Assessment of Oral Anticoagulant Use in Residents of Long-Term Care Homes: Evidence for Contemporary Suboptimal Use

• Published in: The Annals of pharmacotherapy 2017-12, Vol.51 (12), p.1053-1062
• Main Authors: Rojas-Fernandez, Carlos H., Goh, Joslin, Hartwick, Jennifer, Auber, Ruth, Zarrin, Aein, Warkentin, Melissa, Hudani, Zain
• Format: Article
• Language: English
• Subjects: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants - therapeutic use; Assisted Living Facilities - statistics & numerical data; Atrial Fibrillation - drug therapy; Drug Utilization - statistics & numerical data; Female; Humans; International Normalized Ratio; Long-Term Care - statistics & numerical data; Male; Retrospective Studies; Venous Thromboembolism - drug therapy; Warfarin - therapeutic use
• ISSN: 1060-0280; 1542-6270
• DOI: 10.1177/1060028017723348

Objective: To describe the quality of warfarin use in residents of long-term care facilities and investigate potential predictors oral anticoagulant use. Design: Retrospective chart review (August 2013 to September 2014). Setting: Thirteen long-term care (LTC) and assisted living facilities (ALF). Participants: Residents from LTC or ALF settings who (a) received warfarin or direct-acting oral anticoagulants (DOACs) and (b) residents with a valid indication for oral anticoagulants such as atrial fibrillation, venous thromboembolism, but were not receiving these drugs. Primary Outcome: Time in therapeutic international normalized ratio (INR) range (TTR). Results: A total of 563 residents (70% female) with an average age of 85 years were identified. Participants had an average of 7.5 comorbidities and 9 medications. A total of 391 (69%) residents with indications for OACs were receiving such medications. Indications were atrial fibrillation (63%), venous or pulmonary embolism (16%), cardiac valves (0.4%); 26% did not have documented indications. Warfarin and DOACs were prescribed for 213 (38%) and 178 (32%) respectively, and 172 (31%) received no OACs The TTR ranged from 56%-75% (mean 63%). The frequency of INR determinations ranged from every 7 to 20 days, (mean 13 days) with no apparent relationship between frequency of testing and TTR. Conclusion: The TTR was higher (63.8%) than literature average (50%), but remains suboptimal given expected benefits of TTRs >75% versus TTRs circa 60%. Documentation of indications for OACs needs improvement, and it is possible that OACs are underused. Further work is necessary to understand how OAC use may be optimized in these facilities.