Discontinuation of oral anticoagulant use among nursing home residents with atrial fibrillation before hospice enrollment

Q: What are the key findings of this study?

Oral anticoagulants were discontinued prior to hospice enrollment in 45.7% of older nursing home residents with atrial fibrillation, with higher discontinuation in those at high bleeding risk.

Q: What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Atrial fibrillation or flutter in nursing home residents entering hospice (n=30503). Intervention: Oral anticoagulant (OAC) use in the year prior to hospice enrollment (warfarin, dabigatran, rivaroxaban, apixaban, or edoxaban) and associated clinical/demographic factors. Primary outcome: Discontinuation of oral anticoagulants (warfarin, dabigatran, rivaroxaban, apixaban, or edoxaban) before hospice enrollment (defined as most recent prescription date plus days of supply plus 14-day grace period not covering the hospice enrollment date).

Qiaoxi Chen; Jonggyu Baek; Robert J. Goldberg; Jennifer Tjia; Kate L. Lapane; Matthew Alcusky

doi:10.1111/jgs.18512

July 19, 2023Journal of the American Geriatrics SocietyOpen Access

Discontinuation of oral anticoagulant use among nursing home residents with atrial fibrillation before hospice enrollment

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Key result

Nearly half of nursing home residents with AF stop oral anticoagulants before hospice enrollment.

n=30,503

Why the study?

Most nursing home residents with atrial fibrillation qualify for oral anticoagulants, but net clinical benefits may diminish as residents approach the end of life.

What is the prevalence of and what clinical and demographic factors are associated with discontinuing oral anticoagulants before hospice enrollment among older nursing home residents with atrial fibrillation?

Key Points

To assess the prevalence and predictors of oral anticoagulant (OAC) discontinuation among older nursing home residents with atrial fibrillation prior to hospice enrollment.
Cross-sectional study of 30,503 US nursing home residents aged 65 years or older with atrial fibrillation who used OACs in the year prior to hospice enrollment during 2012–2016.
Data were derived from Minimum Data Set 3.0 assessments linked with Medicare Part A and Part D claims.
Modified Poisson models estimated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for factors associated with OAC discontinuation before hospice entry.
Prior to hospice enrollment, 45.7% of residents with recent OAC use discontinued therapy.
Discontinuation before hospice was more prevalent among residents who were underweight (aPR: 1.02, 95% CI: 1.01–1.03), had high bleeding risk (aPR: 1.04, 95% CI: 1.03–1.05), or had moderate or severe cognitive impairment (aPR: 1.02, 95% CI: 1.02–1.03).
Discontinuation was less likely among residents with venous thromboembolism (aPR: 0.94, 95% CI: 0.93–0.96), statin users (aPR: 0.88, 95% CI: 0.87–0.89), and residents with polypharmacy of 10 or more medications (aPR: 0.72, 95% CI: 0.71–0.73).

Study Design

Type

Cross-Sectional (n=30,503)

Multicenter

Yes

Structured PICO

What is the prevalence of and what clinical and demographic factors are associated with discontinuing oral anticoagulants before hospice enrollment among older nursing home residents with atrial fibrillation?

P

Population

30,503 US nursing home residents aged ≥65 years (median age 89, majority female and white) with atrial fibrillation or flutter who used oral anticoagulants in the year prior to hospice enrollment during 2012-2016.

E

Exposure

Prior oral anticoagulant (OAC) use (warfarin, dabigatran, rivaroxaban, apixaban, or edoxaban) in the year before hospice enrollment, evaluated across clinical and demographic exposures (e.g., underweight BMI <18.5 kg/m², ATRIA bleeding risk, cognitive impairment, venous thromboembolism, statin use, polypharmacy)

C

Comparator

Continued OAC use at the time of hospice enrollment (or reference categories of clinical/demographic characteristics in multivariable modified Poisson models)

O

Outcome

Discontinuation of OAC use before hospice enrollment, defined using Medicare Part D claims as the most recent OAC prescription date plus days of supply plus a 14-day grace period not covering the hospice enrollment index date

Nearly half of nursing home residents with atrial fibrillation on oral anticoagulants discontinue therapy before entering hospice, though substantial proportions with intact cognition discontinue while many with severe cognitive and functional impairment continue treatment.

