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BMC Primary Care
Published in: BMC Primary Care 1/2012

Open Access 01-12-2012 | Research article

Predictors of warfarin use in atrial fibrillation in the United States: a systematic review and meta-analysis

Authors: Victoria L Baczek, Wendy T Chen, Jeffrey Kluger, Craig I Coleman

Published in: BMC Primary Care | Issue 1/2012

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Abstract

Background

Despite warfarin's marked efficacy, not all eligible patients receive it for stroke prevention in AF. The aim of this meta-analysis was to evaluate the association between prescriber and/or patient characteristics and subsequent prescription of warfarin for stroke prevention in patients with atrial fibrillation (AF).

Methods

Observational studies conducted in the US using multivariate analysis to determine the relationship between characteristics and the odds of receiving warfarin for stroke prevention were identified in MEDLINE, EMBASE and a manual review of references. Effect estimates of prescriber and/or patient characteristics from individual studies were pooled to calculate odds ratios (ORs) with 95% confidence intervals.

Results

Twenty-eight studies reporting results of 33 unique multivariate analyses were identified. Warfarin use across studies ranged from 9.1%-79.8% (median = 49.1%). There was a moderately-strong correlation between warfarin use and year of study (r = 0.60, p = 0.002). Upon meta-analysis, characteristics associated with a statistically significant increase in the odds of warfarin use included history of cerebrovascular accident (OR = 1.59), heart failure (OR = 1.36), and male gender (OR = 1.12). Those associated with a significant reduction in the odds of warfarin use included alcohol/drug abuse (OR = 0.62), perceived barriers to compliance (OR = 0.87), contraindication(s) to warfarin (OR = 0.81), dementia (OR = 0.32), falls (OR = 0.60), gastrointestinal hemorrhage (OR = 0.47), intracranial hemorrhage (OR = 0.39), hepatic (OR = 0.59), and renal impairment (OR = 0.69). While age per 10-year increase (OR = 0.78) and advancing age as a dichotomized variable (cut-off varied by study) (OR = 0.57) were associated with significant reductions in warfarin use; qualitative review of results of studies evaluating age as a categorical variable did not confirm this relationship.

