Adverse outcomes and predictors of underuse of antithrombotic therapy in medicare beneficiaries with chronic atrial fibrillation
Abstract
BACKGROUND AND PURPOSE: Antithrombotic therapy can prevent strokes and transient ischemic attacks (TIAs) in carefully selected patients who have chronic nonvalvular atrial fibrillation (NVAF). Our objectives were 3-fold: to document the use of warfarin and aspirin therapy in Missouri Medicare beneficiaries with chronic NVAF; to identify factors associated with warfarin and aspirin underuse; and to determine the association between prescription of warfarin and aspirin at hospital discharge and adverse outcomes in this elderly, frail population. METHODS: We linked chart reviews from all Missouri hospitals to Medicare claims data from 1993 to 1996. From chart reviews, we documented Medicare beneficiaries' demographic factors, comorbid conditions, and antithrombotic therapy prescribed at the time of hospital discharge. From Medicare claims, we determined the date of outcomes-death from any cause or hospitalization for an ischemic event (a stroke, a TIA, or a myocardial infarction). RESULTS: Only 328 (55%) of the 597 Medicare beneficiaries were prescribed antithrombotic therapy at hospital discharge: 34% received warfarin and 21% received aspirin. Advanced age, female gender, and rural residency predicted underuse of antithrombotic therapy. After controlling for these factors, as well as stroke risk factors and contraindications to anticoagulation, the prescription of warfarin was associated with a 24% relative risk reduction (RRR) in adverse outcomes (P=0.003). Prescription of aspirin was associated with a nonsignificant 5% RRR in these events (P=0.56). CONCLUSIONS: The underuse of antithrombotic therapy in Medicare beneficiaries who have NVAF is associated with measurable adverse outcomes. The benefit of warfarin therapy may extend to frail, elderly patients, a group that was excluded from randomized controlled trials. The role of antiplatelet therapy in this population deserves further study because many of these patients have relative contraindications to warfarin.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
OAC is still underutilized in the elderly.
“and yet OAC is still underutilized in the elderly.220,842”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [842]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Feinberg, W. M. (1995) · Archives of Internal Medicine · doi:10.1001/archinte.155.5.469 · Cited by 2,282 · see citing works
Risk Factors for Stroke and Efficacy of Antithrombotic Therapy in Atrial Fibrillation
(1994) · Archives of Internal Medicine · doi:10.1001/archinte.1994.00420130036007 · Cited by 2,066 · see citing works
EAFT (European Atrial Fibrillation Trial) Study Group (1993) · The Lancet · doi:10.1016/0140-6736(93)92358-z · Cited by 1,877 · see citing works
Petersen, P., GODTFREDSEN, J., Boysen, G., Andersen, E. D., & Andersen, B. (1989) · The Lancet · doi:10.1016/s0140-6736(89)91200-2 · Cited by 1,814 · see citing works
Stroke Prevention in Atrial Fibrillation Study. Final results.
Prevention, S., & Atrial Fibrillation Investigators (1991) · Circulation · doi:10.1161/01.cir.84.2.527 · Cited by 1,696 · see citing works
Diener, H., Cunha, L., Forbes, C. D., Sivenius, J., Smets, P., & Lowenthal, A. (1996) · Journal of the Neurological Sciences · doi:10.1016/s0022-510x(96)00308-5 · Cited by 1,559 · see citing works
Atrial Fibrillation: A Major Contributor to Stroke in the Elderly
Wolf, P. A. (1987) · Archives of Internal Medicine · doi:10.1001/archinte.147.9.1561 · Cited by 1,526 · see citing works
The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators* (1990) · New England Journal of Medicine · doi:10.1056/nejm199011293232201 · Cited by 1,525 · see citing works
Forbes, C., & Collaborators, E. (1997) · International Journal of Clinical Practice · doi:10.1111/j.1742-1241.1997.tb11433.x · Cited by 1,412 · see citing works
Warfarin in the Prevention of Stroke Associated with Nonrheumatic Atrial Fibrillation
Ezekowitz, M. D., Bridgers, S. L., James, K. E., Carliner, N. H., Colling, C. L., Gornick, C. C., Krause-Steinrauf, H. J., Kurtzke, J. F., Nazarian, S. M., Radford, M. J., et al. (1992) · New England Journal of Medicine · doi:10.1056/nejm199211123272002 · Cited by 1,204 · see citing works
