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Quality of direct oral anticoagulant prescribing in elderly patients with non-valvular atrial fibrillation: results from a large urban health system

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Abstract

Non-valvular atrial fibrillation (NVAF) is common in older adults. Oral anticoagulation is indicated to reduce the risk of stroke and systemic embolism, but it also poses a risk of bleeding, particularly in the elderly. Direct oral anticoagulants (DOACs) provide an alternative to warfarin and their use in the treatment of AF is growing. We conducted a retrospective cohort study to assess the quality of DOAC prescribing in elderly patients with NVAF in a large academic health system and to compare practice with consensus best practice recommendations. We searched the electronic medical record for patients ≥ 65 years of age who were newly initiated on a DOAC for AF from January 2013 through December 2015. Patient and provider characteristics, baseline laboratory investigations, concomitant medications, and interval to first follow-up were recorded. 192 patients met eligibility criteria. The most commonly prescribed DOACs were rivaroxaban (65%) and apixaban (26%). Despite consensus recommendations that patients have a baseline creatinine, complete blood cell count, and coagulation studies prior to DOAC initiation, these tests were not performed in 18, 31, and 67% of patients, respectively. Consensus recommendations also suggest a follow-up visit within 1 month of DOAC initiation. However, only 39% of patients had a return visit within 6 weeks and 43% did not have follow-up within 12 weeks. DOAC prescribing in elderly patients with NVAF frequently fell short of quality standards. Interventions to enhance the quality of DOAC prescribing in this high-risk population are needed.

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Authors and Affiliations

  1. Division of Hematology-Oncology University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA, USA

    Shakira J. Grant

  2. Department of Medicine, University of Chicago, Chicago, IL, USA

    Shawn Kothari

  3. Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Phyllis A. Gimotty

  4. Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Nalaka S. Gooneratne & Adam Cuker

  5. Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Adam Cuker

  6. Penn Comprehensive Hemophilia and Thrombosis Program, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA

    Adam Cuker

Authors
  1. Shakira J. Grant
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  2. Shawn Kothari
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  3. Phyllis A. Gimotty
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  4. Nalaka S. Gooneratne
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  5. Adam Cuker
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Corresponding author

Correspondence to Adam Cuker.

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Conflict of interest

AC has received research support from Alexion, Bayer, Bioverativ, Novo-Nordisk, Pfizer, Shire, Spark Therapeutics, and Syntimmune and served as a consultant for Genzyme, Kedrion, and Synergy. The other authors have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Grant, S.J., Kothari, S., Gimotty, P.A. et al. Quality of direct oral anticoagulant prescribing in elderly patients with non-valvular atrial fibrillation: results from a large urban health system. J Thromb Thrombolysis 46, 1–6 (2018). https://doi.org/10.1007/s11239-018-1651-0

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  • DOI: https://doi.org/10.1007/s11239-018-1651-0

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