Abstract 20456: Practice Level Variation in the Prescription of Direct Oral Anticoagulants: Insights From the NCDR PINNACLE Registry
Introduction: Previous work has demonstrated significant practice level variation in the rates of warfarin prescription for patients with non-valvular atrial fibrillation (AF). However, it is unknown if similar variation exists in the use of the direct oral anticoagulants (DOACs).
Methods: Within the National Cardiovascular Data Registry (NCDR) PINNACLE registry, we identified 655,000 patients comprising 3,164,236 outpatient encounters with non-valvular AF and CHADS-VASc >1 between April 1, 2008 and September 30, 2014. We examined use of warfarin, any DOAC, and of dabigatran, rivaroxaban, and apixaban individually. A hierarchical logistic regression model including practice specific random effect was then used to adjust for patient factors associated with DOAC use and calculate rates of use of any DOAC and the individual DOACs across practices.
Results: At the end of the study period, the rate of OAC use was 61.2%. After adjusting for patient factors associated with OAC and DOAC use, there was significant practice level variation in the rate of use of any OAC (range 11-78.8%, median odds ratio [MOR] 1.52, 95% confidence interval [CI] 1.45-1.57) and of any DOAC (range 0-40.4%, MOR 3.58, 95% CI 3.05-4.13) (Figure). The MOR indicates the likelihood that 2 random practices in our cohort would differ in treating identical patients. There was also significant practice level variation in the use of the individual DOACs (dabigatran MOR 2.91, 95% CI 2.54-3.28; rivaroxaban MOR 3.44, 95% CI 2.95-3.94; apixaban MOR 3.97, 95%CI 3.33-4.64).
Conclusions: In our cohort, practices differed by 52% and 358% in treating identical AF patients with OAC and DOACs, respectively. In addition, over one third of all patients without a documented contraindication were not treated with any OAC, though rates varied dramatically by practice site.
Author Disclosures: L.N. Marzec: None. J. Wang: None. K. Gosch: None. P.S. Chan: None. H.H. Ting: None. N.D. Shah: None. T.M. Maddox: None.
- © 2016 by American Heart Association, Inc.