Self-citationCanadian atrial fibrillation anticoaguiation (CAFA) study
Connolly, S. J., Laupacis, A., Gent, M., Roberts, R. S., Cairns, J. A., & Joyner, C. D. (1991) · Journal of the American College of Cardiology · doi:10.1016/0735-1097(91)90585-w · Cited by 1,109 · see citing works
Atrial Fibrillation: A Major Contributor to Stroke in the Elderly: The Framingham Study
Wolf, P. A. (1987) · Archives of Internal Medicine · doi:10.1001/archinte.1987.00370090041008 · Cited by 1,108 · see citing works
Warfarin in the Prevention of Stroke Associated with Nonrheumatic Atrial Fibrillation
Barnes, D. J. (1993) · New England Journal of Medicine · doi:10.1056/nejm199301143280227 · Cited by 1,068 · see citing works
Anticoagulant-related bleeding: Clinical epidemiology, prediction, and prevention
Landefeld, C. S., & Beyth, R. J. (1993) · The American Journal of Medicine · doi:10.1016/0002-9343(93)90285-w · Cited by 897 · see citing works
The Stroke Prevention in Atrial Fibrillation Investigators (1992) · Annals of Internal Medicine · doi:10.7326/0003-4819-116-1-6 · Cited by 546 · see citing works
Benesch, C. G., Witter, D. M., Wilder, A. L., Duncan, P. W., Samsa, G. P., & Matchar, D. B. (1997) · Neurology · doi:10.1212/wnl.49.3.660 · Cited by 331 · see citing works
Gage, B. F. (1995) · JAMA · doi:10.1001/jama.1995.03530230025025 · Cited by 329 · see citing works
Self-citationMeszaros, J. R., Asch, D. A., Baron, J., Hershey, J. C., Kunreuther, H., & Schwartz-Buzaglo, J. (1996) · Journal of Clinical Epidemiology · doi:10.1016/0895-4356(96)00007-8 · Cited by 271 · see citing works
Man‐Son‐Hing, M. (1999) · JAMA · doi:10.1001/jama.282.8.737 · Cited by 271 · see citing works
Warfarin Use Among Patients With Atrial Fibrillation
Brass, L. M., Krumholz, H. M., Scinto, J. D., & Radford, M. J. (1997) · Stroke · doi:10.1161/01.str.28.12.2382 · Cited by 238 · see citing works
Self-citationPhysician Attitudes About Anticoagulation for Nonvalvular Atrial Fibrillation in the Elderly
McCrory, D. C. (1995) · Archives of Internal Medicine · doi:10.1001/archinte.1995.00430030071008 · Cited by 231 · see citing works
Contrast sonography for detection of vesicoureteral reflux
Kaneko, K., Kuwatsuru, R., Fukuda, Y., Yamataka, A., Yabuta, K., Katayama, H., & Miyano, T. (1994) · The Lancet · doi:10.1016/s0140-6736(94)92123-7 · Cited by 222 · see citing works
National Patterns of Warfarin Use in Atrial Fibrillation
Stafford, R. S. (1996) · Archives of Internal Medicine · doi:10.1001/archinte.1996.00440210043004 · Cited by 212 · see citing works
Omission Bias and Pertussis Vaccination
Asch, D. A., Baron, J., Hershey, J. C., Kunreuther, H., Meszaros, J. R., Ritov, I., & Spranca, M. D. (1994) · Medical Decision Making · doi:10.1177/0272989x9401400204 · Cited by 206 · see citing works
Atrial Fibrillation and Stroke Prevention With Warfarin in the Long-term Care Setting
Gurwitz, J. H. (1997) · Archives of Internal Medicine · doi:10.1001/archinte.1997.00440300080006 · Cited by 170 · see citing works
The Efficacy of Aspirin in Patients With Atrial Fibrillation
(1997) · Archives of Internal Medicine · doi:10.1001/archinte.1997.00440320143013 · Cited by 161 · see citing works
Status of Antithrombotic Therapy for Patients With Atrial Fibrillation in University Hospitals
Albers, G. W. (1996) · Archives of Internal Medicine · doi:10.1001/archinte.1996.00440190053006 · Cited by 160 · see citing works
Kutner, M. (1991) · Archives of Internal Medicine · doi:10.1001/archinte.1991.00400100038006 · Cited by 152 · see citing works
Monette, J., Gurwitz, J. H., Rochon, P. A., & Avorn, J. (1997) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.1997.tb05967.x · Cited by 149 · see citing works
Failure to prescribe warfarin to patients with nonrheumatic atrial fibrillation
Antani, M. R., Beyth, R. J., Covinsky, K. E., Anderson, P. A., Miller, D. G., Cebul, R. D., Quinn, L., & Landefeld, C. S. (1996) · Journal of General Internal Medicine · doi:10.1007/bf02598984 · Cited by 121 · see citing works
Why isn’t warfarin prescribed to patients with nonrheumatic atrial fibrillation?
