What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Non-valvular atrial fibrillation (n=68056). Intervention: Rural residence vs. Urban residence. Primary outcome: Initiation of NOAC treatment (vs. warfarin) (OR 0.48, 95% CI 0.45-0.51).

February 26, 2019Open Access

Sociodemographic factors and choice of oral anticoagulant in patients with non-valvular atrial fibrillation in Sweden: a population-based cross-sectional study using data from national registers

Key Result

Among Swedish patients with non-valvular atrial fibrillation, those residing in rural areas were half as likely to start treatment with a NOAC compared to those in urban areas (OR 0.48).

Study Design

Type

Cross-Sectional (n=68,056)

Structured PICO

Are sociodemographic factors associated with the choice of NOAC versus warfarin in oral anticoagulant naïve patients with non-valvular atrial fibrillation?

Population

68,056 oral anticoagulant-naïve adults with non-valvular atrial fibrillation in Sweden who filled a first prescription for a NOAC or warfarin between 2011 and 2014.

Exposure

Non-vitamin K antagonist oral anticoagulants (NOACs) as first anticoagulant treatment

Comparator

Warfarin as first anticoagulant treatment

Outcome

Choice of initial anticoagulant treatment (NOAC vs. warfarin)

In Sweden, patients with non-valvular atrial fibrillation who have higher socioeconomic status and live in urban areas are significantly more likely to be prescribed NOACs over warfarin.

Main Result

Odds Ratio: 0.48 (95% CI 0.45–0.51)

Limitations

Medications given during acute hospitalizations are not included in the register
The register does not include information on over-the-counter drugs
Residual confounding is possible as data were not available for smoking and other lifestyle factors
Potential misclassification in the CHA2DS2-VASc risk score due to underreporting of component variables

Abstract

BACKGROUND: The Swedish healthcare system aims to provide equal access to care to all residents yet evidence suggests that patients with low socioeconomic status are less likely to receive new drugs. Associations between sociodemographics and prescription of non-vitamin K antagonist oral anticoagulants (NOACs) as an alternative to warfarin in Sweden have not been investigated. METHODS: We conducted a cross-sectional study using linked national registers in Sweden. The study population included oral anticoagulant naïve patients aged ≥18 years with non-valvular atrial fibrillation (NVAF) who filled a first prescription for a NOAC or warfarin from 01 December 2011 to 31 December 2014. Multivariable logistic regression was used to identify factors associated with the choice of anticoagulant treatment; adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS: Among 68,056 patients with NVAF, 27.4% (N = 18,638) started treatment with a NOAC and 72.6% (N = 49,418) started on warfarin. Patients starting treatment with a NOAC were more likely to be highly educated (OR 1.37, 95% CI: 1.30-1.45), in the highest income quartile (OR 1.23, 95% CI: 1.16-1.31) and have a leading professional occupation (OR 1.41, 95% CI: 1.27-1.58). Patients residing in rural areas were half as likely to start treatment with a NOAC as those in urban areas (OR 0.48, 95% CI: 0.45-0.51). CONCLUSION: Among Swedish patients with NVAF, those with high socioeconomic status and urban residence were more likely to start preventative treatment with a NOAC than warfarin. Future research should explore reasons for these inequalities in NOAC treatment.

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