Date post: | 12-Jan-2016 |
Category: |
Documents |
Upload: | abraham-williamson |
View: | 214 times |
Download: | 0 times |
Adherence and Persistence in the Use of Warfarin After Hospital Discharge
Among Patients With Heart Failure and Atrial Fibrillation
Zubin J. Eapen, Xiaojuan Mi, Laura G. Qualls, Bradley G. Hammill, Gregg C. Fonarow, Mintu P. Turakhia, Paul A. Heidenreich, Eric D. Peterson, Lesley H.
Curtis, Adrian F. Hernandez, Sana M. Al-Khatib
AHA Scientific Sessions November 7, 2012
Presenter disclosure information
DISCLOSURE INFORMATION:
ZJ Eapen: none
X Mi: none
LG Qualls: none
BG Hammill: none
GC Fonarow: consultant for Amgen, Gambro, GlaxoSmithKline, Medtronic, Merck, Novartis, Pfizer, Relypsa, Scios, St. Jude, Takeda, and the Medicines Company; employment with the Ahmanson Foundation; service as the Eliot Corday Chair of Cardiovascular Medicine and Science; grants from the Agency for Healthcare Research and Quality, the National Institutes of Health, and GlaxoSmithKline; speakers fees from Boston Scientific/Guidant, GlaxoSmithKline, Medtronic, Merck, Novartis, Pfizer, and St. Jude Medical.
MP Turakhia: consultant for Medtronic, Precision Health Economics, and St. Jude Medical; grants from the American Heart Association, Gilead Sciences, iRhythm, and Medtronic; speakers fees from Boston Scientific and St. Jude Medical; stock in Zipline Medical; travel/meeting expenses from Medtronic.
PA Heidenreich: none
ED Peterson: grants from Eli Lilly and Janssen Pharmaceuticals.
LH Curtis: grants from GlaxoSmithKline and Johnson & Johnson.
AF Hernandez: grant from Portola Pharmaceuticals.
SM Al-Khatib: travel/meeting expenses from Bristol-Myers Squibb.
Background
• Practice guidelines recommend warfarin at hospital discharge for patients with heart failure (HF) and atrial fibrillation (AF)
• Warfarin prescription at hospital discharge is an ACC/AHA clinical performance measure for patients with HF and AF
• More than one-third of eligible patients with HF and AF are not discharged with a prescription for warfarin
Adherence to anticoagulation among these high-risk patients is not well described
Rationale
ObjectiveDescribe the transitional and long-term adherence to
anticoagulation therapy among Medicare beneficiaries with HF and AF
Methods: data sources
• Demographics
• Medical history
• Results of laboratory tests and examinations
• Discharge medications
• Medicare Part A• hospitalization claims
• Denominator files• program eligibility and enrollment• date of death
• Medicare Part D• generic names of prescription
drugs• days’ supply• program enrollment and benefit
phases
admission date
sex
discharge date
date of birth
Methods: data sources
Methods: study cohort
Inclusions • Age > 65 years with GWTG-HF hospitalization linked to Medicare claims
8240 patients
• Discharged home between January 1, 2006 and December 31, 2009
• Enrolled in fee-for-service Medicare at discharge
• AF in medical history and recorded admission vital signs
Exclusions • > 90 days of Medicare Part D before index hospitalization (n = 5097)
5549 patients• Contraindications to anticoagulation (n=373)
• Missing documentation (n = 79)
Final population2691 patients
207 sites
Warfarin contraindications
Allerg
y or
com
plica
tion
Bleed
ing
or b
leed
ing
risk
Patie
nt o
r fam
ily re
fusa
l
Serio
us s
ide
effe
ct
Miss
ing
0102030405060
5.6
52.3
6.4 2.1
33.5
%
Methods:measuring adherence and persistence
• Obtained postdischarge prescription claims for warfarin from Medicare Part D claims during 1 year after discharge from the index hospitalization
• Defined the initial outpatient dispensing date as the date of the first prescription claim during 1 year of follow-up
• Calculated the days to the first outpatient prescription claim from the index discharge date
• Outpatient dispensing rates: cumulative incidence of the first filled outpatient prescription for warfarin within 90 days or 1 year after discharge from the index hospitalization.
• Discontinuation of therapy: first 90-day gap in the days’ supply of warfarin during 1 year of follow-up.
• Medication possession ratio: sum of the days’ supply of warfarin divided by the number of days alive during 1 year of follow-up.
