Background: Frailty is often cited as a factor influencing oral anticoagulation (OAC) prescription in patients with non-valvular atrial fibrillation (NVAF). We sought to determine the prevalence of frailty and its association with OAC prescription in older veterans with NVAF. Methods: We used ICD-9 codes in Veterans Affairs (VA) records and Medicare claims data to identify patients with NVAF and CHA2DS2VASC ≥2 receiving care between February 2010 and September 2015. We examined rates of OAC prescription, further stratified by direct oral anticoagulant (DOAC) or vitamin K antagonist (VKA). Participants were characterized into 3 categories: non-frail, pre-frail, and frail based on a validated 30-item EHR-derived frailty index. We examined relations between frailty and OAC receipt; and frailty and type of OAC prescribed in regression models adjusted for factors related to OAC prescription. Results: Of 308,664 veterans with NVAF and a CHA2DS2VASC score ≥2, 121,839 (39%) were prescribed OAC (73% VKA). The mean age was 77.7 (9.6) years; CHA2DS2VASC and ATRIA scores were 4.6 (1.6) and 5.0 (2.9) respectively. Approximately a third (38%) were frail, another third (32%) were pre-frail, and the remainder were not frail. Veterans prescribed OAC were younger, had higher bleeding risk, and were less likely to be frail than participants not receiving OAC (all p’s<0.001). After adjustment for factors associated with OAC use, pre-frail (OR: 0.89, 95% CI: 0.87–0.91) and frail (OR: 0.66, 95% CI: 0.64–0.68) veterans were significantly less likely to be prescribed OAC than non-frail veterans. Of those prescribed OAC, pre-frail (OR:1.27, 95% CI: 1.22–1.31) and frail (OR: 1.75, 95% CI: 1.67–1.83) veterans were significantly more likely than non-frail veterans to be prescribed a DOAC than a VKA. Conclusions: There are high rates of frailty among older veterans with NVAF. Frailty using an EHR-derived index is associated with decreased OAC prescription.
Bibliographical noteFunding Information:
This manuscript was supported by grants R01HL137794 and R01HL125089 from the National Heart, Lung, and Blood Institute. DDM’s time was also supported by grants R01HL126911, R01HL13660, and R01HL141434, also from the National Heart, Lung, and Blood Institute. HY’s time was also supported by grants R01DA045816,R01HL125089, 1R01MH125027, R01HL137794, R01HL135219, and R01LM012817. ARO is supported by National Heart, Lung, and Blood Institure grant 5R01HL137794-02 VA CSR&D CDA-2 IK2CX001800-01A1 and National Institute on Aging grant R03-AG060169. AK's time was supported by National Heart, Lung, and Blood institute grant R01HL137794-01A1. Support for VA/CMS data is provided by the Department of Veterans Affairs, VA Health Services Research and Development Service, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004).
DDM has received research grant support from Apple Computer, Bristol-Myers Squibb, Boehringer-Ingelheim, Pfizer, Flexcon, Samsung, Philips Healthcare, Biotronik, has received consultancy fees from Bristol-Myers Squibb, Pfizer, Flexcon, Boston Biomedical Associates, Avania. AK has received research grant support from Pfizer and Bristol-Myers Squibb.
© 2021, Society of General Internal Medicine.
- atrial fibrillation
- oral anticoagulation
- Administration, Oral
- Anticoagulants/adverse effects
- United States/epidemiology
- Atrial Fibrillation/complications