Mark H Eckman1,2,3, Gregory Y H Lip4, Ruth E Wise1,2, Barbara Speer5, Megan Sullivan6, Nita Walker1,2, Brett Kissela7, Matthew L Flaherty7, Dawn Kleindorfer7, Peter Baker3, Robert Ireton3, Dave Hoskins3, Brett M Harnett3, Carlos Aguilar3, Anthony Leonard5, Lora Arduser8, Dylan Steen9, Alexandru Costea9, John Kues5. 1. Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio. 2. Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio. 3. Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio. 4. Centre for Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom. 5. Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio. 6. Academic Health Center, University of Cincinnati, Cincinnati, Ohio. 7. Department of Neurology, University of Cincinnati, Cincinnati, Ohio. 8. Department of English, University of Cincinnati, Cincinnati, Ohio. 9. Division of Cardiology, University of Cincinnati, Cincinnati, Ohio.
Abstract
OBJECTIVES: To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment. DESIGN: Retrospective cohort study. SETTING: Primary care practices of an academic healthcare system. PARTICIPANTS: Adults (aged 28-93) with nonvalvular atrial fibrillation (AF) seen between March 2013 and February 2014 (N = 1,585). MEASUREMENTS: Treatment recommendations were made using an AF decision support tool (AFDST) based on projections of quality-adjusted life expectancy calculated using a decision analytical model that integrates individual-specific risk factors for stroke and hemorrhage. RESULTS: Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and 39% (338/860) of men (P = .02). Although current treatment was discordant from recommended in 35% (89/258) of participants aged 85 and older and in 43% (575/1,328) of those younger than 85 (P = .01), many undertreated elderly adults were receiving aspirin as the sole antithrombotic agent. CONCLUSION: Physicians should understand that female sex is a significant risk factor for AF-related stroke and incorporate this into decision-making about thromboprophylaxis. Treating older adults with aspirin instead of OAT exposes them to significant risk of bleeding with little to no reduction in AF-related stroke risk.
OBJECTIVES: To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment. DESIGN: Retrospective cohort study. SETTING: Primary care practices of an academic healthcare system. PARTICIPANTS: Adults (aged 28-93) with nonvalvular atrial fibrillation (AF) seen between March 2013 and February 2014 (N = 1,585). MEASUREMENTS: Treatment recommendations were made using an AF decision support tool (AFDST) based on projections of quality-adjusted life expectancy calculated using a decision analytical model that integrates individual-specific risk factors for stroke and hemorrhage. RESULTS: Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and 39% (338/860) of men (P = .02). Although current treatment was discordant from recommended in 35% (89/258) of participants aged 85 and older and in 43% (575/1,328) of those younger than 85 (P = .01), many undertreated elderly adults were receiving aspirin as the sole antithrombotic agent. CONCLUSION: Physicians should understand that female sex is a significant risk factor for AF-related stroke and incorporate this into decision-making about thromboprophylaxis. Treating older adults with aspirin instead of OAT exposes them to significant risk of bleeding with little to no reduction in AF-related stroke risk.
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