Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis.
OBJECTIVE
To quantify the influence of physicians' experiences of adverse events in patients with atrial fibrillation who were taking warfarin.


METHODS
Population based, matched pair before and after analysis.


METHODS
Database study in Ontario, Canada.


METHODS
The physicians of patients with atrial fibrillation admitted to hospital for adverse events (major haemorrhage while taking warfarin and thromboembolic strokes while not taking warfarin). Pairs of other patients with atrial fibrillation treated by the same physicians were selected.


METHODS
Odds of receiving warfarin by matched pairs of a given physician's patients (one treated after and one treated before the event) were compared, with adjustment for stroke and bleeding risk factors that might also influence warfarin use. The odds of prescriptions for angiotensin converting enzyme (ACE) inhibitor before and after the event was assessed as a neutral control.


RESULTS
For the 530 physicians who had a patient with an adverse bleeding event (exposure) and who treated other patients with atrial fibrillation during the 90 days before and the 90 days after the exposure, the odds of prescribing warfarin was 21% lower for patients after the exposure (adjusted odds ratio 0.79, 95% confidence interval 0.62 to 1.00). Greater reductions in warfarin prescribing were found in analyses with patients for whom more time had elapsed between the physician's exposure and the patient's treatment. There were no significant changes in warfarin prescribing after a physician had a patient who had a stroke while not on warfarin or in the prescribing of ACE inhibitors by physicians who had patients with either bleeding events or strokes.


CONCLUSIONS
A physician's experience with bleeding events associated with warfarin can influence prescribing warfarin. Adverse events that are possibly associated with underuse of warfarin may not affect subsequent prescribing.
Choudhry
Niteesh K
NK
Harvard Medical School and Brigham and Women's Hospital, Boston 02120, USA. nchoudhry@partners.org
Anderson
Geoffrey M
GM
Laupacis
Andreas
A
Ross-Degnan
Dennis
D
Normand
Sharon-Lise T
SL
Soumerai
Stephen B
SB
D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy*; D001294:Attitude to Health; D002983:Clinical Competence / Q000592:standards*; D004812:Epidemiologic Methods; D005260:Female; D006470:Hemorrhage / Q000523:psychology; D006801:Humans; D008297:Male; D008505:Medical Staff, Hospital / Q000523:psychology* / Q000592:standards; D008875:Middle Aged; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians'; D020521:Stroke / Q000523:psychology; D013923:Thromboembolism / Q000523:psychology; D014859:Warfarin / Q000009:adverse effects / Q000627:therapeutic use*
D000925:Anticoagulants; D014859:Warfarin