Key result
Higher country health spending is linked to ~21% lower odds of withholding OAC in AF.
Why the study?
Guidelines recommend oral anticoagulants for patients with AF at high thromboembolic risk, but the reasons for guideline non-adherence remain unclear.
What demographic, clinical, and system-level characteristics are associated with withholding oral anticoagulation in patients with atrial fibrillation at high risk of stroke?
Observational (n=40,416)
Yes
What demographic, clinical, and system-level characteristics are associated with withholding oral anticoagulation in patients with atrial fibrillation at high risk of stroke?
Odds Ratio: 0.79 (95% CI 0.78–0.8)
Country of residence and per-capita health expenditure are the strongest independent predictors of whether high-risk atrial fibrillation patients are inappropriately withheld from guideline-recommended oral anticoagulation.
Higher per-capita health expenditure was associated with greater OAC use in high-risk AF; leaves open whether system-level investments reduce treatment gaps.
Background Guidelines for patients with atrial fibrillation (AF) at high thromboembolic risk recommend oral anticoagulants (OACs) for preventing stroke and systemic embolism (SE). The reasons for guideline non-adherence are still unclear. Aim The aim is to identify clinical, demographic and non-patient characteristics associated with withholding OAC in patients with AF at high stroke risk. Methods Patients in the Global Anticoagulant Registry in the FIELD-AF, newly diagnosed with AF between March 2010 and August 2016, and with CHA 2 DS 2 -VASc Score≥2 (excluding sex), were grouped by OAC treatment at enrolment. Factors associated with OAC non-use were analysed by multivariable logistic regression. Results Of 40 416 eligible patients, 12 126 (30.0%) did not receive OACs at baseline. Globally, OAC prescription increased over time, from 60.4% in 2010–2011 to 74.7% in 2015–2016. Country of enrolment was the major predictor for OAC withholding (χ 2 −df=2576). Clinical predictors of OAC non-use included type of AF (χ 2 −df=404), history of bleeding (χ 2 −df=263) and vascular disease (χ 2 −df=99). OACs were used most frequently around the age of 75 years and decreasingly with younger as well as older age beyond 75 years (χ 2 −df=148). Non-cardiologists (χ 2 −df=201) and emergency room physicians (χ 2 −df=14) were less likely to prescribe OACs. OAC prescription correlated positively with country health expenditure. Conclusions Approximately one out of three AF patients did not receive OAC, while eligible according to the guidelines. Country of enrolment was the major determinant of anticoagulation strategy, while higher country health expenditure was associated with lower likelihood of withholding anticoagulation.
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Siegal et al. (2023) conducted an observational in Atrial Fibrillation (n=40,416). Country health expenditure (per US$1000 increase) vs. Lower health expenditure was evaluated on Withholding of oral anticoagulants at baseline (OR 0.79, 95% CI 0.78-0.80). An increase of US$1000 in country health expenditure per capita was associated with a 21% lower likelihood of withholding guideline-recommended oral anticoagulation in eligible patients with atrial fibrillation (OR 0.79).
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