Greater than 1 in 10 sufferers hospitalized for atrial fibrillation (AF) are discharged on an off-label dose of a direct oral anticoagulant (DOAC), as reported in Circulation: Cardiovascular High quality and Outcomes.
Researchers used knowledge from the Get With The Tips-Atrial Fibrillation (GWTG-AFIB) registry to evaluate off-label DOAC dosing charges at discharge in sufferers hospitalized for AF, in addition to patient- and facility-level elements related to off-label DOAC dosing and temporal modifications within the proportion of sufferers who acquired off-label DOAC dosing.
The individuals required hospital take care of administration of AF or atrial flutter and had been discharged on a DOAC (apixaban, rivaroxaban, or dabigatran) from January 1, 2014, to March 31, 2020.
A complete of twenty-two,470 sufferers had been discharged after a hospital encounter for AF, of whom 2006 (8.9%) acquired a DOAC that was decrease than the beneficial dose, 19,953 (88.8%) acquired a DOAC at beneficial dosing, and 511 (2.3%) acquired a DOAC that was increased than the beneficial dose. The sufferers had an total imply age of 70.1±12.1 years and 48.1% had been ladies.
These outcomes characterize favorable nationwide traits in DOAC use whereas figuring out continued alternatives to enhance protected and acceptable DOAC dosing at hospital discharge.
Multivariable modeling confirmed that elevated charges of underdosing had been related to patient-level elements similar to older age (odds ratio [OR], 4.08; 95% CI, 3.60-4.62), dialysis dependence (OR, 5.50; 95% CI, 3.76-8.05), and former hemorrhage (OR, 1.73; 95% CI, 1.35-2.22), in addition to hospital-level elements similar to Western and concrete location and servicing comparatively few beds. Elevated overdosing charges had been related to patient-level elements similar to older age (OR, 5.57; 95% CI, 4.19-7.40) and dialysis dependence (OR, 5.47; 95% CI, 2.74-10.88).
The median share of off-label DOAC dosage was 10.9% (IQR, 6.8%-15.9%) among the many collaborating websites. The general adjusted median odds ratio (MOR) for off-label DOAC dosage was 1.45 (95% CI, 1.34-1.65; random results mannequin [REM] vary, 0.47-2.14) among the many hospitals, which signifies important variation throughout websites.
For underdosing, the adjusted MOR was 1.52 (95% CI, 1.39-1.76; REM vary, 0.42-2.36) in contrast with 1.32 for overdosing (95% CI, 1.20-1.84; REM vary, 0.56-1.78). Though affected person elements contributed extra to variability than facility-level elements, facility-level elements had a major impact on underdosing and overdosing.
A big improve was present in beneficial dosing in the course of the examine interval (81.9% in 2014 to 90.9% in 2020; P <.0001 for development). A big lower occurred in underdosing (14.4% in 2014 to six.6% in 2020, P <.0001 for development) and overdosing (3.8% in 2014 to 2.5% in 2020, P =.001 for development).
Limitations of the examine embody the evaluation of hospitals collaborating within the GWTG-AF registry and lacking knowledge resulting in affected person exclusion. Additionally, elements similar to frailty are usually not obtainable within the registry, and weight is just obtainable at 1 timepoint throughout or near admission.
“These outcomes characterize favorable nationwide traits in DOAC use whereas figuring out continued alternatives to enhance protected and acceptable DOAC dosing at hospital discharge,” the investigators wrote.
Disclosure: The Get With The Tips–AFIB (GWTG-AFIB) program is supplied by the American Coronary heart Affiliation. GWTG-AFIB is sponsored, partially, by BMS Pfizer, Tylenol, and Philips Picture Guided Remedy. Please see the unique reference for a full record of disclosures.