Provider Specialty, Anticoagulation Prescription Patterns, and Stroke Risk in Atrial Fibrillation

Abstract

BackgroundDifferences in anticoagulation rates and direct oral anticoagulant use by provider specialty may identify an area of practice improvement to reduce future stroke events in patients with atrial fibrillation (AF).Methods and ResultsWe examined anticoagulant prescription fills in 388 045 (mean age, 68±15 years; 59% male) patients with incident AF from the MarketScan databases between 2009 and 2014. Provider specialty and filled anticoagulant prescriptions around the time of AF diagnosis (3 months before through 6 months after) were obtained from outpatient services and pharmacy claims. We estimated the association of provider specialty (cardiology versus primary care) with filling oral anticoagulant prescriptions, adjusting for patient characteristics. The risk of stroke and bleeding events also was explored. A total of 235 739 patients (61%) had a cardiology provider claim, whereas 152 306 (39%) were exclusively managed by primary care. Patients seen by cardiology providers were more likely to fill anticoagulant prescriptions than those seen by primary care (39% versus 27%; relative risk, 1.39; 95% confidence interval [CI], 1.37–1.40). Differences were observed for direct oral anticoagulants (relative risk, 1.74; 95% CI, 1.71–1.78) and warfarin (relative risk, 1.24; 95% CI, 1.22–1.26). A reduced risk of stroke events was observed among those seen by cardiology providers (hazard ratio, 0.90; 95% CI, 0.86–0.94) compared with primary care, without an increased bleeding risk (hazard ratio, 1.03; 95% CI, 0.98–1.07).ConclusionsPatients seen by an outpatient cardiology provider shortly after AF diagnosis were more likely to initiate oral anticoagulation and were at lower risk of future stroke events without a higher rate of bleeding. Early referral to cardiology specialists may increase initiation of anticoagulant therapies and improve outcomes in AF.

Provider Specialty, Anticoagulation, and Stroke Risk in Patients With Atrial Fibrillation and Cancer

“…We also examined whether there was a beneficial association of early cardiology involvement around the time of AF diagnosis among patients who had a history of cancer. In addition to confirming this beneficial association (9,10), we have demonstrated that early cardiology involvement shortly after AF diagnosis is less likely in those who have a history of cancer. Due to the favorable association of cardiology provider involvement on oral anticoagulant prescription fills in AF patients with a history of cancer, early referral to cardiology specialists shortly after diagnosis may be beneficial to increase the use of antithrombotic agents and reduce the risk of future stroke events in this subset of AF patients.…”

“…This suggests that greater differences in oral anticoagulant fills will be observed in AF patients with a history of cancer who are younger, and this possibly is related to provider perception of poor survival in younger patients with a history of cancer. Alternatively, cancer history may have limited additive influence in older adults, as they are less likely to see a cardiology provider or fill an anticoagulant prescription regardless of cancer history (10). However, the explanations provided for variation by age are speculative and further research is needed to understand this difference.…”

“…In the United States, it is unknown whether patients with AF and cancer receive antithrombotic therapies or have early cardiology involvement after their AF diagnosis similar to those without cancer. Early cardiology involvement within 90 days of AF diagnosis has been shown to be associated with greater oral anticoagulant use (8–10), and reduced risk of future stroke events (9,10). It is possible that patients with AF and history of cancer are less likely to receive antithrombotic therapies or see cardiology providers after their diagnosis due to negative perception of survival or a lack of perceived benefit with anticoagulant agents.…”

Prevalence and Knowledge of Potential Interactions Between Over‐the‐Counter Products and Apixaban

“…Our goals were to determine the prevalence of use of OTC medications and dietary supplements with potentially serious interactions with apixaban, one of the most frequently prescribed DOACs, and to assess patient knowledge of potentially serious OTC product–apixaban interactions.…”

Anticoagulants for cancer-associated ischemic stroke

“…A recent claimed data analysis in the United States evaluated the occurrence of stroke and risk of bleeding among the atrial fibrillation patients with history of cancer. The results found that early cardiology involvement with oral anticoagulant reduced the risk of stroke with an increase of bleeding in patients with either active or remote history of cancer [29].…”