Methods:analyzing adherence and persistence
Baseline characteristics
Characteristic Eligible for
Warfarin Therapy(n = 2691)
Did Not Meet theInclusion Criteria
(n = 5549)P Value
Age, median (IQR), y 80.0 (73.0-85.0) 80.0 (75.0-85.0) < .01
Male, No. (%) 1168 (43.4) 3137 (56.5) < .01
White race, No. (%) 2261 (84.0) 4979 (89.7) < .01
Medical history, No. (%)
Anemia 463 (17.2) 973 (17.5) .71
Cerebrovascular accident or TIA 440 (16.4) 886 (16.0) .66
Diabetes mellitus 1002 (37.2) 1877 (33.8) < .01
Heart failure with ischemic etiology 1654 (61.5) 3546 (63.9) .03
Hypertension 2073 (77.0) 4111 (74.1) < .01
Renal insufficiency 435 (16.2) 992 (17.9) .05
Study population by CHADS2 score
1 2 3 4 5 60
10
20
30
40
50
60
3.2
21.9
44.1
19
8.53.3
%
N = 2691
Baseline characteristics
Characteristic Eligible for
Warfarin Therapy(n = 2691)
Did Not Meet theInclusion Criteria
(n = 5549)P Value
Medications at discharge, No. (%)
ACE inhibitor and/or ARB 1722 (64.0) 3459 (62.3) .15
Aldosterone antagonist 426 (15.8) 908 (16.4) .54
Antiplatelet agents 1354 (50.3) 2747 (49.5) .49
Aspirin 1333 (49.5) 2714 (48.9) .59
Clopidogrel 373 (13.9) 747 (13.5) .62
Aspirin plus clopidogrel 252 (9.4) 513 (9.2) .86
β-Blocker 2100 (78.0) 4286 (77.2) .42
Digoxin 848 (31.5) 1687 (30.4) .31
Lipid-lowering agent 1432 (53.2) 2906 (52.4) .47
Diuretic 2129 (79.1) 4334 (78.1) .30
No. of medications prescribed at discharge, median (IQR)
6.0 (5.0,7.0) 6.0 (5.0, 7.0) < .01
Postdischarge prescription & outpatient dispensing
0
30
60
90
%
N = 2691
Outpatient dispensing, persistence, and adherence
Prescription Status Outpatient Dispensing Persistence Adherence
Filled Prescription
Within 90 Days,
No. (Rate)
Filled Prescription
Within 1 Year,No. (Rate)
Discontinued Therapy
Within 1 Year,No. (Rate)
Medication Possession Ratio,
Median (IQR)
All patients 1631 (61.8) 1770 (67.9) 104 (7.1) 0.77 (0.51-0.98)
Prescription at discharge 1530 (84.5)* 1637 (91.6)* 98 (7.2) 0.78 (0.52-0.99)*
No prescription at discharge 101 (12.3)* 133 (16.8)* —** 0.63 (0.35-0.88)*
Previous non-users
Prescription at discharge 162 (86.1)* 169 (91.6)* 19 (12.6) 0.74 (0.38-0.96)
No prescription at discharge 34 (4.9)* 58 (9.0)* —** 0.54 (0.31-0.82)
Existing users
Prescription at discharge 1368 (84.2)* 1468 (91.5)* 79 (6.5) 0.78 (0.54-0.99)
No prescription at discharge 67 (51.1)* 75 (58.1)* —** 0.74 (0.43-0.93)
* P < .001 for the comparison between patients prescribed warfarin at discharge and patients not prescribed warfarin at discharge.** To protect patient confidentiality, cells with observations < 11 are not shown.
Prespecified subgroup analysisPrescription Status Outpatient Dispensing Persistence Adherence
Filled PrescriptionWithin 90 Days,
No. (Rate)
Filled PrescriptionWithin 1 Year,
No. (Rate)
Discontinued TherapyWithin 1 Year,
No. (Rate)
Medication Possession Ratio,
Median (IQR)All patients 1631 (61.8) 1770 (67.9) 104 (7.1) 0.77 (0.51-0.98)Age group
65-79 y 847 (64.8)* 926 (71.7)* 54 (7.1) 0.77 (0.52-0.97)≥ 80 y 784 (58.8)* 844 (64.1)* 50 (7.2) 0.77 (0.52-1.00)
Sex Female 923 (61.6) 994 (67.1) 58 (7.1) 0.78 (0.53-0.99)Male 708 (62.0) 776 (69.0) 46 (7.1) 0.76 (0.49-0.97)
Race Black 154 (60.3) 162 (63.9) 10 (7.7) 0.79 (0.51-1.03)White 1396 (62.9) 1518 (69.1) 91 (7.2) 0.77 (0.51-0.98)Other/unknown 81 (49.2) 90 (57.0) —** 0.81 (0.57-0.99)
* P < .001 ** To protect patient confidentiality, cells with observations < 11 are not shown.
