Skip to main content

Advertisement

SpringerLink
Log in

Real life anticoagulation treatment of patients with atrial fibrillation in Germany: extent and causes of anticoagulant under-use

  • Published:
Journal of Thrombosis and Thrombolysis Aims and scope Submit manuscript

Abstract

Oral anticoagulation (OAC) with either new oral anticoagulants (NOACs) or Vitamin-K antagonists (VKAs) is recommended by guidelines for patients with atrial fibrillation (AF) and a moderate to high risk of stroke. Based on a claims-based data set the aim of this study was to quantify the stroke-risk dependent OAC utilization profile of German AF patients and possible causes of OAC under-use. Our claims-based data set was derived from two German statutory health insurance funds for the years 2007–2010. All prevalent AF-patients in the period 2007–2009 were included. The OAC-need in 2010 was assumed whenever a CHADS2- or CHA2DS2-VASC-score was >1 and no factor that disfavored OAC use existed. Causes of OAC under-use were analyzed using multivariate logistic regression. 108,632 AF-prevalent patients met the inclusion criteria. Average age was 75.43 years, average CHA2DS2-VASc-score was 4.38. OAC should have been recommended for 56.1/62.9 % of the patients (regarding factors disfavouring VKA/NOAC use). For 38.88/39.20 % of the patient-days in 2010 we could not observe any coverage by anticoagulants. Dementia of patients (OR 2.656) and general prescription patterns of the treating physician (OR 1.633) were the most important factors increasing the risk of OAC under-use. Patients who had consulted a cardiologist had a lower risk of being under-treated with OAC (OR 0.459). OAC under-use still seems to be one of the major challenges in the real-life treatment of AF patients. Our study confirms that both patient/disease characteristics and treatment environment/general prescribing behaviour of physicians may explain the OAC under-use in AF patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Heeringa J, van der Kuip DA, Hofman A et al (2006) Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 27(8):949–953

    Article  PubMed  Google Scholar 

  2. Schnabel RB, Sullivan LM, Levy D et al (2009) Development of a risk score for atrial fibrillation (Framingham Heart Study): a community-based cohort study. Lancet 373(9665):739–745

    Article  PubMed Central  PubMed  Google Scholar 

  3. Fang MC, Go AS, Chang Y, Borowsky L, Pomernacki NK (2008) Singer DE; ATRIA Study Group. Comparison of risk stratification schemes to predict thromboembolism in people with nonvalvular atrial fibrillation. J Am Coll Cardiol 51(8):810–815

    Article  PubMed Central  PubMed  Google Scholar 

  4. Camm AJ, Lip GY, De Caterina R et al (2012) ESC Committee for Practice Guidelines-CPG. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation-developed with the special contribution of the European Heart Rhythm Association. Europace 14(10):1385–1413

    Article  PubMed  Google Scholar 

  5. Fuster V, Rydén LE, Cannom DS et al (2011) American College of Cardiology Foundation/American Heart Association Task Force. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123(10):e269–e367

    Article  PubMed  Google Scholar 

  6. Singer DE, Albers GW, Dalen JE et al (2008) American College of Chest Physicians. Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133(6 Suppl):546S–592S

    Article  CAS  PubMed  Google Scholar 

  7. Lip GY, Rudolf M, Kakar P (2007) Management of atrial fibrillation: the NICE guidelines. Int J Clin Pract 61(1):9–11

    Article  PubMed  Google Scholar 

  8. Connolly SJ, Ezekowitz MD, Yusuf S et al (2009) RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 361(12):1139–1151

    Article  CAS  PubMed  Google Scholar 

  9. Andersen KK, Olsen TS (2007) Reduced poststroke mortality in patients with stroke and atrial fibrillation treated with anticoagulants: results from a Danish quality-control registry of 22,179 patients with ischemic stroke. Stroke 38(2):259–263

    Article  PubMed  Google Scholar 

  10. Gorin L, Fauchier L, Nonin E et al (2010) Antithrombotic treatment and the risk of death and stroke in patients with atrial fibrillation and a CHADS2 score = 1. Thromb Haemost 103(4):833–840

