Uptake of Direct Oral Anticoagulants in Older Adults with Atrial Fibrillation in 2010-2018

Introduction: Under-treatment with oral anticoagulants (OAC) in atrial fibrilliation (AF) is a persistent management gap, particularly in older adults. Understanding patterns of OAC adoption may enable design of implementation strategies to improve evidence-based care. Objectives: Determine changes in OAC use and overall uptake of direct oral anticoagulants (DOACs) in older adults. Methods: We analyzed administrative claims data (years 2010 to 2018) from Optum Clinformatics Data Mart to identify Medicare Advance Plan beneficiaries (aged ≥65) with AF and CHA 2 DS 2 -VASc score ≥2. We excluded patients with history of intracranial hemorrhage and end-stage renal disease. We calculated the proportion of patients prescribed a DOAC, warfarin, or no OAC each year. We examined uptake by patient subgroups, including those with dementia diagnoses and those with frailty, defined by a claims-based frailty index. Results: Our sample size ranged from 123,700 in 2010 to 398,385 in 2018. The mean age ranged 76-79 years and the proportion of women ranged 50-53%. The proportion of eligible patients receiving OAC increased from 50.9% to 53.8% for the total sample (+2.9%) (Figure A). This increase was greater for younger patients (65-79 years: 53.7% to 58.1% vs ≥80 years: 48.9 to 49.5%) (Figures B & C), those with dementia (dementia: 39.6% to 44.8% vs no dementia: 52.5% to 55.3%) (Figures D & E), and those with frailty (frailty: 48.1% to 52.1% vs no frailty: 53.4% to 55.3%) (Figures F & G). There was a consistent decreasing trend in warfarin use in all subgroups from 2010 to 2018 (51 to 19 % in the total population, Figures A-G). Conclusion: Following the advent of DOACs, overall OAC use modestly increased in older adults, including for those with dementia and frailty. A large proportion of patients with guidelines-based eligibility for OAC remain untreated. Implementation strategies for improving OAC use are needed, particularly for high-risk older patients who stand to benefit the most.