Trajectories of Oral Anticoagulation Adherence Among Medicare Beneficiaries Newly Diagnosed With Atrial Fibrillation

• Published in: Journal of the American Heart Association Vol. 8; no. 12; p. e011427
• Main Authors: Hernandez, Inmaculada, He, Meiqi, Chen, Nemin, Brooks, Maria M, Saba, Samir, Gellad, Walid F
• Format: Journal Article
• Language: English
• Published: England John Wiley and Sons Inc 18.06.2019; Wiley
• Subjects: adherence; Administration, Oral; Aged; Aged, 80 and over; Anticoagulants - administration & dosage; anticoagulation; atrial fibrillation; Atrial Fibrillation - complications; Cohort Studies; Female; Humans; Male; Medicare; Medication Adherence - statistics & numerical data; Middle Aged; Original Research; Stroke - etiology; Stroke - prevention & control; Time Factors; United States; United States; atrial fibrillation; adherence; anticoagulation
• ISSN: 2047-9980; 2047-9980
• DOI: 10.1161/JAHA.118.011427

Background Only 50% of atrial fibrillation ( AF ) patients recommended for oral anticoagulation ( OAC ) use these medications, and less than half of them adhere to OAC . In a cohort of Medicare beneficiaries newly diagnosed with AF , we identified groups of patients with similar trajectories of OAC use and adherence, and evaluated patient characteristics affecting group membership. Methods and Results We selected continuously enrolled Medicare Part D beneficiaries with first AF diagnosis in 2014 to 2015 (n=34 898). We calculated the proportion of days covered with OAC over the first 12 months after diagnosis and identified OAC adherence trajectories using group-based trajectory models. We constructed multinomial logistic regression models to evaluate how demographics, system-level factors, and clinical characteristics were associated with group membership. We identified 4 trajectories of OAC adherence: patients who never used OAC (43.8%), late OAC initiators (7.6%), early OAC discontinuers (8.9%), and continuously adherent patients (40.1%). Predictors such as sex, black race, residence in the South, or HAS - BLED score were associated with not only OAC use, but also the timing of initiation and the likelihood of discontinuation. For example, HAS - BLED score ≥4 was associated with a higher likelihood of not using OAC (odds ratio 1.35; 95% CI , 1.14-1.62), of late initiation (1.55; 95% CI , 1.11-2.05), and of early discontinuation (odds ratio 1.35; 95% CI , 1.01-1.84). Conclusions We identified 4 distinct trajectories of OAC adherence after first AF diagnosis, with <45% of newly diagnosed AF patients belonging to the trajectory group characterized by continuous OAC adherence. Trajectories were associated not only with demographic and clinical characteristics but also with regional factors.