Low Use of Oral Anticoagulant Prescribing for Secondary Stroke Prevention
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Background:Oral anticoagulation reduces the risk of stroke in atrial fibrillation but is often underused.Objectives:To identify factors associated with oral anticoagulant prescribing and adherence after stroke or transient ischemic attack (TIA).Research Design:Retrospective cohort study using linked Ontario Stroke Registry and prescription claims data.Subjects:Consecutive patients with atrial fibrillation and ischemic stroke/TIA admitted to 11 stroke centers in Ontario, Canada between 2003 and 2011.Measures:We used modified Poisson regression models to determine predictors of anticoagulant prescribing and multiple logistic regression to determine predictors of 1-year adherence.Results:Of the 5781 patients in the study cohort, 4235 (73%) were prescribed oral anticoagulants at discharge. Older patients were less likely to receive anticoagulation [adjusted relative risk (aRR) for each additional year=0.997; 95% confidence interval (CI), 0.995–0.998], as were those with TIA compared with ischemic stroke (aRR=0.904; 95% CI, 0.865–0.945), prior gastrointestinal bleed (aRR=0.778; 95% CI, 0.693–0.873), dementia (aRR=0.912; 95% CI, 0.856–0.973), and those from a long-term care facility (aRR=0.810; 95% CI, 0.737–0.891). After limiting the sample to those without obvious contraindications to anticoagulation, age, dementia, and long-term care residence continued to be associated with lower prescription of oral anticoagulants. One-year adherence to therapy was similar across most patient groups.Conclusions:Age, dementia, and long-term care residence are predictors of lower oral anticoagulant use for secondary stroke prevention and represent key target areas for quality improvement initiatives.