Beyth, R. J., Antani, M. R., Covinsky, K. E., Miller, D. G., Chren, M., Quinn, L., & Landefeld, C. S. (1996) · Journal of General Internal Medicine · doi:10.1007/bf02598985 · Cited by 114 · see citing works
Gage, B. F., Cardinalli, A. B., & Owens, D. K. (1998) · Stroke · doi:10.1161/01.str.29.6.1083 · Cited by 112 · see citing works
Self-citationTemporal Trends in the Use of Anticoagulants Among Older Adults With Atrial Fibrillation
Smith, N. L., Psaty, B. M., Furberg, C. D., White, R., Lima, J. A. C., Newman, A. B., & Manolio, T. A. (1999) · Archives of Internal Medicine · doi:10.1001/archinte.159.14.1574 · Cited by 111 · see citing works
Thromboembolism Prophylaxis in Chronic Atrial Fibrillation
Munschauer, F. E., Priore, R. L., Hens, M. M., & Castilone, A. (1997) · Stroke · doi:10.1161/01.str.28.1.72 · Cited by 110 · see citing works
Petty, G. W., Brown, R. D., Whisnant, J. P., Sicks, J. D., O'Fallon, W. M., & Wiebers, D. O. (1999) · Annals of Internal Medicine · doi:10.7326/0003-4819-130-1-199901050-00004 · Cited by 98 · see citing works
White, R. H. R., McBurnie, M. A., Manolio, T. A., Furberg, C. D., Gardin, J. M., Kittner, S. J., Bovill, E., & Knepper, L. E. (1999) · The American Journal of Medicine · doi:10.1016/s0002-9343(98)00389-1 · Cited by 95 · see citing works
Golzari, H., Cebul, R. D., & Bahler, R. C. (1996) · Annals of Internal Medicine · doi:10.7326/0003-4819-125-4-199608150-00010 · Cited by 93 · see citing works
Warfarin Use Following Ischemic Stroke Among Medicare Patients With Atrial Fibrillation
Brass, L. M., Krumholz, H. M., Scinto, J. D., Mathur, D., & Radford, M. J. (1998) · Archives of Internal Medicine · doi:10.1001/archinte.158.19.2093 · Cited by 88 · see citing works
Self-citationPhysician Variation in Anticoagulating Patients With Atrial Fibrillation
Chang, H. J. (1990) · Archives of Internal Medicine · doi:10.1001/archinte.1990.00390130089012 · Cited by 86 · see citing works
Mendelson, G., & Aronow, W. S. (1998) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.1998.tb06011.x · Cited by 85 · see citing works
Underutilization of antithrombotic therapy in elderly rural patients with atrial fibrillation
Flaker, G. C., McGowan, D. J., Boechler, M., et al. (1999) · American Heart Journal · doi:10.1053/hj.1999.v137.91403 · Cited by 83 · see citing works
Self-citationThe Use of Oral Anticoagulants (warfarin) in Older People
(2000) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2000.tb03917.x · Cited by 64 · see citing works
A differential effect of aspirin on prevention of stroke in atrial fibrillation
(1993) · Journal of Stroke and Cerebrovascular Diseases · doi:10.1016/s1052-3057(10)80159-4 · Cited by 62 · see citing works
How do physicians weigh iatrogenic complications?
Cohen, B. J., & Pauker, S. G. (1994) · Journal of General Internal Medicine · doi:10.1007/bf02599137 · Cited by 37 · see citing works
Controversies Surrounding Long-term Anticoagulation of Very Elderly Patients in Atrial Fibrillation
Marine, J. E., & Goldhaber, S. Z. (1998) · CHEST Journal · doi:10.1378/chest.113.4.1115 · Cited by 26 · see citing works
Non-anticoagulation in atrial fibrillation
O’Hare, J. A., Ul-Iman, N., & Geoghegan, M. (1994) · Irish Journal of Medical Science (1971 -) · doi:10.1007/bf02940563 · Cited by 9 · see citing works
Laupacis, A., & Sullivan, K. (1996) · PubMed · Cited by 9 · see citing works
The Use Of Oral Anticoagulants (Warfarin) in Older People
AGS Clinical Practice Committee (1996) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.1996.tb02949.x · Cited by 9 · see citing works
Underutilization of Cardiac Medications in the Pacemaker Selection in the Elderly Study
Aronow, W. S. (1999) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.1999.tb04587.x · Cited by 3 · see citing works
Flagged first, then by citations
Research works printed but not linked: 4
- Stroke Prevention in Atrial Fibrillation Investigators. Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II Study. Lancet. 1994;343:687-691.
- Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prev- alence, age distribution, and gender of patients with atrial fibrillation. Arch Intern Med. 1995;155:469 -473.
- Walker GA. Logistic regression. In: Common Statistical Methods for Clinical Research with SAS® Examples. Cary, NC: SAS Institute Inc; 1996:225-242.
- Petty GW, Brown RD, Whisnant JP, Sicks JD, O'Fallon M, Wiebers DO. Frequency of major complications of aspirin, warfarin, and intravenous heparin for secondary stroke prevention. Ann Intern Med. 1998;130: 14 -22.
Cited by
Sorted by citations
2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS
Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., Castella, M., Diener, H.-C., Heidbuchel, H., Hendriks, J., et al. (2016) · European Heart Journal · doi:10.1093/eurheartj/ehw210 · Cited by 6,418 · see citing works
A comparison of rate control and rhythm control in patients with atrial fibrillation
(2002) · New England Journal of Medicine · doi:10.1056/nejmoa021328 · Cited by 4,405 · see citing works
2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS
Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., Castella, M., Diener, H.-C., Heidbuchel, H., Hendriks, J., et al. (2016) · European Journal of Cardio-Thoracic Surgery · doi:10.1093/ejcts/ezw313 · Cited by 1,403 · see citing works
Gage, B. F., Yan, Y., Milligan, P. E., Waterman, A. D., Culverhouse, R., Rich, M. W., & Radford, M. J. (2006) · American Heart Journal · doi:10.1016/j.ahj.2005.04.017 · Cited by 1,008 · see citing works
Self-citationMatchar, D. B., Samsa, G. P., Cohen, S. J., Oddone, E. Z., & Jurgelski, A. E. (2002) · The American Journal of Medicine · doi:10.1016/s0002-9343(02)01131-2 · Cited by 141 · see citing works
Female sex as an independent risk factor for stroke in atrial fibrillation: Possible mechanisms
Albert, C. M., Andreotti, F., Badimon, L., Van Gelder, I. C., Hylek, E. M., & Cove, C. L. (2014) · Thrombosis and Haemostasis · doi:10.1160/th13-04-0347 · Cited by 116 · see citing works
- Authors
- Gage, B. F., Boechler, M., Doggette, A. L., Fortune, G., Flaker, G. C., Rich, M. W., & Radford, M. J.
- Affiliations
- Yale New Haven Hospital (US)
- Venue
- Stroke
- Published
- 2000-04
- Volume
- 31
- Issue
- 4
- Pages
- 822-827
- ISSN
- 0039-2499 (ISSN-L)
- 1524-4628
- OpenAlex
- W2030279551
- Cited by
- 302
- References
- 49
- Citations by year
- 2026: 3 · 2025: 2 · 2024: 3 · 2023: 3 · 2022: 2 · 2021: 9 · 2020: 3 · 2019: 12 · 2018: 11 · 2017: 9 · 2016: 20 · 2015: 11 · 2014: 17 · 2013: 19 · 2012: 18
- FWCI
- 9.64
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Stroke (publishedVersion)
- PubMed (publishedVersion)
- Funders
- U.S. Department of Health and Human Services
- American Heart Association
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Epidemiology › Acute Ischemic Stroke Management
- Health Sciences › Medicine › Internal Medicine › Venous Thromboembolism Diagnosis and Management
- Keywords
- antithrombotic therapy, warfarin, aspirin, underuse of anticoagulation, antiplatelet therapy, stroke prevention, transient ischemic attack, myocardial infarction, hospital discharge prescribing, Medicare beneficiaries, elderly patients, vulnerable patients, adverse outcomes
- MeSH terms
- Aged, Atrial Fibrillation, Chronic Disease, Drug Utilization, Female, Fibrinolytic Agents, Medicare, Humans, Male, Sampling Studies, United States
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
