Association of Healthcare Plan with atrial fibrillation prescription patterns

Factors associated with oral anticoagulant prescription status among patients with a new diagnosis of atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia in adults and increases stroke risk. Treatment with oral anticoagulants (OACs) may reduce this risk however many patients do not receive OAC therapy. This study aimed to use electronic health record data to identify newly diagnosed AF patients at high risk for stroke and not anticoagulated as well as factors associated with OAC prescription.

HYPOTHESIS

Timely prescription of OACs among patients with newly diagnosed AF is poor.

METHODS

We performed a retrospective study of patients with a new diagnosis of AF. We assessed stroke risk with the CHA2 DS2 -VASc score. The primary outcome was prescription of an OAC within 6 months following diagnosis. We used logistic regression to see how the odds of being prescribed an OAC differs for 17 independent variables.

RESULTS

We identified 18 404 patients with a new diagnosis of AF. Among patients at high risk for stroke, 41.3% received an OAC prescription within 6 months. Male sex, Caucasian compared to African American race, stroke, obesity, congestive heart failure, vascular disorder, current antiplatelet, beta blocker, or calcium channel blocker prescription, and increasing CHA2 DS2 -VASc score were positively associated with receiving an OAC. Whereas anemia, renal dysfunction, liver dysfunction, antiarrhythmic drug use and increasing HAS-BLED score were negatively associated.

CONCLUSIONS

Most newly diagnosed AF patients at high stroke risk do not receive an OAC prescription in the first 6 months following diagnosis. Our analysis suggests that patient sex, race, comorbidities, and additional prescriptions are associated with rates of OAC prescribing.

Healthcare resource utilization in patients with newly diagnosed atrial fibrillation in the United States

OBJECTIVES

To summarize healthcare resource utilization (HCRU) in patients with newly diagnosed (incident) paroxysmal or persistent atrial fibrillation (AF).

METHODS

This retrospective, observational cohort study assessed HCRU among patients with incident paroxysmal or persistent AF using data from 1 January 2015 to 30 September 2019 in the IBM MarketScan® Research Databases.

RESULTS

A total of 50,796 patients were identified in the overall incident AF cohort. Rates of all-cause inpatient hospital stays, all-cause emergency room visits, and all-cause outpatient visits in the overall incident cohort were 46.8, 114.7, and 2,752.7 events per 100 patient-years (PY), respectively. Rates of cardiovascular-related inpatient stays for the overall population were 11.3 events per 100 PY. During follow-up, 50.4% of the overall cohort filled prescriptions for direct-acting oral anticoagulants and 5.0% had catheter ablation.

CONCLUSIONS

Advances in anticoagulation and ablation have been realized since previously published HCRU analyses of patients with atrial fibrillation. This update suggests that HCRU among patients with incident AF in the US remains high with some subgroups of patients receiving more specialized care.

Sex Differences in Oral Anticoagulation and Outcomes of Stroke and Intracranial Bleeding in Newly Diagnosed Atrial Fibrillation

Background

Female sex is an independent predictor of stroke in patients with atrial fibrillation (AF). Older data suggest undertreatment with anticoagulation among women compared with men. However, it is unknown if novel therapies and updated guidelines have impacted sex differences in AF treatment and outcomes.

Methods and Results

We performed a retrospective cohort study of 2.3 million women and men with a new diagnosis of AF and CHA₂DS₂‐VASc ≥2 from Marketscan US commercial claims data from 2008 to 2015 to determine whether women with AF remain undertreated and whether this difference mediates observed differences in outcomes. There were 358 649 patients with newly diagnosed AF (43% women). Compared with men, women were older, with higher CHA₂DS₂‐VASc scores, and higher comorbidity burden (P<0.0001 for all). Oral anticoagulation‐eligible women with CHA₂DS₂‐VASc scores ≥2 were more likely to not receive anticoagulation (50.0% women versus 43.9% men). Women, compared with men, had a higher risk of ischemic stroke (adjusted hazard ratio [aHR], 1.27; 95% CI, 1.21–1.32; P<0.0001) and hospitalization (aHR, 1.06; 95% CI, 1.05–1.07, P<0.0001) but had a lower risk of intracranial bleeding (aHR, 0.91; 95% CI, 0.83–0.99, P=0.03). In mediation analysis, nonreceipt of oral anticoagulation partially mediated the observed increased risk of stroke and decreased risk of intracranial bleeding in women.

Conclusions

In the care of newly diagnosed AF in the United States, women, compared with men, are less likely to receive oral anticoagulation. This appears to mediate the increased risk of both stroke and hospitalization but also appears to mediate lower observed intracranial bleeding risk.

Association of Healthcare Plan with atrial fibrillation prescription patterns

BACKGROUND

Atrial fibrillation (AF) is treated by many types of physician specialists, including primary care physicians (PCPs). Health plans have different policies for how patients encounter these providers, and these may affect selection of AF treatment strategy.

HYPOTHESIS

We hypothesized that healthcare plans with PCP-gatekeeping to specialist access may be associated with different pharmacologic treatments for AF.

METHODS

We performed a retrospective cohort study using a commercial pharmaceutical claims database. We utilized logistic regression models to compare odds of prescription of oral anticoagulant (OAC), non-vitamin K-dependent oral anticoagulant (NOAC), rate control, and rhythm control medications used to treat AF between patients with PCP-gated healthcare plans (eg, HMO, EPO, POS) and patients with non-PCP-gated healthcare plans (eg, PPO, CHDP, HDHP, comprehensive) between 2007 and 2012. We also calculated median time to receipt of therapy within 90 days of index AF diagnosis.

RESULTS

We found similar odds of OAC prescription at 90 days following new AF diagnosis in patients with PCP-gated plans compared to those with non-PCP-gated plans (OR: OAC 1.01, P = 0.84; warfarin 1.05, P = 0.08). Relative odds were similar for rate control (1.17, P < 0.01) and rhythm control agents (0.93, P = 0.03). However, PCP-gated plan patients had slightly lower likelihood of being prescribed NOACs (0.82, P = 0.001) than non-gated plan patients. Elapsed time until receipt of medication was similar between PCP-gated and non-gated groups across drug classes.

CONCLUSIONS

Pharmaceutical claims data do not suggest that PCP-gatekeeping by healthcare plans is a structural barrier to AF therapy, although it was associated with lower use of NOACs.