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Adherence and Persistence in the Use of Warfarin After Hospital Discharge Among Patients With Heart Failure and Atrial Fibrillation.

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  1. Adherence and Persistence in the Use of Warfarin After Hospital DischargeAmong Patients With Heart Failure and Atrial Fibrillation Zubin J. Eapen, Xiaojuan Mi, Laura G. Qualls, Bradley G. Hammill, Gregg C. Fonarow, Mintu P. Turakhia, Paul A. Heidenreich, Eric D. Peterson, Lesley H. Curtis, Adrian F. Hernandez, Sana M. Al-Khatib AHA Scientific Sessions November 7, 2012

  2. Presenter disclosure information ZJ Eapen: none X Mi: none LG Qualls: none BG Hammill: none GC Fonarow: consultant for Amgen, Gambro, GlaxoSmithKline, Medtronic, Merck, Novartis, Pfizer, Relypsa, Scios, St. Jude, Takeda, and the Medicines Company; employment with the Ahmanson Foundation; service as the Eliot Corday Chair of Cardiovascular Medicine and Science; grants from the Agency for Healthcare Research and Quality, the National Institutes of Health, and GlaxoSmithKline; speakers fees from Boston Scientific/Guidant, GlaxoSmithKline, Medtronic, Merck, Novartis, Pfizer, and St. Jude Medical. MP Turakhia: consultant for Medtronic, Precision Health Economics, and St. Jude Medical; grants from the American Heart Association, Gilead Sciences, iRhythm, and Medtronic; speakers fees from Boston Scientific and St. Jude Medical; stock in Zipline Medical; travel/meeting expenses from Medtronic. PA Heidenreich: none ED Peterson: grants from Eli Lilly and Janssen Pharmaceuticals. LH Curtis: grants from GlaxoSmithKline and Johnson & Johnson. AF Hernandez: grant from Portola Pharmaceuticals. SM Al-Khatib: travel/meeting expenses from Bristol-Myers Squibb. DISCLOSURE INFORMATION:

  3. Background • Practice guidelines recommend warfarin at hospital discharge for patients with heart failure (HF) and atrial fibrillation (AF) • Warfarin prescription at hospital discharge is an ACC/AHA clinical performance measure for patients with HF and AF • More than one-third of eligible patients with HF and AF are not discharged with a prescription for warfarin

  4. Rationale Adherence to anticoagulation among these high-risk patients is not well described Objective Describe the transitional and long-term adherence to anticoagulation therapy among Medicare beneficiaries with HF and AF

  5. Methods: data sources • Demographics • Medical history • Results of laboratory tests and examinations • Discharge medications • Medicare Part A • hospitalization claims • Denominator files • program eligibility and enrollment • date of death • Medicare Part D • generic names of prescription drugs • days’ supply • program enrollment and benefit phases

  6. Methods: data sources discharge date admission date sex date of birth

  7. Methods: study cohort

  8. Warfarin contraindications

  9. Methods:measuring adherence and persistence • Obtained postdischarge prescription claims for warfarin from Medicare Part D claims during 1 year after discharge from the index hospitalization • Defined the initial outpatient dispensing date as the date of the first prescription claim during 1 year of follow-up • Calculated the days to the first outpatient prescription claim from the index discharge date

  10. Methods:analyzing adherence and persistence • Outpatient dispensing rates: cumulative incidence of the first filled outpatient prescription for warfarin within 90 days or 1 year after discharge from the index hospitalization. • Discontinuation of therapy: first 90-day gap in the days’ supply of warfarin during 1 year of follow-up. • Medication possession ratio: sum of the days’ supply of warfarin divided by the number of days alive during 1 year of follow-up.

  11. Baseline characteristics

  12. Study population by CHADS2 score N = 2691

  13. Baseline characteristics

  14. Postdischarge prescription & outpatient dispensing N = 2691

  15. Outpatient dispensing, persistence, and adherence * P< .001 for the comparison between patients prescribed warfarin at discharge and patients not prescribed warfarin at discharge. ** To protect patient confidentiality, cells with observations < 11 are not shown.

  16. Prespecified subgroup analysis * P< .001 ** To protect patient confidentiality, cells with observations < 11 are not shown.

  17. Prespecified subgroup analysis

  18. Outpatient dispensing, adherence, and persistence by CHADS2 score Appendix

  19. Sensitivity analysis * P< .001 for the comparison between patients prescribed therapy at discharge and patients not prescribed therapy at discharge. ** To protect patient confidentiality, cells with observations < 11 are not shown.

  20. Limitations • We restricted the analysis to fee-for-service Medicare beneficiaries 65 years or older enrolled in Medicare Part D. • A proportion of the failure to prescribe may be due to undocumented physician impressions • Adherence was assessed by outpatient dispensing rather than actual monitoring

  21. Conclusions • One-third of eligible patients with HF and AF were not prescribed warfarin therapy at discharge from a HF hospitalization. • Eligible patients without a discharge prescription seldom initiated therapy as outpatients. • In contrast, the majority of patients who were prescribed warfarin at discharge filled the prescription within 90 days and remained on therapy for 1 year. • These findings highlight the importance of hospital discharge and care transitions for enhancing evidence-based prescribing of anticoagulation therapy.

  22. This study was supported by an award from the American Heart Association Pharmaceutical Roundtable and David and Stevie Spina. Dr Eapen received funding from an American Heart Association Pharmaceutical Roundtable outcomes training grant (0875142N). The study was also funded under contract #HHSA29020050032I (Duke University DEcIDE Center) from the Agency for Healthcare Research and Quality, US Department of Health and Human Services, as part of the Developing Evidence to Inform Decisions About Effectiveness (DEcIDE) program. Acknowledgements

  23. Thank you

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