    Article  CAS  PubMed  Google Scholar 

  11. Ruff CT, Giugliano RP, Braunwald E et al (2014) Comparison of the efficacy and safety of new oral anticoagulants with warfarin inpatients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 383(9921):955–962

    Article  CAS  PubMed  Google Scholar 

  12. Ntaios G, Papavasileiou V, Diener HC, Makaritsis K, Michel P (2012) Nonvitamin-K-antagonist oral anticoagulants in patients with atrial fibrillation and previous stroke or transient ischemic attack: a systematic review and meta-analysis of randomized controlled trials. Stroke 43(12):3298–3304

    Article  CAS  PubMed  Google Scholar 

  13. Ru San T, Chan MY, Wee Siong T et al (2012) Stroke prevention in atrial fibrillation: understanding the new oral anticoagulants dabigatran, rivaroxaban, and apixaban. Thrombosis. 2012:108983

    Article  PubMed Central  PubMed  Google Scholar 

  14. Nieuwlaat R, Capucci A, Lip GY et al (2006) Euro Heart Survey Investigators. Antithrombotic treatment in real-life atrial fibrillation patients: a report from the Euro Heart Survey on Atrial Fibrillation. Eur Heart J 27(24):3018–3026

    Article  CAS  PubMed  Google Scholar 

  15. Ogilvie IM, Newton N, Welner SA, Cowell W, Lip GY (2010) Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med 123(7):638–645

    Article  CAS  PubMed  Google Scholar 

  16. Wilke T, Groth A, Mueller S et al (2012) Oral anticoagulation use by patients with atrial fibrillation in Germany. Adherence to guidelines, causes of anticoagulation under-use and its clinical outcomes, based on claims-data of 183,448 patients. Thromb Haemost 107(6):1053–1065

    Article  CAS  PubMed  Google Scholar 

  17. McBride D, Brüggenjürgen B, Roll S, Willich SN (2007) Anticoagulation treatment for the reduction of stroke in atrial fibrillation: a cohort study to examine the gap between guidelines and routine medical practice. J Thromb Thrombolysis 24(1):65–72

    Article  PubMed  Google Scholar 

  18. Dreischulte T, Barnett K, Madhok V, Guthrie B (2014) Use of oral anticoagulants in atrial fibrillation is highly variable and only weakly associated with estimated stroke risk: Cross-sectional population database study. Eur J Gen Pract. 20(3):181–189

    Article  PubMed  Google Scholar 

  19. Cowan C, Healicon R, Robson I et al (2013) The use of anticoagulants in the management of atrial fibrillation among general practices in England. Heart 99(16):1166–1172

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  20. Lip GY (2011) Implications of the CHA(2)DS(2)-VASc and HAS-BLED Scores for thromboprophylaxis in atrial fibrillation. Am J Med 124(2):111–114

    Article  PubMed  Google Scholar 

  21. SMPC Marcumar. Open drug base. http://de.oddb.org/de/drugs/fachinfo/uid/86726. Accessed 31 Jan 2014

  22. SMPC Pradaxa. Boehringer Ingelheim Pharma GmbH & Co. KG. http://www.boehringer-interaktiv.de/produkte/-gebrauchsinfo.pdf?pzn=g3420760&MTITEL=Gebrauchsinformation+Pradaxa%AE+110+mg+Hartkapseln+%28VTE+und+VHF%29.pdf. Accessed 31 Jan 2014

  23. Harley CR, Riedel AA, Hauch O, Nelson M, Wygant G, Reynolds M (2005) Anticoagulation therapy in patients with chronic atrial fibrillation: a retrospective claims data analysis. Curr Med Res Opin 21(2):215–222

    Article  CAS  PubMed  Google Scholar 

  24. WHO Collaborating Centre for Drug Statistics Methodology (2010) Guidelines for ATC classification and DDD assignment 2011, Oslo

  25. Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X (2008) Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews. (2)

  26. Peterson AM, Nau DP, Cramer JA et al (2007) A checklist for medication compliance and persistence studies using retrospective databases. Value Health 10(1):3–12

