Shah Reema, Li Shudong, Stamplecoski Melissa, Kapral Moira K
*Department of Medicine, McMaster University, Hamilton †Institute for Clinical Evaluative Sciences ‡Institute of Health Policy, Management and Evaluation, University of Toronto §Division of General Internal Medicine, Women's Health Program, and Toronto General Research Institute, University Health Network ∥Department of Medicine, Division of General Internal Medicine, University of Toronto, Toronto, ON, Canada.
Med Care. 2016 Oct;54(10):907-12. doi: 10.1097/MLR.0000000000000589.
Oral anticoagulation reduces the risk of stroke in atrial fibrillation but is often underused.
To identify factors associated with oral anticoagulant prescribing and adherence after stroke or transient ischemic attack (TIA).
Retrospective cohort study using linked Ontario Stroke Registry and prescription claims data.
Consecutive patients with atrial fibrillation and ischemic stroke/TIA admitted to 11 stroke centers in Ontario, Canada between 2003 and 2011.
We used modified Poisson regression models to determine predictors of anticoagulant prescribing and multiple logistic regression to determine predictors of 1-year adherence.
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.
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.
口服抗凝药可降低心房颤动患者的中风风险，但该药的使用常常不足。
确定与中风或短暂性脑缺血发作（TIA）后口服抗凝药处方及依从性相关的因素。
采用安大略省中风登记处与处方索赔数据相链接的回顾性队列研究。
2003年至2011年期间，加拿大安大略省11个中风中心收治的连续性心房颤动合并缺血性中风/TIA患者。
我们使用修正泊松回归模型来确定抗凝药处方的预测因素，并使用多元逻辑回归来确定1年依从性的预测因素。
在研究队列的5781例患者中，4235例（73%）在出院时被开具了口服抗凝药。老年患者接受抗凝治疗的可能性较小[每增加一岁的调整相对风险（aRR）=0.997；95%置信区间（CI），0.995 - 0.998]，与缺血性中风患者相比，TIA患者也是如此（aRR = 0.904；95%CI，0.865 - 0.945），有胃肠道出血史者（aRR = 0.778；95%CI，0.693 - 0.873）、痴呆患者（aRR = 0.912；95%CI，0.856 - 0.973）以及来自长期护理机构的患者（aRR = 0.810；95%CI，0.737 - 0.891）也是如此。在将样本限制为无明显抗凝禁忌证的患者后，年龄、痴呆和长期护理居住情况仍与口服抗凝药处方率较低相关。大多数患者组的1年治疗依从性相似。
年龄、痴呆和长期护理居住情况是二级中风预防中口服抗凝药使用较少的预测因素，也是质量改进举措的关键目标领域。
