Trends in Oral Anticoagulant Use Among 436 864 Patients With Atrial Fibrillation in Community Practice, 2011 to 2020

Abstract

Background Among patients with nonvalvular atrial fibrillation (AF) and an elevated stroke risk, guidelines recommend direct oral anticoagulants (DOACs) over warfarin for stroke prevention. Changes in DOAC use over the past decade have not been well described. Methods and Results We evaluated trends in use of DOACs and warfarin from 2011 to 2020 among adults with AF and a CHA₂DS₂-VASc score ≥2 based on electronic health record data from 88 health systems in the United States contributing to Cerner Real World Data. The use of DOACs and warfarin was described over time, by age, sex, race, and ethnicity, and at the health-system level. We identified 436 864 patients with AF at risk for stroke (median age, 78 years; 52.1% men). From 2011 to 2020, overall anticoagulation rates increased from 56.3% to 64.7%, as DOAC use increased steadily (from 4.7% to 47.9%), while warfarin use declined (from 52.4% to 17.7%). DOAC uptake was similar across age, sex, and race and ethnicity groups but varied by health system. In 2020, the median health-system-level proportion of patients with AF on a DOAC was 49% (interquartile range, 40%-54%). Conclusions Over the past decade, anticoagulation rates for patients with AF have increased modestly as DOACs largely replaced warfarin, though significant gaps remain: One in 3 high-risk patients with AF is not on any anticoagulant. While DOAC adoption was generally consistent across major demographic groups, use between health systems remained highly variable, suggesting that provider and system factors influence DOAC uptake use more than patient-level factors.

Keywords: atrial fibrillation; direct oral anticoagulant; quality of care; stroke prevention.

Figure 1. Rates of anticoagulation in patients with AF and CHA₂DS₂‐VASc score ≥2, 2011 to 2020.

Proportion of patients with AF on any anticoagulant, DOAC, and warfarin between 2011 and 2020. AF indicates atrial fibrillation; and DOAC, direct oral anticoagulant.

Figure 2. Proportion of patients with atrial fibrillation on a DOAC by age, race and ethnicity, and sex over time.

Proportion of patients with atrial fibrillation on any anticoagulant, DOAC, and warfarin between 2011 and 2020, stratified by age (A), race and ethnicity (B), and sex (C). DOAC indicates direct oral anticoagulant.

Figure 3. Health‐system‐level proportion of patients with AF on a DOAC by year, 2011 to2020.

Distribution of health‐system rates of DOAC use between 2011 and 2020, including health systems that had at least 20 patients with AF in the data set in a given year. The data table shows the number of health systems in the year and the percentiles of patients on a DOAC across those health systems in each year. AF indicates atrial fibrillation; and DOAC, direct oral anticoagulant.