TY - JOUR
T1 - Switching warfarin to direct oral anticoagulants in atrial fibrillation
T2 - Insights from the NCDR PINNACLE registry
AU - Sciria, Christopher T.
AU - Maddox, Thomas M.
AU - Marzec, Lucas
AU - Rodwin, Benjamin
AU - Virani, Salim S.
AU - Annapureddy, Amarnath
AU - Freeman, James V.
AU - O'Hare, Ali
AU - Liu, Yuyin
AU - Song, Yang
AU - Doros, Gheorghe
AU - Zheng, Yue
AU - Lee, Jane J.
AU - Daggubati, Ramesh
AU - Vadlamani, Lina
AU - Cannon, Christopher
AU - Desai, Nihar R.
N1 - Funding Information:
Dr Christopher T. Sciria, MD and Dr Nihar Desai had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The Baim Institute conducted and is responsible for the data analysis. T. M. M.: Washington University School of Medicine (employment); NIH NCATS 1U24TR002306‐01 (grant funding); Creative Educational Concepts (consultant). A. O.; Y. L., Y. S., Y. Z., J. J. L.: None. S. S. V.: Department of Veterans Affairs Health Services Research and Development; World Heart Federation, Freeman: NHLBI: K23 HL118147‐01; R56HL142765; R01HL142765; American College of Cardiology National Cardiovascular Data Registry.
Funding Information:
Dr Christopher T. Sciria, MD and Dr Nihar Desai had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The Baim Institute conducted and is responsible for the data analysis. T. M. M.: Washington University School of Medicine (employment); NIH NCATS 1U24TR002306-01 (grant funding); Creative Educational Concepts (consultant). A. O.; Y. L., Y. S., Y. Z., J. J. L.: None. S. S. V.: Department of Veterans Affairs Health Services Research and Development; World Heart Federation, Freeman: NHLBI: K23 HL118147-01; R56HL142765; R01HL142765; American College of Cardiology National Cardiovascular Data Registry.
Publisher Copyright:
© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.
PY - 2020/7/1
Y1 - 2020/7/1
N2 - Background: Previous studies examining the use of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) have largely focused on patients newly initiating therapy. Little is known about the prevalence/patterns of switching to DOACs among AF patients initially treated with warfarin. Hypothesis: To examine patterns of anticoagulation among patients chronically managed with warfarin upon the availability of DOACs and identify patient/practice-level factors associated with switching from chronic warfarin therapy to a DOAC. Methods: Prospective cohort study of AF patients in the NCDR PINNACLE registry prescribed warfarin between May 1, 2008 and May 1, 2015. Patients were followed at least 1 year (median length of follow-up 375 days, IQR 154-375) through May 1, 2016 and stratified as follows: continued warfarin, switched to DOAC, or discontinued anticoagulation. To identify significant predictors of switching, a three-level multivariable hierarchical regression was developed. Results: Among 383 008 AF patients initially prescribed warfarin, 16.3% (n = 62 620) switched to DOACs, 68.8% (n = 263 609) continued warfarin, and 14.8% (n = 56 779) discontinued anticoagulation. Among those switched, 37.6% received dabigatran, 37.0% rivaroxaban, 24.4% apixaban, and 1.0% edoxaban. Switched patients were more likely to be younger, women, white, and have private insurance (all P <.001). Switching was less likely with increased stroke risk (OR, 0.92; 95%CI, 0.91-0.93 per 1-point increase CHA2DS2-VASc), but more likely with increased bleeding risk (OR, 1.12; 95%CI, 1.10-1.13 per 1-point increase HAS-BLED). There was substantial variation at the practice-level (MOR, 2.33; 95%CI, 2.12-2.58) and among providers within the same practice (MOR, 1.46; 95%CI, 1.43-1.49). Conclusions: Among AF patients treated with warfarin between October 1, 2010 and May 1, 2016, one in six were switched to DOACs, with differences across sociodemographic/clinical characteristics and substantial practice-level variation. In the context of current guidelines which favor DOACs over warfarin, these findings help benchmark performance and identify areas of improvement.
AB - Background: Previous studies examining the use of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) have largely focused on patients newly initiating therapy. Little is known about the prevalence/patterns of switching to DOACs among AF patients initially treated with warfarin. Hypothesis: To examine patterns of anticoagulation among patients chronically managed with warfarin upon the availability of DOACs and identify patient/practice-level factors associated with switching from chronic warfarin therapy to a DOAC. Methods: Prospective cohort study of AF patients in the NCDR PINNACLE registry prescribed warfarin between May 1, 2008 and May 1, 2015. Patients were followed at least 1 year (median length of follow-up 375 days, IQR 154-375) through May 1, 2016 and stratified as follows: continued warfarin, switched to DOAC, or discontinued anticoagulation. To identify significant predictors of switching, a three-level multivariable hierarchical regression was developed. Results: Among 383 008 AF patients initially prescribed warfarin, 16.3% (n = 62 620) switched to DOACs, 68.8% (n = 263 609) continued warfarin, and 14.8% (n = 56 779) discontinued anticoagulation. Among those switched, 37.6% received dabigatran, 37.0% rivaroxaban, 24.4% apixaban, and 1.0% edoxaban. Switched patients were more likely to be younger, women, white, and have private insurance (all P <.001). Switching was less likely with increased stroke risk (OR, 0.92; 95%CI, 0.91-0.93 per 1-point increase CHA2DS2-VASc), but more likely with increased bleeding risk (OR, 1.12; 95%CI, 1.10-1.13 per 1-point increase HAS-BLED). There was substantial variation at the practice-level (MOR, 2.33; 95%CI, 2.12-2.58) and among providers within the same practice (MOR, 1.46; 95%CI, 1.43-1.49). Conclusions: Among AF patients treated with warfarin between October 1, 2010 and May 1, 2016, one in six were switched to DOACs, with differences across sociodemographic/clinical characteristics and substantial practice-level variation. In the context of current guidelines which favor DOACs over warfarin, these findings help benchmark performance and identify areas of improvement.
KW - atrial fibrillation
KW - direct oral anticoagulants
KW - patterns of care
KW - practice patterns
KW - warfarin
UR - http://www.scopus.com/inward/record.url?scp=85085067681&partnerID=8YFLogxK
U2 - 10.1002/clc.23376
DO - 10.1002/clc.23376
M3 - Article
C2 - 32378265
AN - SCOPUS:85085067681
SN - 0160-9289
VL - 43
SP - 743
EP - 751
JO - Clinical Cardiology
JF - Clinical Cardiology
IS - 7
ER -