    Article  PubMed  Google Scholar 

  27. Bravata DM, Rosenbeck K, Kancir S, Brass LM (2004) The use of warfarin in veterans with atrial fibrillation. BMC Cardiovasc Disord 4(1):18

    Article  PubMed Central  PubMed  Google Scholar 

  28. Kirchhof P, Nabauer M, Gerth M et al (2011) Impact of the type of centre on management of AF patients: Surprising evidence for differences in antithrombotic therapy decisions. Thromb Haemost. 105(6):1010–1023

    Article  CAS  PubMed  Google Scholar 

  29. Chae JW, Song CS, Kim H, Lee KB, Seo BS, Kim DI (2011) Prediction of mortality in patients undergoing maintenance hemodialysis by Charlson Comorbidity Index using ICD-10 database. Nephron Clin Pract. 117(4):c379–c384

    Article  PubMed  Google Scholar 

  30. Martin BC, Wiley-Exley EK, Richards S, Domino ME, Carey TS, Sleath BL (2009) Contrasting measures of adherence with simple drug use, medication switching, and therapeutic duplication. Ann Pharmacother 43(1):36–44

    Article  PubMed  Google Scholar 

  31. Khoo CW, Lip GY (2009) Acute management of atrial fibrillation. Chest 135(3):849–859

    Article  CAS  PubMed  Google Scholar 

  32. DeWilde S, Carey IM, Emmas C, Richards N, Cook DG (2006) Trends in the prevalence of diagnosed atrial fibrillation, its treatment with anticoagulation and predictors of such treatment in UK primary care. Heart 92(8):1064–1070

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  33. Olesen JB, Lip GY, Hansen ML et al (2011) Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ 342:d124

    Article  PubMed Central  PubMed  Google Scholar 

  34. Kaya H, Ertas F, Köroglu B, et al (2013) Predictors of Anticoagulant Treatment in Patients With Nonvalvular Atrial Fibrillation: Results From Atrial Fibrillation in Turkey: Epidemiologic Registry. Clin Appl Thromb Hemost

  35. Mazzaglia G, Filippi A, Alacqua M et al (2010) A national survey of the management of atrial fibrillation with antithrombotic drugs in Italian primary care. Thromb Haemost 103(5):968–975

    Article  CAS  PubMed  Google Scholar 

  36. Monte S, Macchia A, Pellegrini F et al (2006) Antithrombotic treatment is strongly underused despite reducing overall mortality among high-risk elderly patients hospitalized with atrial fibrillation. Eur Heart J 27(18):2217–2223

    Article  PubMed  Google Scholar 

  37. Ferro D, Loffredo L, Polimeni L, Violi F (2007) Underuse of oral anticoagulants in patients with nonvalvular atrial fibrillation in Italy. Intern Emerg Med 2(1):24–28

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  38. Deplanque D, Leys D, Parnetti L et al (2006) Secondary prevention of stroke in patients with atrial fibrillation: factors influencing the prescription of oral anticoagulation at discharge. Cerebrovasc Dis. 21(5–6):372–379

    Article  CAS  PubMed  Google Scholar 

  39. Gattellari M, Worthington JM, Zwar NA, Middleton S (2008) The management of non-valvular atrial fibrillation (NVAF) in Australian general practice: bridging the evidence-practice gap A national, representative postal survey. BMC Fam Pract. 13(9):62

    Article  Google Scholar 

  40. Haynes RB, Taylor DW, Sackett DL, Gibson ES, Bernholz CD, Mukherjee J (1980) Can simple clinical measurements detect patient noncompliance? Hypertension. 2(6):757–764

    Article  CAS  PubMed  Google Scholar 

  41. Andrade SE, Kahler KH, Frech F, Chan KA (2006) Methods for evaluation of medication adherence and persistence using automated databases. Pharmacoepidemiol Drug Saf 15(8):565–574

    Article  PubMed  Google Scholar 

  42. Deplanque D, Leys D, Parnetti L et al (2004) Stroke prevention and atrial fibrillation: reasons leading to an inappropriate management. Main results of the SAFE II study. Br J Clin Pharmacol 57(6):798–806

