PDF herunterladen
CC BY 4.0 · TH Open 2023; 07(02): e133-e142
DOI: 10.1055/a-2080-6171
Original Article

Geographical Variation in the Use of Oral Anticoagulation and Clinical Outcomes among Patients with Atrial Fibrillation in Denmark, Sweden, and Finland

Lars Frost 
1   Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
2   Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
,
Olli Halminen
3   Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
,
Mika Lehto
4   Department of Internal Medicine, Hospital District of Helsinki and Uusimaa, Lohja Hospital, Lohja, Finland
5   Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
,
K E. Juhani Airaksinen
6   Turku University Hospital, University of Turku, Turku, Finland
,
Tomas Andersson
7   Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
,
Per Wändell 
8   Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
,
Martin Holzmann
9   Functional Area of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
10   Department of Internal Medicine Solna, Karolinska Institutet, Stockholm, Sweden
,
Pia Cordsen
11   Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
,
Nicklas Vinter
1   Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
2   Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
11   Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
,
Søren Paaske Johnsen 
11   Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
› Institutsangaben Funding This work was supported by Bristol Myers Squibb and Pfizer through a grant from the ERISTA program. The ERISTA program had no influence on the conception of the study, writing of the protocol, data analyses, and interpretation or writing of the manuscript.
› Weitere Informationen
   Lizenzen und Reprints

Abstract

Background Geographical mapping of variations in the treatment and outcomes of a disease is a valuable tool for identifying inequity. We examined international and intranational variations in initiating oral anticoagulation (OAC) therapy and clinical outcomes among patients with atrial fibrillation (AF) in Nordic countries. We also tracked real-world trends in initiating OAC and the clinical outcomes.

Methods We conducted a registry-based multinational cohort study of OAC-naive patients with an incident hospital diagnosis of AF in Denmark (N = 61,345), Sweden (N = 124,120), and Finland (N = 59,855) and a CHA2DS2-VASc score of ≥1 in men and ≥2 in women between 2012 and 2017. Initiation of OAC therapy was defined as dispensing at least one prescription between 90 days before and 90 days after the AF diagnosis. Clinical outcomes included ischemic stroke, intracerebral hemorrhage, intracranial bleeding, other major bleeding, and all-cause mortality.

Results The proportion of patients initiating OAC therapy ranged from 67.7% (95% CI: 67.5–68.0) in Sweden to 69.6% (95% CI: 69.2–70.0) in Finland, with intranational variation. The 1-year risk of stroke varied from 1.9% (95% CI: 1.8–2.0) in Sweden and Finland to 2.3% (95% CI: 2.2–2.4) in Denmark, with intranational variation. The initiation of OAC therapy increased with a preference for direct oral anticoagulants over warfarin. The risk of ischemic stroke decreased with no increase in intracranial and intracerebral bleeding.

Conclusion We documented inter- and intranational variation in initiating OAC therapy and clinical outcomes across Nordic countries. Adherence to structured care of patients with AF could reduce future variation.

Keywords

atrial fibrillation - anticoagulation - bleed - geographical variation - stroke

Availability of Data

Individual-level data cannot be shared publicly due to national legislation. Data from individual countries can be accessed through an application to the relevant public authorities. The authors did not have special access privileges to these data.


Authors' Contributions

Conception and design: L.F., N.V., S.P.J. Acquisition of data: S.P.J., M.H., P.W. Data analyses: P.C., O.H., T.A. Interpretation of data: all authors. Manuscript drafting: L.F., N.V., S.P.J., P.C. Manuscript revision: all authors. Approved the final version of the manuscript: all authors. Obtaining funding: S.P.J. Full access to all data in Denmark: P.C. Full access to all data in Sweden: T.A. Full access to all data in Finland: O.H. Responsible for all aspects of the study, reliability, and control of bias of the results presented: all authors.


