What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Nonvalvular atrial fibrillation (n=3165). Intervention: Oral anticoagulants vs. No oral anticoagulants. Primary outcome: Underprescription of oral anticoagulants (Age ≥90 vs 80-84 years) (OR 2.66, 95% CI 2.09-3.42).

March 30, 2022Open Access

Barriers to prescribing oral anticoagulants to inpatients aged 80 years and older with nonvalvular atrial fibrillation: a cross-sectional study

Key Result

Among inpatients aged 80 years and older with nonvalvular atrial fibrillation, 67.6% were not prescribed oral anticoagulants, with patients aged 90 and older having significantly higher odds of underprescription (OR 2.66) compared to those aged 80-84.

Study Design

Type

Cross-Sectional (n=3,165)

Multicenter

Structured PICO

Population

3,165 inpatients aged ≥ 80 years with nonvalvular atrial fibrillation (NVAF), mean age 85.3, 42.4% female, based in a tertiary teaching hospital in western China. Excluded: invasive procedures, absolute contraindications to anticoagulation, mitral valve stenosis, or previous prosthetic valve replacement.

Outcome

Prevalence of underprescription of oral anticoagulants (OACs) and associated risk factors

Despite guideline recommendations, oral anticoagulants remain severely underprescribed in octogenarians and nonagenarians with NVAF, particularly those managed outside cardiology departments or concurrently prescribed antiplatelets.

Main Result

Effect estimate: OR 2.66 (95% CI 2.09-3.42)

Limitations

Lack of comprehensive geriatric assessment (CGA) implementation by most non-geriatrician physicians
Inability to assess physicians' perceptions, patients' preferences, and attitudes toward anticoagulation due to lack of medical records
Conducted in a single teaching hospital, limiting generalizability to other hospitals in different regions

Abstract

BACKGROUND: To investigate the temporal trend of the prevalence of underprescription of anticoagulation treatment and explore the factors associated with underprescription of oral anticoagulants (OACs) among inpatients aged ≥ 80 years with nonvalvular atrial fibrillation (NVAF). METHODS: We retrospectively reviewed the medical records of inpatients with a discharge diagnosis of NVAF from a medical database. We used the Pearson chi-square or Fisher's exact test to compare categorical variables between patients with and without OAC prescriptions during hospitalization. Logistic regression analysis was used to assess the association between risk factors and underprescription of OACs. RESULTS: A total of 4375 patients aged ≥ 80 years with AF were assessed in the largest academic hospital in China from August 1, 2016, to July 31, 2020, and 3165 NVAF patients were included. The prevalence of underprescription of OACs was 79.1% in 2017, 71.3% in 2018, 64.4% in 2019, and 56.1% in 2020. Of all participants, 2138 (67.6%) were not prescribed OACs; 66.3% and 68.2% of patients with and without prior stroke did not receive OACs, respectively. Age (85-89 vs 80-84, OR = 1.48, 95% CI (1.25-1.74); 90 + vs 80-84, OR = 2.66, 95% CI: 2.09-3.42), clinical department where patients were discharged (Reference = Cardiology, Geriatrics: OR = 2.97, 95% CI: 2.45- 3.61; neurology: OR = 1.25, 95% CI: 0.96, 1.63; others: OR = 4.23, 95% CI: 3.43- 5.24), use of antiplatelets (OR = 1.69, 95% CI: 1.45- 1.97), and history of stroke (OR = 0.83, 95% CI: 0.71- 0.98 adjusted age), and dementia (OR = 2.16, 95% CI: 1.60- 2.96) were significantly associated with not prescribing OACs. CONCLUSIONS: The prevalence of underprescription of OACs has decreased over the past several years. The rate of underprescription of OACs was higher among NVAF patients who were older, prescribed antiplatelets, discharged from nondepartmental cardiology, and suffered from comorbidities. This study found iatrogenic factors affecting the underprescription of OACs in inpatients aged ≥ 80 years, providing clues and a basis for the standardized use of OACs in inpatients.

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