Conclusions

Warfarin use has increased somewhat over time. The decision to prescribe warfarin for stroke prevention in atrial fibrillation is based upon multiple prescriber and patient characteristics. These findings can be used by family practice prescribers and other healthcare decision-makers to target interventions or methods to improve utilization of warfarin when it is indicated for stroke prevention.
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Literature
1.
Go AS, Hylek EM, Phillips KA, et al: Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001, 285: 2370-2375. 10.1001/jama.285.18.2370.CrossRefPubMed
2.
Wolf PA, Abbott RD, Kannel WB: Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991, 22: 983-988. 10.1161/01.STR.22.8.983.CrossRefPubMed
3.
Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation: analysis of pooled data from five randomized controlled trials. Arch Intern Med. 1994, 154: 1449-1457.
4.
Lightowlers S, McGuire A: Cost-effectiveness of anticoagulation in nonrheumatic atrial fibrillation in the primary prevention of ischemic stroke. Stroke. 1998, 29: 1827-1832. 10.1161/01.STR.29.9.1827.CrossRefPubMed
5.
Bungard TJ, Ghali WA, Teo KK, McAlister FA, Tsuyuki RT: Why do patients with atrial fibrillation not receive warfarin?. Arch Intern Med. 2000, 160: 41-46. 10.1001/archinte.160.1.41.CrossRefPubMed
6.
Cohen N, Almoznino-Sarafian D, Alon I, et al: Warfarin for stroke prevention still underused in atrial fibrillation: patterns of omission. Stroke. 2000, 31: 1217-1222. 10.1161/01.STR.31.6.1217.CrossRefPubMed
7.
Monette J, Gurwitz JH, Rochon PA, et al: Physician attitudes concerning warfarin for stroke prevention in atrial fibrillation: Results of a survey of long-term care practitioners. J Am Geriatr Soc. 1997, 45: 1060-65.CrossRefPubMed
8.
McCormick D, Gurwitz JH, Goldberg RJ, et al: Prevalence and quality of warfarin use for patients with atrial fibrillation in the long-term care setting. Arch Intern Med. 2001, 161: 2458-63. 10.1001/archinte.161.20.2458.CrossRefPubMed
9.
Peterson GM, Boom K, Jackson SL, et al: Doctors' beliefs on the use of antithrombotic therapy in atrial fibrillation: identifying barriers to stroke prevention. Intern Med J. 2002, 32: 15-23. 10.1046/j.1445-5994.2002.00156.x.CrossRefPubMed
10.
Gattellari M, Worthington J, Zwar N, et al: Barriers to the use of anticoagulation for nonvalvular atrial fibrillation: a representative survey of Australian family physicians. Stroke. 2008, 39: 227-30. 10.1161/STROKEAHA.107.495036.CrossRefPubMed
11.
Abdel-Latif AK, Peng X, Messinger-Rapport BJ: Predictors of anticoagulation prescription in nursing home residents with atrial fibrillation. J Am Med Dir Assoc. 2005, 6 (2): 128-131. 10.1016/j.jamda.2005.01.006.CrossRefPubMed
12.
Agarwal S, Bennett D, Smith DJ: Predictors of warfarin use in atrial fibrillation patients in the inpatient setting. Am J Cardiovasc Drugs. 2010, 10 (1): 37-48. 10.2165/11318870-000000000-00000.CrossRefPubMed
13.
Antani MR, Beyth RJ, Covinsky KE, et al: Failure to prescribe warfarin to patients with nonrheumatic atrial fibrillation. J Gen Intern Med. 1996, 11 (12): 713-720. 10.1007/BF02598984.CrossRefPubMed
14.
Beyth RJ, Antani MR, Covinsky KE, et al: Why isn't warfarin prescribed to patients with nonrheumatic atrial fibrillation?. J Gen Intern Med. 1996, 11 (12): 721-728. 10.1007/BF02598985.CrossRefPubMed
15.
Birman-Deych E, Radford MJ, Nilasena DS, Gage BF: Use and effectiveness of warfarin in Medicare beneficiaries with atrial fibrillation. Stroke. 2006, 37: 1070-1074. 10.1161/01.STR.0000208294.46968.a4. Epub 2006 Mar 9CrossRefPubMed
16.
Brass LM, Krumholz HM, Scinto JD, Mathur D, Radford M: Warfarin use following ischemic stroke among Medicare patients with atrial fibrillation. Arch Intern Med. 1998, 158 (19): 2093-2100. 10.1001/archinte.158.19.2093.CrossRefPubMed
