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

• Type of Material: Article
• Authors: Wesley T. O'Neal, Emory University; Pratik B. Sandesara, Emory University; J'Neka S. Claxton, Emory University; Richard F. MacLehose, University of Minnesota; Lin Y. Chen, University of Minnesota; Lindsay G. S. Bengtson, Optum; Alanna M. Chamberlain, Mayo Clinic; Faye L. Norby, University of Minnesota; Pamela L. Lutsey, University of Minnesota; Alvaro Alonso, Emory University
• Language: English
• Date: 2018-03-20
• Publisher: Wiley Open Access: Creative Commons Attribution Non-Commercial
• Publication Version: Final Published Version
• Copyright Statement: © 2018 The Authors.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1161/JAHA.117.007943
• Title of Journal or Parent Work: Journal of the American Heart Association
• ISSN: 2047-9980
• Volume: 7
• Issue: 6
• Grant/Funding Information: Research reported in this publication was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award numbers R01‐HL122200 and F32‐HL134290, and from the American Heart Association under award number 16EIA26410001.; The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the American Heart Association.
• Keywords: TRENDS; Science & Technology; outcomes; MANAGEMENT; Cardiac & Cardiovascular Systems; Cardiovascular System & Cardiology; Life Sciences & Biomedicine; PRIMARY-CARE; atrial fibrillation; OUTCOMES; TREAT-AF; anticoagulation
• Research Categories: Health Sciences, Epidemiology; Health Sciences, Public Health

Abstract

Differences 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 Results--We 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). Conclusions--Patients 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.