Faye L Norby1,2, Pamela L Lutsey3, Nathan D Shippee4, Lin Y Chen5, Carrie Henning-Smith4,6, Alvaro Alonso7, Rob F Walker3, Aaron R Folsom3. 1. Department of Cardiology, Center for Cardiac Arrest Prevention, Smidt Heart Institute, Cedars-Sinai Health System, Advanced Health Sciences Pavilion, Suite A9220, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA. faye.norby@cshs.org. 2. Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA. faye.norby@cshs.org. 3. Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA. 4. Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA. 5. Cardiovascular Division, Department of Medicine, Cardiac Arrhythmia Center, University of Minnesota Medical School, Minneapolis, MN, USA. 6. Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis, MN, USA. 7. Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
Abstract
BACKGROUND: Data are needed on the use of oral anticoagulation in patients with atrial fibrillation (AF) in rural versus urban areas, including the initiation of direct oral anticoagulants (DOACs). OBJECTIVE: We used Medicare data to examine rural/urban differences in anticoagulation use in patients with AF. METHODS: We identified incident AF in a 20% sample of fee-for-service Medicare beneficiaries (aged ≥ 65 years) from 2011 to 2016 and collected ZIP code and covariates at the time of AF. We identified the first anticoagulant prescription filled, if any, following AF diagnosis. We categorized beneficiaries into four rural/urban areas using rural-urban commuting area codes and used Poisson regression models to compare anticoagulant use. RESULTS: We included 447,252 patients with AF (mean age 79 ± 8 years), of which 82% were urban, 9% large rural, 5% small rural, and 4% isolated. The percentage who initiated an anticoagulant rose from 34% in 2011 to 53% in 2016, paralleling the uptake of DOACs. In a multivariable-adjusted analysis, those in rural areas (vs. urban) were more likely to initiate an anticoagulant. However, rural beneficiaries (vs. urban) were less likely to initiate a DOAC; those in isolated areas were 17% less likely (95% confidence interval [CI] 13-20), those in small rural areas were 12% less likely (95% CI 9-15), and those in large rural areas were 10% less likely (95% CI 8-12). CONCLUSION: Among Medicare beneficiaries with AF, anticoagulation use was low but increased over time with the introduction of DOACs. Rural beneficiaries were less likely to receive a DOAC.
BACKGROUND: Data are needed on the use of oral anticoagulation in patients with atrial fibrillation (AF) in rural versus urban areas, including the initiation of direct oral anticoagulants (DOACs). OBJECTIVE: We used Medicare data to examine rural/urban differences in anticoagulation use in patients with AF. METHODS: We identified incident AF in a 20% sample of fee-for-service Medicare beneficiaries (aged ≥ 65 years) from 2011 to 2016 and collected ZIP code and covariates at the time of AF. We identified the first anticoagulant prescription filled, if any, following AF diagnosis. We categorized beneficiaries into four rural/urban areas using rural-urban commuting area codes and used Poisson regression models to compare anticoagulant use. RESULTS: We included 447,252 patients with AF (mean age 79 ± 8 years), of which 82% were urban, 9% large rural, 5% small rural, and 4% isolated. The percentage who initiated an anticoagulant rose from 34% in 2011 to 53% in 2016, paralleling the uptake of DOACs. In a multivariable-adjusted analysis, those in rural areas (vs. urban) were more likely to initiate an anticoagulant. However, rural beneficiaries (vs. urban) were less likely to initiate a DOAC; those in isolated areas were 17% less likely (95% confidence interval [CI] 13-20), those in small rural areas were 12% less likely (95% CI 9-15), and those in large rural areas were 10% less likely (95% CI 8-12). CONCLUSION: Among Medicare beneficiaries with AF, anticoagulation use was low but increased over time with the introduction of DOACs. Rural beneficiaries were less likely to receive a DOAC.
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