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dc.contributor.advisorKate Lapane
dc.contributor.authorAlcusky, Matthew J
dc.date2022-08-11T08:08:38.000
dc.date.accessioned2022-08-23T16:02:03Z
dc.date.available2022-08-23T16:02:03Z
dc.date.issued2019-06-05
dc.date.submitted2019-07-03
dc.identifier.doi10.13028/tfcw-vx13
dc.identifier.urihttp://hdl.handle.net/20.500.14038/31254
dc.description.abstractBackground 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.
dc.language.isoen_US
dc.rightsCopyright is held by the author, with all rights reserved.
dc.subjectAnticoagulants
dc.subjectepidemiology
dc.subjectnursing home
dc.subjectolder adults
dc.subjectcomparative effectiveness
dc.subjecthealth outcomes
dc.subjectCardiovascular Diseases
dc.subjectClinical Epidemiology
dc.subjectEpidemiology
dc.subjectHealth Services Administration
dc.titleAnticoagulant Use, Safety and Effectiveness for Ischemic Stroke Prevention in Nursing Home Residents with Atrial Fibrillation
dc.typeDoctoral Dissertation
dc.identifier.legacyfulltexthttps://escholarship.umassmed.edu/cgi/viewcontent.cgi?article=2043&context=gsbs_diss&unstamped=1
dc.identifier.legacycoverpagehttps://escholarship.umassmed.edu/gsbs_diss/1034
dc.legacy.embargo2021-06-05T00:00:00-07:00
dc.identifier.contextkey14860344
refterms.dateFOA2022-08-25T03:55:29Z
html.description.abstract<p><strong>Background</strong></p> <p>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.</p> <p><strong>Methods</strong></p> <p>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).</p> <p><strong>Results</strong></p> <p>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.</p> <p>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.</p> <p><strong>Conclusions</strong></p> <p>In nursing homes, DOACs are being used commonly and with equal or greater benefit than warfarin.</p>
dc.identifier.submissionpathgsbs_diss/1034
dc.contributor.departmentPopulation and Quantitative Health Sciences
dc.description.thesisprogramClinical and Population Health Research
dc.identifier.orcid0000-0001-5604-721X


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