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    Anticoagulant Use, Safety and Effectiveness for Ischemic Stroke Prevention in Nursing Home Residents with Atrial Fibrillation

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    Authors
    Alcusky, Matthew
    Faculty Advisor
    Kate Lapane
    Academic Program
    Clinical and Population Health Research
    UMass Chan Affiliations
    Population and Quantitative Health Sciences
    Document Type
    Doctoral Dissertation
    Publication Date
    2019-06-05
    Keywords
    Anticoagulants
    epidemiology
    nursing home
    older adults
    comparative effectiveness
    health outcomes
    Cardiovascular Diseases
    Clinical Epidemiology
    Epidemiology
    Health Services Administration
    
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    Abstract
    Background Fewer than one-third of nursing home residents with atrial fibrillation were treated with the only available oral anticoagulant, warfarin, historically. Management of atrial fibrillation has transformed in recent years with the approval of 4 direct-acting oral anticoagulants (DOACs) since 2010. Methods Using the national Minimum Data Set 3.0 linked to Medicare Part A and D claims, we first described contemporary (2011-2016) warfarin and DOAC utilization in the nursing home population (Aim 1). In Aim 2, we linked residents to nursing home and county level data to study associations between resident, facility, county, and state characteristics and anticoagulant treatment. Using a new-user active comparator design, we then compared the incidence of safety (i.e., bleeding), effectiveness (i.e., ischemic stroke), and mortality outcomes between residents initiating DOACs versus warfarin (Aim 3). Results The proportion of residents with atrial fibrillation receiving treatment increased from 42.3% in 2011 to 47.8% as of December 31, 2016, at which time 48.2% of treated residents received DOACs. Demographic and clinical characteristics of residents using DOACs and warfarin were similar in 2016. Half of the 8,734 DOAC users received standard dosages and most were treated with apixaban (54.4%) or rivaroxaban (35.8%) in 2016. Compared with warfarin, bleeding rates were lower and ischemic stroke rates were higher for apixaban users. Ischemic stroke and bleeding rates for dabigatran and rivaroxaban were comparable to warfarin. Mortality rates were lower versus warfarin for each DOAC. Conclusions In nursing homes, DOACs are being used commonly and with equal or greater benefit than warfarin.
    DOI
    10.13028/tfcw-vx13
    Permanent Link to this Item
    http://hdl.handle.net/20.500.14038/31254
    Rights
    Copyright is held by the author, with all rights reserved.
    ae974a485f413a2113503eed53cd6c53
    10.13028/tfcw-vx13
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    Morningside Graduate School of Biomedical Sciences Dissertations and Theses

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