title: Using an Atrial Fibrillation Decision Support Tool for Thromboprophylaxis in Atrial Fibrillation: Effect of Sex and Age.
abstract: To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment.
  
  
  
  Retrospective cohort study.
  
  
  
  Primary care practices of an academic healthcare system.
  
  
  
  Adults (aged 28-93) with nonvalvular atrial fibrillation (AF) seen between March 2013 and February 2014 (N = 1,585).
  
  
  
  Treatment recommendations were made using an AF decision support tool (AFDST) based on projections of quality-adjusted life expectancy calculated using a decision analytical model that integrates individual-specific risk factors for stroke and hemorrhage.
  
  
  
  Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and 39% (338/860) of men (P = .02). Although current treatment was discordant from recommended in 35% (89/258) of participants aged 85 and older and in 43% (575/1,328) of those younger than 85 (P = .01), many undertreated elderly adults were receiving aspirin as the sole antithrombotic agent.
  
  
  
  Physicians should understand that female sex is a significant risk factor for AF-related stroke and incorporate this into decision-making about thromboprophylaxis. Treating older adults with aspirin instead of OAT exposes them to significant risk of bleeding with little to no reduction in AF-related stroke risk.
authors.affiliation: Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio.|Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio.|Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Mark H
authors.initials: MH
authors.lastname: Eckman
authors.affiliation: Centre for Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.
authors.forename: Gregory Y H
authors.initials: GY
authors.lastname: Lip
authors.affiliation: Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio.|Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Ruth E
authors.initials: RE
authors.lastname: Wise
authors.affiliation: Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Barbara
authors.initials: B
authors.lastname: Speer
authors.affiliation: Academic Health Center, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Megan
authors.initials: M
authors.lastname: Sullivan
authors.affiliation: Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio.|Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Nita
authors.initials: N
authors.lastname: Walker
authors.affiliation: Department of Neurology, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Brett
authors.initials: B
authors.lastname: Kissela
authors.affiliation: Department of Neurology, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Flaherty
authors.affiliation: Department of Neurology, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Dawn
authors.initials: D
authors.lastname: Kleindorfer
authors.affiliation: Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Peter
authors.initials: P
authors.lastname: Baker
authors.affiliation: Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Robert
authors.initials: R
authors.lastname: Ireton
authors.affiliation: Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Dave
authors.initials: D
authors.lastname: Hoskins
authors.affiliation: Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Brett M
authors.initials: BM
authors.lastname: Harnett
authors.affiliation: Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Carlos
authors.initials: C
authors.lastname: Aguilar
authors.affiliation: Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Anthony
authors.initials: A
authors.lastname: Leonard
authors.affiliation: Department of English, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Lora
authors.initials: L
authors.lastname: Arduser
authors.affiliation: Division of Cardiology, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Dylan
authors.initials: D
authors.lastname: Steen
authors.affiliation: Division of Cardiology, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Alexandru
authors.initials: A
authors.lastname: Costea
authors.affiliation: Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio.
authors.forename: John
authors.initials: J
authors.lastname: Kues
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy*; D018890:Chemoprevention / Q000379:methods; D003661:Decision Support Techniques; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D008297:Male; D011320:Primary Health Care; D019057:Quality-Adjusted Life Years; D012189:Retrospective Studies; D012307:Risk Factors; D012737:Sex Factors; D020521:Stroke / Q000517:prevention & control*; D013923:Thromboembolism / Q000517:prevention & control*; D019564:Unnecessary Procedures
chemical_list: D000925:Anticoagulants
keywords: anticoagulation; aspirin; atrial fibrillation; elderly; novel oral anticoagulants; sex differences; warfarin