Brian Meissner

Why is warfarin underused for stroke prevention in atrial fibrillation? A detailed review of electronic medical records

Abstract Objective: Automated electronic queries of structured data fields in electronic medical records (EMR) found no barriers to warfarin in 42% of patients with atrial fibrillation or atrial flutter (AF) with moderate or high risk of stroke and no warfarin. A thorough manual review of records (including text reports) from the same EMR may better identify physicians’ reasons for not using warfarin. Methods: This was a cross-sectional, retrospective, manual EMR review. Patients identified in a previous automated EMR study with a CHADS2 (Chronic heart failure, Hypertension, Age >75 years, Diabetes mellitus, Stroke) score ≥2, no record of warfarin, no barrier to warfarin use, and (in the present study) confirmation of AF diagnosis were included in the manual EMR review. A structured chart abstraction form was used to extract data visible in the clinicians’ EMR user interface. Reasons why warfarin had not been prescribed were reported using descriptive statistics. Results: Among 408 patients with ‘no barriers’ to warfarin in the automated EMR review, AF diagnosis was confirmed in 319 patients (mean age 74.8; 65% female). Forty-one percent (n = 132) did not have chart records explaining why they were not on warfarin. Among the 59% (187) with a rationale against warfarin found in the records, the most common category (52%) was indicative of the risk of bleeding, either risk of fall or history of recent bleeding. The second most common category (16%) reflected that the patient was back in sinus rhythm. These findings are subject to inherent limitations of retrospective chart reviews. Conclusions: Many patients with AF and moderate-to-high risk of stroke are not treated with warfarin, and reasons for not using warfarin could not always be identified in patient records. Among patients with documented reasons, risk of bleeding (risk of fall or recent bleeding) was the most common category.

Switching of biologic disease modifying anti-rheumatic drugs in patients with rheumatoid arthritis in a real world setting.

Abstract Objectives: This study examined total healthcare costs and rates of patients with rheumatoid arthritis (RA) who switch biologic disease-modifying anti-rheumatic drug (bDMARD) therapy in a real world setting. Methods: A retrospective longitudinal analysis was conducted in patients with RA using IMS PharMetrics Plus database from 1/1/2004 to 3/31/2010. The first-line cohort included patients newly initiated on abatacept or the tumor necrosis factor-alpha inhibitors (anti-TNFs) adalimumab, etanercept, or infliximab, with 12 months of continuous follow-up. The second-line cohort included patients initiating a bDMARD with evidence of a different bDMARD within the previous 2 years and with 12 months of continuous follow-up. Switching was defined as a different bDMARD claim within a 200% gap in days supply from the previous bDMARD claim. Non-switchers stayed on their bDMARD in the follow-up period. Monthly total healthcare costs for switchers and non-switchers and rates of bDMARD switching were examined. Switch rates for each bDMARD were also compared. Results: First-line switchers had significantly higher monthly total healthcare costs after the switch than non-switchers (

Stroke and Bleeding Risk Associated With Antithrombotic Therapy for Patients With Nonvalvular Atrial Fibrillation in Clinical Practice

3759 vs

TIME IN THERAPEUTIC RANGE ≥55% VERSUS <55% ON WARFARIN THERAPY OUTCOMES IN NON-VALVULAR ATRIAL FIBRILLATION PATIENTS

2343; p < 0.05), as did second-line switchers (

Abstract W P330: Antithrombotic Treatment Patterns Among Patients with Non-Valvular Atrial Fibrillation in a Managed Care Setting

3956 vs

Original article Switching of biologic disease modifying anti-rheumatic drugs in patients with rheumatoid arthritis in a real world setting

2616; p < 0.05). First-line abatacept (2.1%) had significantly lower rates of switching compared to adalimumab (9.5%), etanercept (9.0%), and infliximab (5.5%). Second-line abatacept (8.0%) had significantly lower rates of switching compared to adalimumab (16.7%), etanercept (14.4%), and infliximab (14.3%). Limitations: There are no clinical data available in this database and, therefore, this study did not examine the clinical drivers of healthcare costs and switch rates. Conclusions: Monthly total healthcare costs were higher for bDMARD switchers following the switch compared to non-switchers. Patients on abatacept switched less frequently than patients on anti-TNFs. This study highlights the need to identify patients who are likely to switch in order to ensure they receive the appropriate therapy which may improve outcomes and decrease healthcare costs.

Abstract 263: The Risk of Stroke or Systemic Embolism for Antithrombotic Treatment Episodes among Non-Valvular Atrial Fibrillation (NVAF) Patients

Background The quality of antithrombotic therapy for patients with nonvalvular atrial fibrillation during routine medical care is often suboptimal. Evidence linking stroke and bleeding risk with antithrombotic treatment is limited. The purpose of this study was to evaluate the associations between antithrombotic treatment episodes and outcomes. Methods and Results A retrospective longitudinal observational cohort study was conducted using patients newly diagnosed with nonvalvular atrial fibrillation with 1 or more stroke risk factors (CHADS2 ≥1) in Kaiser Permanente Southern California between January 1, 2006 and December 31, 2011. A total of 1782 stroke and systemic embolism (SE) and 3528 major bleed events were identified from 23 297 patients during the 60 021 person-years of follow-up. The lowest stroke/SE rates and major bleed rates were observed in warfarin time in therapeutic range (TTR) ≥55% episodes (stroke/SE: 0.87 [0.71 to 1.04]; major bleed: 4.91 [4.53 to 5.28] per 100 person-years), which was similar to the bleed rate in aspirin episodes (4.95 [4.58 to 5.32] per 100 person-years). The warfarin TTR ≥55% episodes were associated with a 77% lower risk of stroke/SE (relative risk=0.23 [0.18 to 0.28]) compared to never on therapy; and the warfarin TTR <55% and on-aspirin episodes were associated with a 20% lower and with a 26% lower risk of stroke/SE compared to never on therapy, respectively. The warfarin TTR <55% episodes were associated with nearly double the risk of a major bleed compared to never on therapy (relative risk=1.93 [1.74 to 2.14]). Conclusions Continuation of antithrombotic therapy as well as maintaining an adequate level of TTR is beneficial to prevent strokes while minimizing bleeding events.

Abstract 262: Aspirin vs. Warfarin Therapy Outcomes for Non-Valvular Atrial Fibrillation Patients with Moderate Stroke Risk

Increased time in therapeutic range (TTR) on warfarin is often used as a balance between preventing stroke without excess bleeding. This study evaluated stroke or systemic embolism (SE) and bleeding risks of antithrombotic therapies in non-valvular atrial fibrillation (NVAF) patients within an