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Direct Oral Anticoagulants and Warfarin for Atrial Fibrillation Treatment: Rural and Urban Trends in Medicare Beneficiaries

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Abstract

Background

Data are needed on the use of oral anticoagulation in patients with atrial fibrillation (AF) in rural versus urban areas, including the initiation of direct oral anticoagulants (DOACs).

Objective

We used Medicare data to examine rural/urban differences in anticoagulation use in patients with AF.

Methods

We identified incident AF in a 20% sample of fee-for-service Medicare beneficiaries (aged ≥ 65 years) from 2011 to 2016 and collected ZIP code and covariates at the time of AF. We identified the first anticoagulant prescription filled, if any, following AF diagnosis. We categorized beneficiaries into four rural/urban areas using rural–urban commuting area codes and used Poisson regression models to compare anticoagulant use.

Results

We included 447,252 patients with AF (mean age 79 ± 8 years), of which 82% were urban, 9% large rural, 5% small rural, and 4% isolated. The percentage who initiated an anticoagulant rose from 34% in 2011 to 53% in 2016, paralleling the uptake of DOACs. In a multivariable-adjusted analysis, those in rural areas (vs. urban) were more likely to initiate an anticoagulant. However, rural beneficiaries (vs. urban) were less likely to initiate a DOAC; those in isolated areas were 17% less likely (95% confidence interval [CI] 13–20), those in small rural areas were 12% less likely (95% CI 9–15), and those in large rural areas were 10% less likely (95% CI 8–12).

Conclusion

Among Medicare beneficiaries with AF, anticoagulation use was low but increased over time with the introduction of DOACs. Rural beneficiaries were less likely to receive a DOAC.

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Acknowledgement

This manuscript is part of Dr. Faye Norby’s PhD dissertation (manuscript 3). A non-peer-reviewed, full-text version of the dissertation is available online at Proquest, LLC.

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Authors and Affiliations

  1. Department of Cardiology, Center for Cardiac Arrest Prevention, Smidt Heart Institute, Cedars-Sinai Health System, Advanced Health Sciences Pavilion, Suite A9220, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA

    Faye L. Norby

  2. Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA

    Faye L. Norby, Pamela L. Lutsey, Rob F. Walker & Aaron R. Folsom

  3. Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA

    Nathan D. Shippee & Carrie Henning-Smith

  4. Cardiovascular Division, Department of Medicine, Cardiac Arrhythmia Center, University of Minnesota Medical School, Minneapolis, MN, USA

    Lin Y. Chen

  5. Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis, MN, USA

    Carrie Henning-Smith

  6. Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA

    Alvaro Alonso

Authors
  1. Faye L. Norby
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Corresponding author

Correspondence to Faye L. Norby.

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Funding

Alvaro Alonso has received funding from American Heart Association grant 16EIA26410001 and NHLBI grant K24HL148521.

Conflict of interest

Faye L. Norby, Pamela L. Lutsey, Nathan D. Shippee, Lin Y. Chen, Carrie Henning-Smith, Alvaro Alonso, Rob F. Walker, and Aaron R. Folsom have no potential conflicts of interest that might be relevant to the contents of this manuscript.

Ethics approval

This study was approved by the University of Minnesota Institutional Review Board as exempt because deidentified data were used.

Consent to participate

Not applicable.

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Not applicable.

Availability of data and material

The authors are unable to share the data since they were obtained under a data use agreement that does not allow data sharing.

Code availability

Available upon request.

Author contributions

FN, PL, NS, LC, and AF designed the study; FN and RW undertook the statistical analysis; FN wrote the manuscript; and PL, NS, LC, CHS, AA, RW, and AF undertook critical revision of the manuscript.

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Norby, F.L., Lutsey, P.L., Shippee, N.D. et al. Direct Oral Anticoagulants and Warfarin for Atrial Fibrillation Treatment: Rural and Urban Trends in Medicare Beneficiaries. Am J Cardiovasc Drugs 22, 207–217 (2022). https://doi.org/10.1007/s40256-021-00502-9

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