TY - JOUR
T1 - Prescribing of direct oral anticoagulants and warfarin to older people with atrial fibrillation in UK general practice
T2 - a cohort study
AU - Mitchell, Anneka
AU - Snowball, Julia
AU - Welsh, Tomas J.
AU - Watson, Margaret C.
AU - McGrogan, Anita
N1 - Funding Information:
This study was supported by a research training fellowship for AM from The Dunhill Medical Trust [grant number RTF109/0117]. The funder had no role in the data collection, analysis, interpretation of data or writing the manuscript.
PY - 2021/12/31
Y1 - 2021/12/31
N2 - Background: Anticoagulation for stroke prevention in atrial fibrillation (AF) has, historically, been under-used in older people. The aim of this study was to investigate prescribing of oral anticoagulants (OACs) for people aged ≥ 75 years in the UK before and after direct oral anticoagulants (DOACs) became available. Methods: A cohort of patients aged ≥ 75 years with a diagnosis of AF was derived from the Clinical Practice Research Datalink (CPRD) between January 1, 2003, and December 27, 2017. Patients were grouped as no OAC, incident OAC (OAC newly prescribed) or prevalent OAC (entered study on OAC). Incidence and point prevalence of OAC prescribing were calculated yearly. The risk of being prescribed an OAC if a co-morbidity was present was calculated; the risk difference (RD) was reported. Kaplan-Meier curves were used to explore persistence with anticoagulation. A Cox regression was used to model persistence with warfarin and DOACs over time. Results: The cohort comprised 165,596 patients (66,859 no OAC; 47,916 incident OAC; 50,821 prevalent OAC). Incidence of OAC prescribing increased from 111 per 1000 person-years in 2003 to 587 per 1000 person-years in 2017. Older patients (≥ 90 years) were 40% less likely to receive an OAC (RD −0.40, 95% CI −0.41 to −0.39) than younger individuals (75–84 years). The likelihood of being prescribed an OAC was lower with a history of dementia (RD −0.34, 95% CI −0.35 to −0.33), falls (RD −0.17, 95% CI −0.18 to −0.16), major bleeds (RD −0.17, 95% CI −0.19 to −0.15) and fractures (RD −0.13, 95% CI −0.14 to −0.12). Persistence with warfarin was higher than DOACs in the first year (0–1 year: HR 1.25, 95% CI 1.17–1.33), but this trend reversed by the third year of therapy (HR 0.75, 95% CI 0.63–0.89). Conclusions: OAC prescribing for older people with AF has increased; however, substantial disparities persist with age and co-morbidities. Whilst OACs should not be withheld solely due to the risk of falls, these results do not reflect this national guidance. Furthermore, the under-prescribing of OACs for patients with dementia or advancing age may be due to decisions around risk-benefit management. Trial registration: EUPAS29923. First registered on: 27/06/2019.
AB - Background: Anticoagulation for stroke prevention in atrial fibrillation (AF) has, historically, been under-used in older people. The aim of this study was to investigate prescribing of oral anticoagulants (OACs) for people aged ≥ 75 years in the UK before and after direct oral anticoagulants (DOACs) became available. Methods: A cohort of patients aged ≥ 75 years with a diagnosis of AF was derived from the Clinical Practice Research Datalink (CPRD) between January 1, 2003, and December 27, 2017. Patients were grouped as no OAC, incident OAC (OAC newly prescribed) or prevalent OAC (entered study on OAC). Incidence and point prevalence of OAC prescribing were calculated yearly. The risk of being prescribed an OAC if a co-morbidity was present was calculated; the risk difference (RD) was reported. Kaplan-Meier curves were used to explore persistence with anticoagulation. A Cox regression was used to model persistence with warfarin and DOACs over time. Results: The cohort comprised 165,596 patients (66,859 no OAC; 47,916 incident OAC; 50,821 prevalent OAC). Incidence of OAC prescribing increased from 111 per 1000 person-years in 2003 to 587 per 1000 person-years in 2017. Older patients (≥ 90 years) were 40% less likely to receive an OAC (RD −0.40, 95% CI −0.41 to −0.39) than younger individuals (75–84 years). The likelihood of being prescribed an OAC was lower with a history of dementia (RD −0.34, 95% CI −0.35 to −0.33), falls (RD −0.17, 95% CI −0.18 to −0.16), major bleeds (RD −0.17, 95% CI −0.19 to −0.15) and fractures (RD −0.13, 95% CI −0.14 to −0.12). Persistence with warfarin was higher than DOACs in the first year (0–1 year: HR 1.25, 95% CI 1.17–1.33), but this trend reversed by the third year of therapy (HR 0.75, 95% CI 0.63–0.89). Conclusions: OAC prescribing for older people with AF has increased; however, substantial disparities persist with age and co-morbidities. Whilst OACs should not be withheld solely due to the risk of falls, these results do not reflect this national guidance. Furthermore, the under-prescribing of OACs for patients with dementia or advancing age may be due to decisions around risk-benefit management. Trial registration: EUPAS29923. First registered on: 27/06/2019.
KW - Anticoagulant
KW - Apixaban
KW - Atrial fibrillation
KW - Dabigatran
KW - Edoxaban
KW - Older people
KW - Rivaroxaban
KW - Warfarin
UR - http://www.scopus.com/inward/record.url?scp=85113889399&partnerID=8YFLogxK
U2 - 10.1186/s12916-021-02067-5
DO - 10.1186/s12916-021-02067-5
M3 - Article
AN - SCOPUS:85113889399
SN - 1741-7015
VL - 19
JO - BMC medicine
JF - BMC medicine
IS - 1
M1 - 189
ER -