Ali Saad, MD

Sjölander M, Eriksson M, Asplund K, Norrving B, and Glader EL. Socioeconomic Inequalities in the Prescription of Oral Anticoagulants in Stroke Patients With Atrial Fibrillation. Stroke. 2015

This study looked at differences in prescribing patterns for oral anticoagulants (OAC) in 12,088 patients with Afib from the Swedish stroke registry. They found that 36.3% of patients were prescribed these drugs and several factors influenced prescribing pattern. Here are the odds ratios with 95% CIs:

Patients born in other Nordic countries vs those born in Sweden
OR 0.82, 0.68-0.98

Patients born in non-European countries vs those born in Sweden
OR 0.65, 0.42-0.99

University education vs primary school
OR 1.2, 1.05-1.36

Highest income vs lowest income level
OR 1.19, 1.06-1.33

Older vs age 18-69
Age 70-79
OR 0.84 (0.73–0.96)

Aged 80-89
OR 0.39 (0.34–0.44)

Aged 90
OR 0.13 (0.10–0.15) 

It seems that Swedish practitioners are most likely to prescribe anticoagulation to younger, Swedish-born people who make a lot of money and have a college degree. This is consistent with studies in other countries which show that OACs are being under-prescribed and that there are socio-economic disparities. age appears to play the biggest role.

Interestingly, patients with vascular risk factors (30.4%) were less likely to be prescribed OACs compared to those without them (39.6%). Although not surprisingly, people who were older, living alone, had dependant ADLs, or were not discharged home were less likely to be prescribed them.

Limitations of this study include:
– swedish-only population
– the OACs in question would have included the DAOCs (xarelto, dabigatran, or apixaban) which may have different prescribing patterns from warfarin and the study did not distinguish between which agent or drug class the patients were prescribed
– the data only looked at prescription for secondary prevention after first stroke, not primary prevention or after repeated strokes
– patients in the study were not controlled for possible risk factors for hemorrhage, patients’ mRS, or other relative contraindications for OACs
– determining whether a patient was not prescribed an anticoagulant is based on hospital discharge data, but these patients may have gotten their prescriptions during follow up in clinic, especially if they were not seen by a stroke specialist. This may also be relevant in non-Swedes who followed up with their doctors in their countries of origin after discharge.

How does this study change my practice?
Personally, I’m aggressive with prescribing OACs so I don’t think it’ll have much effect. the message that I get out of this study is quite the opposite; prescribing practices are changing significantly. Looking at the trends, 30.9% of patients left the hospital with OACs in 2009 and this increased to 43.3% in 2012. There was a steady increase throughout the years as well as a 10% jump from 2010 to 2011 when the first DAOCs were introduced. The introduction of DAOCs as well as Joint Commission’s guidelines for stroke center certification are making it making more likely that patients will leave on OAC when warranted. There will always be disparities and the reasons for not prescribing OACs to someone can be variegated and nuanced, making it challenging to study through national registers alone.