17.
Brass LM, Krumholz HM, Scinto JM, Radford M: Warfarin use among patients with atrial fibrillation. Stroke. 1997, 28 (12): 2382-2389. 10.1161/01.STR.28.12.2382.CrossRefPubMed
18.
Brophy MT, Snyder K, Gaehde S, Ives C, Gagnon D, Fiore LD: Anticoagulant use for atrial fibrillation in the elderly. J Am Geriatr Soc. 2004, 52: 1151-1156. 10.1111/j.1532-5415.2004.52314.x.CrossRefPubMed
19.
Burkiewicz JS: Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation. Pharmacotherapy. 2005, 25 (8): 1062-1067. 10.1592/phco.2005.25.8.1062.CrossRefPubMed
20.
Glazer NL, Dublin S, Smith NL, French B, et al: Newly detected atrial fibrillation and compliance with antithrombotic guidelines. Arch Intern Med. 2007, 167: 246-252. 10.1001/archinte.167.3.246.CrossRefPubMed
21.
Go AS, Hylek EM, Borowsky LH, Phillips KA, Selby JV, Singer DE: Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Ann Intern Med. 1999, 131 (12): 927-934.CrossRefPubMed
22.
Hylek E, D'Antonio J, Shea C, Henault LE, Regan S: Translating the results of randomized trials into clinical practice: the challenge of warfarin candidacy among hospitalized elderly patients with atrial fibrillation. Stroke. 2006, 37: 1075-1080. 10.1161/01.STR.0000209239.71702.ce.CrossRefPubMed
23.
Johnston J, Cluxton R, Heaton P, Guo JJ, Moomaw CJ, Eckman MH: Predictors of warfarin use among Ohio medicaid patients with new-onset nonvalvular atrial fibrillation. Arch Intern med. 2003, 163: 1705-1710. 10.1001/archinte.163.14.1705.CrossRefPubMed
24.
Lewis W, Fonarow G, LaBresh K, et al: Differential use of warfarin for secondary stroke prevention in patients with various types of atrial fibrillation. Am J Cardiol. 2009, 103: 227-231. 10.1016/j.amjcard.2008.08.062.CrossRefPubMed
25.
Lim M, Roychoudhury C, Baker P, Bossone E, Mehta RH: Differences in quality of care among patients hospitalized with atrial fibrillation as primary or secondary cause for admission. Int J Qual Health Care. 2005, 17 (3): 255-258. 10.1093/intqhc/mzi026.CrossRefPubMed
26.
McCormick D, Gurwitz J, Goldberg R, et al: Prevalence and quality of warfarin use for patients with atrial fibrillation in the long-term care setting. Arch Intern Med. 2001, 161: 2458-2463. 10.1001/archinte.161.20.2458.CrossRefPubMed
27.
Meschia J, Merrill P, Soliman E, et al: Racial disparities in awareness and treatment of atrial fibrillation: the reasons for geographic and racial differences in stroke (REGARDS) study. Stroke. 2010, 41: 581-587. 10.1161/STROKEAHA.109.573907.CrossRefPubMedPubMedCentral
28.
Munschauer FE, Priore RL, Hens M, Castilone A: Thromboembolism prophylaxis in chronic artial fibrillation: practice patterns in community and tertiary-care hospitals. Stroke. 1997, 28: 72-76. 10.1161/01.STR.28.1.72.CrossRefPubMed
29.
Niska R, Han B: Anticoagulation for patients with atrial fibrillation in ambulatory care settings. J Am Board Fam Med. 2009, 22: 299-306. 10.3122/jabfm.2009.03.080218.CrossRefPubMed
30.
Piccini J, Hernandez A, Zhao X, et al: Quality of care for atrial fibrillation among patients hospitalized for heart failure. J Am Coll Cardiol. 2009, 54: 1280-1289. 10.1016/j.jacc.2009.04.091.CrossRefPubMed
31.
Rahimi AR, Wrights B, Akhondi H, Richard CM: Clinical correlation between effective anticoagulants and risk of stroke: are we using evidence-based strategies?. Southern Med J. 2004, 97 (10): 924-931. 10.1097/01.SMJ.0000129930.40928.3F.CrossRefPubMed
32.
Schauer D, Johnston J, Moomaw C, Wess M, Eckman MH: Racial disparities in the filling of warfarin prescriptions for nonvalvular atrial fibrillation. Am J Med Sci. 2007, 333 (2): 67-73. 10.1097/00000441-200702000-00001.CrossRefPubMed
33.