Limitations

Data from 2012 to 2016 do not capture recent effects of COVID-19 or longer-term market presence of DOACs on prescribing practices.
Cross-sectional study design precludes causal inference; OAC discontinuation could precede or follow the occurrence of covariates during the one-year pre-hospice period.
Unable to evaluate restarting or discontinuing OACs after hospice enrollment because hospice medications may be covered by the hospice benefit rather than Medicare Part D.
Findings may not be generalizable to hospice enrollees in community settings, those who do not enroll in hospice, or Medicare Advantage members.
Data are from 2012 to 2016 and do not capture effects of COVID-19 or more recent DOAC prescribing patterns.
Cross-sectional study design means observed relationships cannot be considered causal, and OAC discontinuation could precede or follow covariates during the one-year baseline period.
Unable to evaluate restarting or discontinuing OACs after hospice enrollment because medications on hospice may be covered by the hospice benefit rather than Medicare Part D.
Findings may not be generalizable to community-dwelling hospice enrollees, residents not enrolling in hospice, or Medicare Advantage beneficiaries.

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Implication

OAC discontinuation before hospice is common in nursing home AF residents; cross-sectional data leave optimal deprescribing strategies open for prospective study.

Abstract

BACKGROUND: Oral anticoagulants (OACs) are effective in reducing the risk of cardioembolic stroke due to atrial fibrillation. While most nursing home residents with atrial fibrillation qualify for anticoagulation based on clinical guidelines, the net clinical benefits of OACs may diminish as residents approach the end of life. METHODS: We conducted a cross-sectional study of 30,503 US nursing home residents with atrial fibrillation (based on Minimum Data Set 3.0 and Medicare Part A records) who used OACs in the year before enrolling in hospice care during 2012-2016. Whether residents discontinued OACs before hospice enrollment was determined using Part D claims and date of hospice enrollment. Modified Poisson models estimated adjusted prevalence ratios (aPR). RESULTS: Almost half (45.7%) of residents who had recent OAC use discontinued prior to hospice enrollment. Residents who were underweight (aPR: 1.02; 95% confidence interval [CI]: 1.01-1.03), those with high bleeding risk (aPR: 1.04, 95% CI: 1.03-1.05), and those with moderate or severe cognitive impairment (aPR: 1.02, 95% CI: 1.02-1.03) had a higher prevalence of OAC discontinuation before entering hospice. Residents with venous thromboembolism (aPR: 0.94, 95% CI: 0.93-0.96), statin users (aPR: 0.88, 95% CI: 0.87-0.89), and those on polypharmacy (≥10 medications, aPR: 0.72; 95% CI: 0.71-0.73) were less likely to discontinue OACs before enrollment in hospice. CONCLUSION: Anticoagulants are often discontinued among older nursing home residents with atrial fibrillation before hospice enrollment; it is not clear that these decisions are driven solely by net clinical benefit considerations. Further research is needed on comparative outcomes to inform resident-centered decisions regarding OAC use in older adults entering hospice.

Discussion

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Cite This Study

Chen et al. (2023) conducted a cross-sectional in Atrial fibrillation or flutter in nursing home residents entering hospice (n=30,503). Oral anticoagulant (OAC) use in the year prior to hospice enrollment (warfarin, dabigatran, rivaroxaban, apixaban, or edoxaban) and associated clinical/demographic factors was evaluated on Discontinuation of oral anticoagulants (warfarin, dabigatran, rivaroxaban, apixaban, or edoxaban) before hospice enrollment (defined as most recent prescription date plus days of supply plus 14-day grace period not covering the hospice enrollment date). Oral anticoagulants were discontinued prior to hospice enrollment in 45.7% of older nursing home residents with atrial fibrillation, with higher discontinuation in those at high bleeding risk.

synapsesocial.com/papers/6a75dc100294aedd57e696f2 https://doi.org/10.1111/jgs.18512

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Discontinuation of oral anticoagulant use among nursing home residents with atrial fibrillation before hospice enrollment

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Discontinuation of oral anticoagulant use among nursing home residents with atrial fibrillation before hospice enrollment

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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