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

  • Shakira J. Grant
  • Shawn Kothari
  • Phyllis A. Gimotty
  • Nalaka S. Gooneratne
  • Adam Cuker


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.


Apixaban Atrial fibrillation Dabigatran Direct oral anticoagulants Elderly Rivaroxaban 


Compliance with ethical standards

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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© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Hematology-Oncology University of WashingtonFred Hutchinson Cancer Research CenterSeattleUSA
  2. 2.Department of MedicineUniversity of ChicagoChicagoUSA
  3. 3.Department of Biostatistics, Epidemiology and InformaticsPerelman School of Medicine, University of PennsylvaniaPhiladelphiaUSA
  4. 4.Department of MedicinePerelman School of Medicine, University of PennsylvaniaPhiladelphiaUSA
  5. 5.Department of Pathology and Laboratory MedicinePerelman School of Medicine, University of PennsylvaniaPhiladelphiaUSA
  6. 6.Penn Comprehensive Hemophilia and Thrombosis ProgramHospital of the University of PennsylvaniaPhiladelphiaUSA

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