dose of dabigatran [110 mg twice daily (BID)] vs. standard dose [150 mg BID] in high bleeding risk subgroups with AF. We identified adult patients with AF who initiated dabigatran (index date) with creatinine clearance (CrCl) ≥30 mL/min between 2012-2018 from Kaiser Permanente Southern California. Three high bleeding risk subgroups were identified: 1) patients aged ≥80 years; 2) patients with moderate renal impairment (CrCl 30-49 mL/min) regardless of age; or 3) patients with bleeding within 12 months prior to the index date or HAS-BLED score ≥3. Patients were followed through December 2018 for stroke or systemic embolism, major bleeding requiring hospitalization, and all-cause mortality. Cause-specific hazard regression models were used to investigate associations between dabigatran dose and clinical outcomes adjusting for covariates and considering competing risks of death. Among high bleeding risk patients with AF [3,749 aged ≥80 years; 1,716 with moderate renal impairment; 3,051 with recent bleed or high HAS-BLED score], 34% received reduced dose of dabigatran. Patients who received reduced dose were older, had reduced renal function, and had more comorbidities. Compared with standard dose, reduced dose of dabigatran was not associated with an increased risk of stroke or systemic embolism but was associated with lower risk of major bleed in patients aged ≥80 years ( Table ). Reduced dose of dabigatran was also associated with lower risk of mortality among patients aged ≥80 years and patients with moderate renal impairment. A lower risk of bleeds and mortality associated with reduced vs standard dose of dabigatran in high-risk patients with AF suggest a better dosing strategy for these risk groups.