Prespecified subgroup analysisPrescription Status Outpatient Dispensing Persistence Adherence
Filled Prescription
Within 90 Days,No. (Rate)
Filled Prescription
Within 1 Year,No. (Rate)
Discontinued TherapyWithin 1 Year,
No. (Rate)
Medication Possession Ratio,Median (IQR)
All patients 1631 (61.8) 1770 (67.9) 104 (7.1) 0.77 (0.51-0.98)
Coverage gap within 90 days of discharge
Yes 545 (61.0) 592 (67.2) 26 (5.3) 0.79 (0.53-1.01)No 1086 (62.2) 1178 (68.2) 78 (8.1) 0.76 (0.50-0.96)
Coverage gap during 1 year of follow-up
Yes 902 (63.4) 979 (69.5) 56 (6.7) 0.78 (0.52-1.00)No 729 (59.9) 791 (66.1) 48 (7.8) 0.75 (0.50-0.96)
Outpatient dispensing, adherence, and persistence by CHADS2 score
Prescription Status
Outpatient Dispensing Persistence Adherence
Filled Prescription
Within 90 Days,No. (Rate)
Filled Prescription
Within 1 Year,No. (Rate)
Discontinued Therapy
Within 1 Year,No. (Rate)
Medication Possession Ratio,
Median (IQR)
All patients 1631 (61.8) 1770 (67.9) 104 (7.1) 0.77 (0.51-0.98)
CHADS2 score
<3 422 (63.6) 459 (70.1) 31 (8.1) 0.76 (0.49-0.96)
≥3 1209 (61.2) 1311 (67.2) 73 (6.8) 0.77 (0.52-0.99)
Appendix
Sensitivity analysisPrescription Status Outpatient Dispensing Persistence Adherence
Filled Prescription
Within 90 Days,No. (Rate)
Filled Prescription
Within 1 Year,No. (Rate)
Discontinued Therapy
Within 1 Year,No. (Rate)
Medication Possession Ratio,
Median (IQR)
β-Blockers
All patients 937 (82.5) 999 (89.3) 61 (7.2) 0.90 (0.64, 1.03)Prescription at discharge 915 (86.5)* 965 (92.3)* 59 (7.1) 0.92 (0.67, 1.04)*
No prescription at discharge
22 (28.8)* 34 (48.3)* —** 0.58 (0.33, 0.73)*
Angiotensin receptor blockers
All patients 494 (21.1) 573 (25.2) 26 (5.7) 0.76 (0.46, 0.98)
Prescription at discharge 424 (76.3)* 452 (81.9)* 24 (6.2) 0.83 (0.60, 0.99)*
No prescription at discharge
70 (4.0)* 121 (7.5)* —** 0.60 (0.27, 0.81)*
* P < .001 for the comparison between patients prescribed therapy at discharge and patients not prescribed therapy at discharge.** To protect patient confidentiality, cells with observations < 11 are not shown.
Limitations
• We restricted the analysis to fee-for-service Medicare beneficiaries 65 years or older enrolled in Medicare Part D.
• A proportion of the failure to prescribe may be due to undocumented physician impressions
• Adherence was assessed by outpatient dispensing rather than actual monitoring
Conclusions• One-third of eligible patients with HF and AF were not
prescribed warfarin therapy at discharge from a HF hospitalization.
• Eligible patients without a discharge prescription seldom initiated therapy as outpatients.
• In contrast, the majority of patients who were prescribed warfarin at discharge filled the prescription within 90 days and remained on therapy for 1 year.
• These findings highlight the importance of hospital discharge and care transitions for enhancing evidence-based prescribing of anticoagulation therapy.
Acknowledgements
• This study was supported by an award from the American Heart Association Pharmaceutical Roundtable and David and Stevie Spina.
• Dr Eapen received funding from an American Heart Association Pharmaceutical Roundtable outcomes training grant (0875142N).
• The study was also funded under contract #HHSA29020050032I (Duke University DEcIDE Center) from the Agency for Healthcare Research and Quality, US Department of Health and Human Services, as part of the Developing Evidence to Inform Decisions About Effectiveness (DEcIDE) program.
Thank you