GSBS Dissertations and Theses
ORCID ID
0000-0001-5604-721X
Publication Date
2019-06-05
Document Type
Doctoral Dissertation
Academic Program
Clinical and Population Health Research
Department
Population and Quantitative Health Sciences
First Thesis Advisor
Kate Lapane
Keywords
Anticoagulants, epidemiology, nursing home, older adults, comparative effectiveness, health outcomes
Abstract
Background
Fewer than one-third of nursing home residents with atrial fibrillation were treated with the only available oral anticoagulant, warfarin, historically. Management of atrial fibrillation has transformed in recent years with the approval of 4 direct-acting oral anticoagulants (DOACs) since 2010.
Methods
Using the national Minimum Data Set 3.0 linked to Medicare Part A and D claims, we first described contemporary (2011-2016) warfarin and DOAC utilization in the nursing home population (Aim 1). In Aim 2, we linked residents to nursing home and county level data to study associations between resident, facility, county, and state characteristics and anticoagulant treatment. Using a new-user active comparator design, we then compared the incidence of safety (i.e., bleeding), effectiveness (i.e., ischemic stroke), and mortality outcomes between residents initiating DOACs versus warfarin (Aim 3).
Results
The proportion of residents with atrial fibrillation receiving treatment increased from 42.3% in 2011 to 47.8% as of December 31, 2016, at which time 48.2% of treated residents received DOACs. Demographic and clinical characteristics of residents using DOACs and warfarin were similar in 2016. Half of the 8,734 DOAC users received standard dosages and most were treated with apixaban (54.4%) or rivaroxaban (35.8%) in 2016.
Compared with warfarin, bleeding rates were lower and ischemic stroke rates were higher for apixaban users. Ischemic stroke and bleeding rates for dabigatran and rivaroxaban were comparable to warfarin. Mortality rates were lower versus warfarin for each DOAC.
Conclusions
In nursing homes, DOACs are being used commonly and with equal or greater benefit than warfarin.
Repository Citation
Alcusky, M. Anticoagulant Use, Safety and Effectiveness for Ischemic Stroke Prevention in Nursing Home Residents with Atrial Fibrillation. (2019). University of Massachusetts Medical School. GSBS Dissertations and Theses. Paper 1034. DOI: 10.13028/tfcw-vx13. https://escholarship.umassmed.edu/gsbs_diss/1034
DOI
10.13028/tfcw-vx13
DOI Link
Rights and Permissions
Copyright is held by the author, with all rights reserved.
Included in
Cardiovascular Diseases Commons, Clinical Epidemiology Commons, Epidemiology Commons, Health Services Administration Commons