    Article  PubMed Central  PubMed  Google Scholar 

  43. Marcucci M, Iorio A, Nobili A et al (2010) Factors affecting adherence to guidelines for antithrombotic therapy in elderly patients with atrial fibrillation admitted to internal medicine wards. Eur J Intern Med 21(6):516–523

    Article  CAS  PubMed  Google Scholar 

  44. Zacharski LR, Prandoni P, Moneral M (2005) Warfarin versus low-molecular-weight heparin therapy in cancer patients. Oncologist 10(1):72–79

    Article  CAS  PubMed  Google Scholar 

  45. Cannon CP, Rhee KE, Califf RM et al (2010) Current use of aspirin and antithrombotic agents in the United States among outpatients with atherothrombotic disease (from the REduction of Atherothrombosis for Continued Health [REACH] Registry). Am J Cardiol 105(4):445–452

    Article  CAS  PubMed  Google Scholar 

  46. Gattellari M, Worthington JM, Zwar NA, Middleton S (2008) The management of non-valvular atrial fibrillation (NVAF) in Australian general practice: bridging the evidence-practice gap A national, representative postal survey. BMC Fam Pract. 13(9):62

    Article  Google Scholar 

  47. Gross CP, Vogel EW, Dhond AJ et al (2003) Factors influencing physicians’ reported use of anticoagulation therapy in nonvalvular atrial fibrillation: a cross-sectional survey. Clin Ther 25(6):1750–1764

    Article  PubMed  Google Scholar 

  48. Crystal S, Akincigil A, Bilder S, Walkup JT (2007) Studying prescription drug use and outcomes with medicaid claims data: strengths, limitations, and strategies. Med Care 45(10 Suppl 2):58–65

    Article  Google Scholar 

  49. Rawson NS (1998) D‘Arcy C. Assessing the validity of diagnostic information in administrative health care utilization data: experience in Saskatchewan. Pharmacoepidemiol Drug Saf 7:389–398

    Article  CAS  PubMed  Google Scholar 

  50. United Nations Population Division; World Population Prospects (2013) The 2012 Revision. UN, New York

    Google Scholar 

Download references

Conflict of interest

Matthias Pfannkuche is employed by Boehringer Ingelheim Pharma (Germany). Thomas Wilke has acted as consultant for Boehringer Ingelheim Pharma, Bayer, GSK, LEO Pharma, Novartis, and BMS, and Pharmerit International. Ulf Maywald, Andreas Fuchs and Oliver Harks work for one of the insurance funds providing the data or their data warehouse providers (AOK Plus: Maywald/Fuchs; GWQ ServicePlus AG: Harks).

Funding

The study was funded by Boehringer Ingelheim Pharma GmbH, Germany. The study design, the collection/analysis of data and the writing of the manuscript were done independently of the funding source.

Author information

Authors and Affiliations

  1. Institut für Pharmakoökonomie und Arzneimittellogistik (IPAM), University of Wismar, Philipp-Müller-Straße 12, 23966, Wismar, Germany

    Thomas Wilke & Antje Groth

  2. Boehringer Ingelheim Pharma GmbH & Co.KG, Binger Straße 173, 55216, Ingelheim am Rhein, Germany

    Matthias Pfannkuche

  3. GWQ Serviceplus AG, Tersteegenstraße 28, 40474, Düsseldorf, Germany

    Oliver Harks

  4. AOK Plus, Sternplatz 7, 01067, Dresden, Germany

    Andreas Fuchs & Ulf Maywald

  5. Klinikum Darmstadt GmbH, Grafenstraße 9, 64283, Darmstadt, Germany

    Bernd Krabbe

Authors
  1. Thomas Wilke
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Antje Groth
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Matthias Pfannkuche
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Oliver Harks
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Andreas Fuchs
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ulf Maywald
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Bernd Krabbe
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Thomas Wilke.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wilke, T., Groth, A., Pfannkuche, M. et al. Real life anticoagulation treatment of patients with atrial fibrillation in Germany: extent and causes of anticoagulant under-use. J Thromb Thrombolysis 40, 97–107 (2015). https://doi.org/10.1007/s11239-014-1136-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11239-014-1136-8

Keywords

Search

Navigation