Patterns of warfarin use and subsequent outcomes in atrial fibrillation in primary care practices

Abstract

Edward Ewen,1 Zugui Zhang,1 Teresa A Simon,2 Paul Kolm,1 Xianchen Liu,3,4 William S Weintraub11Christiana Care Health System, Newark, DE, USA; 2Bristol-Myers Squibb, Princeton, NJ, USA; 3Indiana University School of Medicine, Indianapolis, IN, USA; 4Pfizer, Groton, CT, USABackground: Warfarin is recommended for stroke prevention in high-risk patients with atrial fibrillation. However, it is often underutilized and inadequately managed in actual clinical practice.Objectives: To examine the patterns of warfarin use and their relationship with stroke and bleeding in atrial fibrillation patients in community-based primary care practices.Design: Retrospective longitudinal cohort study.Participants: A total of 1141 atrial fibrillation patients were selected from 17 primary care practices with a shared electronic medical record and characterized by stroke risk, potential barriers to anticoagulation, and comorbid conditions.Main measures: Duration and number of warfarin exposures, interruptions in warfarin exposure > 45 days, stroke, and bleeding events.Results: Among 1141 patients with a mean age of 70 years (standard deviation 13.3) and mean follow-up of 3.4 years (standard deviation 3.0), 764 (67%) were treated with warfarin. Warfarin was discontinued within 1 year in 194 (25.4%), and 349 (45.7%) remained on warfarin at the end of follow-up. Interruptions in warfarin use were common, occurring in 32.6% (249 of 764) of patients. Those with two or more interruptions were younger and at lower baseline stroke risk when compared to those with no interruptions. There were 76 first strokes and 73 first-bleeding events in the follow-up period. When adjusted for baseline stroke risk, time to warfarin start, and total exposure time, two or more interruptions in warfarin use was associated with an increased risk of stroke (relative risk, 2.29; 95% confidence interval: 1.29–4.07). There was no significant association between warfarin interruptions and bleeding events.Conclusion: Warfarin was underutilized in a substantial portion of eligible atrial fibrillation patients in these community-based practices. In addition, prolonged interruptions in anticoagulation were common in this population, and multiple interruptions were associated with over twice the risk of stroke when compared to those treated continuously.Keywords: cardiovascular disease, primary care, quality assessment, outcomes