Division of Geriatrics; Department of Internal Medicine, Sealy Center on Aging, University of Texas Medical Branch (UTMB), Galveston, TX, USA.
Ann Pharmacother. 2013 Jan;47(1):35-42. doi: 10.1345/aph.1R515. Epub 2013 Jan 16.
Although warfarin therapy reduces stroke incidence in patients with atrial fibrillation (AF), the rate of warfarin use in this population remains low. In 2008, the Medicare Part D program was expanded to pay for medications for Medicare enrollees.
To examine rates and predictors of warfarin use in Medicare Part D beneficiaries with AF.
This population-based retrospective cohort study used claims data from 41,447 Medicare beneficiaries aged 66 and older with at least 2 AF diagnoses in 2007 and at least 1 diagnosis in 2008. All subjects had continuous Medicare Part D prescription coverage in 2008. Statistical analysis using χ(2) was used to examine differences in warfarin use by patient characteristics (age, ethnicity, sex, Medicaid eligibility, comorbidities, contraindications to warfarin, and whether they visited a cardiologist or a primary care physician [PCP]), CHADS(2) score (congestive heart failure, hypertension, age, diabetes, and stroke or transient ischemic attack; higher scores indicate higher risks of stroke), and geographic regions. Using hierarchical generalized linear models restricted to subjects without warfarin contraindications (n = 34,947), we examined the effect of patient characteristics and geographic regions on warfarin use.
The overall warfarin use rate was 66.8%. The warfarin use rates varied between hospital referral regions, with highest rates in the Midwestern states and lowest rates in the South. The regional variation persisted even after adjustment for patient characteristics. Multivariable analysis showed that the odds of being on warfarin decreased significantly with age and increasing comorbidity, in blacks, and among those with low income. Seeing a cardiologist (OR 1.10; 95% CI 1.05-1.16), having a PCP (OR 1.23; 95% CI 1.17-1.29), and CHADS(2) score of 2 or greater (OR 1.09; 95% CI 1.01-1.17) were associated with increased odds of warfarin use.
Warfarin use rates vary by patient characteristics and region, with higher rates among residents of the Midwest and among patients seen by cardiologists and PCPs. Preventing stroke-related disability in AF requires implementation of evidence-based initiatives to increase warfarin use.
尽管华法林治疗可降低房颤（AF）患者的中风发生率，但该人群对华法林的使用率仍然较低。2008 年，医疗保险处方药计划（Medicare Part D program）扩大范围，为医疗保险参保者的药物治疗付费。
研究医疗保险处方药计划（Medicare Part D）中 AF 患者使用华法林的比率及其预测因素。
本基于人群的回顾性队列研究使用了 2007 年至少有 2 次 AF 诊断且 2008 年至少有 1 次诊断的 41447 名 66 岁及以上的 Medicare 受益人的索赔数据。所有受试者在 2008 年均持续接受 Medicare Part D 处方药保险。使用卡方检验（χ(2)）分析患者特征（年龄、种族、性别、医疗补助资格、合并症、华法林使用禁忌证以及是否就诊于心脏病专家或初级保健医生[PCP]）、CHADS(2)评分（充血性心力衰竭、高血压、年龄、糖尿病和中风或短暂性脑缺血发作；评分越高，中风风险越高）和地理区域对华法林使用的差异。在不考虑华法林禁忌证的情况下（n=34947），使用分层广义线性模型，我们检验了患者特征和地理区域对使用华法林的影响。
总体华法林使用率为 66.8%。华法林使用率在医院转诊区域之间存在差异，中西部州的使用率最高，南部州的使用率最低。即使在调整了患者特征后，这种地域差异仍然存在。多变量分析显示，随着年龄的增长、合并症的增加、黑人和收入较低的患者，使用华法林的几率显著降低。就诊于心脏病专家（比值比[OR]1.10；95%置信区间[CI]1.05-1.16）、就诊于 PCP（OR 1.23；95% CI 1.17-1.29）和 CHADS(2)评分≥2（OR 1.09；95% CI 1.01-1.17）与使用华法林的几率增加相关。
华法林的使用率因患者特征和地区而异，中西部州居民和心脏病专家及 PCP 就诊者的使用率较高。为了预防 AF 相关的残疾，需要实施循证举措以增加华法林的使用。