Supplementary Material



Publikationsverlauf

Eingereicht: 18. Oktober 2022

Angenommen: 19. April 2023

Accepted Manuscript online:
25. April 2023

Artikel online veröffentlicht:
06. Juni 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Staerk L, Wang B, Preis SR. et al. Lifetime risk of atrial fibrillation according to optimal, borderline, or elevated levels of risk factors: cohort study based on longitudinal data from the Framingham Heart Study. BMJ 2018; 361: k1453
    CrossrefPubMedGoogle Scholar
  • 2 Ruff CT, Giugliano RP, Braunwald E. et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014; 383 (9921): 955-962
    CrossrefPubMedGoogle Scholar
  • 3 Grymonprez M, Simoens C, Steurbaut S, De Backer TL, Lahousse L. Worldwide trends in oral anticoagulant use in patients with atrial fibrillation from 2010 to 2018: a systematic review and meta-analysis. Europace 2022; 24 (06) 887-898
    CrossrefPubMedGoogle Scholar
  • 4 Shroff GR, Solid CA, Herzog CA. Atrial fibrillation, stroke, and anticoagulation in Medicare beneficiaries: trends by age, sex, and race, 1992-2010. J Am Heart Assoc 2014; 3 (03) e000756
    CrossrefPubMedGoogle Scholar
  • 5 Hansen PW, Sehested TSG, Fosbøl EL. et al. Trends in warfarin use and its associations with thromboembolic and bleeding rates in a population with atrial fibrillation between 1996 and 2011. PLoS One 2018; 13 (03) e0194295
    CrossrefPubMedGoogle Scholar
  • 6 Forslund T, Komen JJ, Andersen M. et al. Improved stroke prevention in atrial fibrillation after the introduction of non-vitamin K antagonist oral anticoagulants. Stroke 2018; 49 (09) 2122-2128
    CrossrefPubMedGoogle Scholar
  • 7 Hohnloser SH, Basic E, Nabauer M. Uptake in antithrombotic treatment and its association with stroke incidence in atrial fibrillation: insights from a large German claims database. Clin Res Cardiol 2019; 108 (09) 1042-1052
    CrossrefPubMedGoogle Scholar
  • 8 Lee SR, Choi EK, Kwon S. et al. Effectiveness and safety of direct oral anticoagulants in relation to temporal changes in their use. Circ Cardiovasc Qual Outcomes 2020; 13 (03) e005894
    CrossrefPubMedGoogle Scholar
  • 9 Maggioni AP, Dondi L, Andreotti F. et al. Four-year trends in oral anticoagulant use and declining rates of ischemic stroke among 194,030 atrial fibrillation patients drawn from a sample of 12 million people. Am Heart J 2020; 220: 12-19
    CrossrefPubMedGoogle Scholar
  • 10 Cowan JC, Wu J, Hall M, Orlowski A, West RM, Gale CPA. A 10 year study of hospitalized atrial fibrillation-related stroke in England and its association with uptake of oral anticoagulation. Eur Heart J 2018; 39 (32) 2975-2983
    CrossrefPubMedGoogle Scholar
  • 11 Akao M, Ogawa H, Masunaga N. et al; Fushimi AF Registry Investigators. 10-Year trends of antithrombotic therapy status and outcomes in Japanese atrial fibrillation patients - the Fushimi AF Registry. Circ J 2022; 86 (04) 726-736
    CrossrefPubMedGoogle Scholar
  • 12 Freixa-Pamias R, Blanch Gràcia P, Rodríguez Latre ML. et al; Working Group for Coordination between Cardiology & Primary Care, Barcelona, Spain. Impact of prescription patterns of antithrombotic treatment on atrial fibrillation-related ischemic stroke. Curr Med Res Opin 2021; 37 (03) 357-365
    CrossrefPubMedGoogle Scholar
  • 13 Kennedy C, Gabr A, McCormack J, Collins R, Barry M, Harbison J. The association between increasing oral anticoagulant prescribing and atrial fibrillation related stroke in Ireland. Br J Clin Pharmacol 2022; 88 (01) 178-186
    CrossrefPubMedGoogle Scholar
  • 14 Fauchier L, Philippart R, Clementy N. et al. How to define valvular atrial fibrillation?. Arch Cardiovasc Dis 2015; 108 (10) 530-539
    CrossrefPubMedGoogle Scholar
  • 15 Overgaard M, Andersen PK, Parner ET. Regression analysis of censored data using pseudo-observations: an update. Stata J 2015; 15: 809-821
    CrossrefPubMedGoogle Scholar
  • 16 Klein JP, Logan B, Harhoff M, Andersen PK. Analyzing survival curves at a fixed point in time. Stat Med 2007; 26 (24) 4505-4519
    CrossrefPubMedGoogle Scholar
  • 17 Parner ET, Andersen PK. Regression analysis of censored data using pseudo-observations. Stata J 2010; 10: 408-422
    CrossrefPubMedGoogle Scholar
  • 18 Bayer V, Kotalczyk A, Kea B. et al. Global oral anticoagulation use varies by region in patients with recent diagnosis of atrial fibrillation: the GLORIA-AF Phase III Registry. J Am Heart Assoc 2022; 11 (06) e023907
    CrossrefPubMedGoogle Scholar
  • 19 Teppo K, Airaksinen KEJ, Jaakkola J. et al. Trends in treatment and outcomes of atrial fibrillation during 2007-2017 in Finland. Eur Heart J Qual Care Clin Outcomes 2022; qcac086
    CrossrefPubMedGoogle Scholar
  • 20 Romiti GF, Pastori D, Rivera-Caravaca JM. et al. Adherence to the ‘Atrial Fibrillation Better Care’ pathway in patients with atrial fibrillation: impact on clinical outcomes - a systematic review and meta-analysis of 285,000 patients. Thromb Haemost 2022; 122 (03) 406-414
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 21 Lühdorf P, Overvad K, Schmidt EB, Johnsen SP, Bach FW. Predictive value of stroke discharge diagnoses in the Danish National Patient Register. Scand J Public Health 2017; 45 (06) 630-636
    CrossrefPubMedGoogle Scholar
  • 22 Köster M, Asplund K, Johansson Å, Stegmayr B. Refinement of Swedish administrative registers to monitor stroke events on the national level. Neuroepidemiology 2013; 40 (04) 240-246
    CrossrefPubMedGoogle Scholar
  • 23 Tolonen H, Salomaa V, Torppa J, Sivenius J, Immonen-Räihä P, Lehtonen A. FINSTROKE Register. The validation of the Finnish Hospital Discharge Register and Causes of Death Register data on stroke diagnoses. Eur J Cardiovasc Prev Rehabil 2007; 14 (03) 380-385
    CrossrefPubMedGoogle Scholar
  • 24 Johnsen SP, Overvad K, Sørensen HT, Tjønneland A, Husted SE. Predictive value of stroke and transient ischemic attack discharge diagnoses in the Danish National Registry of Patients. J Clin Epidemiol 2002; 55 (06) 602-607
    CrossrefPubMedGoogle Scholar