Anticoagulant Initiation During Hospital Admissions for Atrial Fibrillation in South-East Queensland, Australia

Abstract

BACKGROUNDAnticoagulation reduces stroke risk in patients with atrial fibrillation (AF) but underprescribing in eligible patients has been commonly reported. Introduction of the direct acting oral anticoagulants (DOACs) was considered to potentially improve prescribing due to increased anticoagulant options. At the time of release to the Australian market, there was limited studies investigating anticoagulant usage during hospitalisations for AF. Therefore, the aim of this study was to investigate prescribing of oral anticoagulants during hospitalisations admissions for AF during the time of DOAC introduction to the Australian market. METHODA retrospective study was conducted of admissions to a tertiary Queensland hospital during 1 July 2012 to 10 June 2015. Patients were categorised according to oral anticoagulant therapy on both hospital admission and discharge. Changes to therapy and patient factors associated with prescribing were analysed. RESULTSA total of 1911 patients were included with 3396 admissions during the study period. There was a significant increase in the number of patients initiated on anticoagulant therapy during their first admission with higher rates of initiation of DOACs compared to warfarin.Ischaemic heart disease and high bleed risk were significantly associated with reduced prescribing of anticoagulant therapy on first and second admission respectively, while patients with history of stroke or transient ischaemic attack were significantly more likely to receive therapy. CONCLUSIONThe introduction of the DOACs to the Australian market increased initiation of anticoagulants to hospitalised patients with AF across all stroke risk categories. The availability of greater anticoagulant options has increased initiation of therapy but there remains potential to further optimise anticoagulant prescribing by targeting therapy according to guidelines and patient factors.

Non-adherence to Thromboprophylaxis Guidelines in Atrial Fibrillation: A Narrative Review of the Extent of and Factors in Guideline Non-adherence

“…[32,35,43,70,73,83] Stroke and bleeding risk or history are important predictors of guideline non-adherence and non-prescription of OACs. As one might expect, risk [36,43,76] or history of [58,83] stroke is directly associated with prescription of OACs, while bleeding risk [58,70,76] or previous bleeding [32,35,36,43,77] has an inverse association.…”

“…[40] When it comes to overtreatment, between 0.6% and 79.8% of patients at low risk of stroke who did not need any antithrombotic medication received treatment, which would be considered to be overtreatment. [18,22,26,31,33,35,[43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62] Recent studies that investigated trends in guideline adherence have shown substantial improvements in guideline adherence over time. Cowan et al [63] reported an increase in the prescription of OACs (by 30.6%) and a decline in the prescription of antiplatelet agents (by 26.8%) over a 10-year period in AF patients at high risk of stroke.…”

“…[39] The presence of comorbidities such as ischemic heart disease, cancer, chronic kidney disease, chronic obstructive pulmonary disease, dementia, peripheral arterial disease, and heart failure have all been associated with guideline non-adherence, in particular less OAC prescribing. [20,32,40,58,69,73,74] On the other hand, patients with deep venous thrombosis, hypertension, valvular heart disease, and higher body mass index are more likely to receive OACs. [20,61,73,83] Prescription of antiplatelet agents or non-steroidal anti-inflammatory drugs [36,41,56,64], recurrent falls or history of falls [32,77], first detected and/or paroxysmal AF [32,35], alcohol abuse [47,73], pharmacological (vs electrical) cardioversion [35], rural residence and illiteracy [20], difficult access to monitoring [40] and frailty [84] have all been associated with underprescription of OACs.…”

“…[64,68,85] Prescribers usually focus on the risk of bleeding associated with OACs rather than the risk associated with not prescribing anticoagulants. [20,35,54,58,70,76,80,85] Reports from qualitative studies indicate that prescribers use formal stroke risk assessment tools but few use formal bleeding assessment tools. [79,86] Instead, prescribers rely on informal and subjective bleeding risk assessments.…”

Use of thromboprophylaxis guidelines and risk stratification tools in atrial fibrillation: A survey of general practitioners in Australia

“…Several factors contribute to OAC undertreatment in AF. Most of the previous studies that reported factors associated with thromboprophylaxis undertreatment in AF were based on findings from retrospective studies and largely outside of the general practice setting 7,10,13–15 . Nonetheless, a previous review article identified that prescriber‐related factors, including their beliefs and practice patterns, were among the major contributors 8 .…”