Smith N, Psaty B, Furberg C, et al: Temporal trends in the use of anticoagulants among older adults with atrial fibrillation. Arch Intern Med. 1999, 159: 1574-1578. 10.1001/archinte.159.14.1574.CrossRefPubMed
34.
Stafford R, Singer D: Recent national patterns of warfarin use in atrial fibrillation. Circulation. 1998, 97: 1231-1233.CrossRefPubMed
35.
Stafford R, Singer D: National patterns of warfarin use in atrial fibrillation. Arch Intern Med. 1996, 156: 2537-2541. 10.1001/archinte.1996.00440210043004.CrossRefPubMed
36.
Waldo A, Becker R, Tapson V: Hospitalized patients with atrial fibrillation and a high risk of stroke are not being provided with adequate anticoagulation. J Am Coll Cardiol. 2005, 46: 1729-1736. 10.1016/j.jacc.2005.06.077.CrossRefPubMed
37.
White RH, McBurnie MA, Manolio T, et al: Oral anticoagulation in patients with atrial fibrillation: adherence with guidelines in an elderly cohort. Am J Med. 1999, 106: 165-171. 10.1016/S0002-9343(98)00389-1.CrossRefPubMed
38.
Fang MC, Stafford RS, Ruskin JN, Singer DE: National trends in antiarrhythmic and antithrombotic medication use in atrial fibrillation. Arch Intern Med. 2004, 164: 55-60. 10.1001/archinte.164.1.55.CrossRefPubMed
39.
Singer DE, Albers GW, Dalen JE, et al: Antithrombotic therapy in atrial fibrillation. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008, 133: 546S-92S. 10.1378/chest.08-0678.CrossRefPubMed
40.
Ansell J, Hirsh J, Hylek E, et al: Pharmacology and management of the vitamin K antagonists. Chest. 2008, 133: 160S-98S. 10.1378/chest.08-0670.CrossRefPubMed
41.
Hylek E, Skates S, Sheehan M, et al: An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation. New Eng J Med. 1996, 335: 540-546. 10.1056/NEJM199608223350802.CrossRefPubMed
42.
43.
Fuster V, Rydén LE, Cannom DS, et al: ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). Circulation. 2006, 114: e257-e354.CrossRefPubMed
44.
Coumadin® (warfarin sodium) Prescribing Information. 2009, Bristol-Myers Squibb, Princeton, NJ
45.
46.
Cohen J: Statistical Power Analysis for the Behavioral Sciences. 1988, Hillsdale, NJ: Lawrence Erlbaum Associates, 2
47.
48.
Lip GY, Frison L, Halperin JL, Lane DA: Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol. 2011, 57: 173-80. 10.1016/j.jacc.2010.09.024.CrossRefPubMed
49.
Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, RE-LY Steering Committee and Investigators, et al: Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009, 361: 1139-51. 10.1056/NEJMoa0905561.CrossRefPubMed
50.
Connolly SJ, Eikelboom J, Joyner C, Diener HC, Hart R, Golitsyn S, AVERROES Steering Committee and Investigators, et al: Apixaban in patients with atrial fibrillation. N Engl J Med. 2011, 364 (9): 806-17. 10.1056/NEJMoa1007432.CrossRefPubMed
51.
Baicker K, Chandra A, Skinner JS: Geographic variation in health care and the problem of measuring racial disparities. Perspectives in Biology and Medicine. 2005, 48: S42-S53.CrossRefPubMed
52.
Fang MC, Go AS, Chang Y, et al: Warfarin Discontinuation After Starting Warfarin for Atrial Fibrillation. Circ Cardiovasc Qual Outcomes. 2010, 3: 624-31. 10.1161/CIRCOUTCOMES.110.937680.CrossRefPubMedPubMedCentral
53.
Weisbord SD, Whittle J, Brooks RC: Is warfarin really underused in patients with atrial fibrillation?. J Gen Intern Med. 2001, 16: 743-9. 10.1111/j.1525-1497.2001.10432.x.CrossRefPubMedPubMedCentral
Metadata
Title
Predictors of warfarin use in atrial fibrillation in the United States: a systematic review and meta-analysis
Authors
Victoria L Baczek
Wendy T Chen
Jeffrey Kluger
Craig I Coleman
Publication date
01-12-2012
Publisher
BioMed Central
Published in
BMC Primary Care / Issue 1/2012
Electronic ISSN: 2731-4553
DOI
https://doi.org/10.1186/1471-2296-13-5

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