Anticoagulation in older people with atrial fibrillation moving to care homes: a data linkage study

Abstract

Background: Treatment decisions about oral anticoagulants (OACs) for atrial fibrillation (AF) are complex in older care home residents.

Aim: To explore factors associated with OAC prescription.

Design and setting: Retrospective cohort study set in care homes in Wales, UK, listed in the Care Inspectorate Wales Registry 2017/18.

Method: Analysis of anonymised individual-level electronic health and administrative data was carried out on people aged ≥65 years entering a care home between 1 January 2003 and 31 December 2018, provisioned from the Secure Anonymised Information Linkage Databank.

Results: Between 2003 and 2018, 14 493 people with AF aged ≥65 years became new residents in care homes in Wales and 7057 (48.7%) were prescribed OACs (32.7% in 2003 compared with 72.7% in 2018) within 6 months before care home entry. Increasing age and prescription of antiplatelet therapy were associated with lower odds of OAC prescription (adjusted odds ratio [aOR] 0.96 per 1-year age increase, 95% confidence interval [CI] = 0.95 to 0.96 and aOR 0.91, 95% CI = 0.84 to 0.98, respectively). Conversely, prior venous thromboembolism (aOR 4.06, 95% CI = 3.17 to 5.20), advancing frailty (mild: aOR 4.61, 95% CI = 3.95 to 5.38; moderate: aOR 6.69, 95% CI = 5.74 to 7.80; and severe: aOR 8.42, 95% CI = 7.16 to 9.90), and year of care home entry from 2011 onwards (aOR 1.91, 95% CI = 1.76 to 2.06) were associated with higher odds of an OAC prescription.

Conclusion: There has been an increase in OAC prescribing in older people newly admitted to care homes with AF. This study provides an insight into the factors influencing OAC prescribing in this population.

Keywords: anticoagulants; atrial fibrillation; long-term care; nursing homes; practice patterns, physicians’; primary health care.

Figure 1.

Proportion of care home residents aged ≥65 years with atrial fibrillation prescribed an oral anticoagulant within 6 months before care home entry between 2003 and 2018. EMA = European Medicines Agency. NOAC = non- vitamin K antagonist oral anticoagulant.

Figure 2.

Factors associated with prescription of oral anticoagulation^a in new care home residents aged ≥65 years with atrial fibrillation, using a multivariable adjusted model. The reference for frailty categories is no frailty. Multivariate model adjusted for dyslipidaemia, smoking history, cancer diagnoses, year of care home entry ≥2011, and individual components of CHA₂DS₂VASc and HAS-BLED risk assessment scores. ^a Prescription within 6 months before care home entry used as a proxy for prescription at the point of care home entry. NSAID = non-steroidal anti-inflammatory drug. OAC = oral anticoagulant. OR = odds ratio.