Background

Data are needed on the use of oral anticoagulation in patients with atrial fibrillation (AF) in rural versus urban areas, including the initiation of direct oral anticoagulants (DOACs).

Objective

We used Medicare data to examine rural/urban differences in anticoagulation use in patients with AF.

Methods

We identified incident AF in a 20% sample of fee-for-service Medicare beneficiaries (aged ≥ 65 years) from 2011 to 2016 and collected ZIP code and covariates at the time of AF. We identified the first anticoagulant prescription filled, if any, following AF diagnosis. We categorized beneficiaries into four rural/urban areas using rural–urban commuting area codes and used Poisson regression models to compare anticoagulant use.

Results

We included 447,252 patients with AF (mean age 79 ± 8 years), of which 82% were urban, 9% large rural, 5% small rural, and 4% isolated. The percentage who initiated an anticoagulant rose from 34% in 2011 to 53% in 2016, paralleling the uptake of DOACs. In a multivariable-adjusted analysis, those in rural areas (vs. urban) were more likely to initiate an anticoagulant. However, rural beneficiaries (vs. urban) were less likely to initiate a DOAC; those in isolated areas were 17% less likely (95% confidence interval [CI] 13–20), those in small rural areas were 12% less likely (95% CI 9–15), and those in large rural areas were 10% less likely (95% CI 8–12).

Conclusion

Among Medicare beneficiaries with AF, anticoagulation use was low but increased over time with the introduction of DOACs. Rural beneficiaries were less likely to receive a DOAC.

中文翻译：

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用于房颤治疗的直接口服抗凝剂和华法林：医疗保险受益人的农村和城市趋势

背景

需要关于农村和城市地区房颤 (AF) 患者使用口服抗凝剂的数据，包括开始使用直接口服抗凝剂 (DOAC)。

客观的

我们使用医疗保险数据来检查 AF 患者抗凝治疗的城乡差异。

方法

我们从 2011 年到 2016 年在 20% 的按服务收费的医疗保险受益人（年龄≥65 岁）样本中发现了 AF，并在 AF 时收集了邮政编码和协变量。我们确定了 AF 诊断后填写的第一个抗凝剂处方（如果有）。我们使用城乡通勤区代码将受益人分为四个农村/城市地区，并使用泊松回归模型来比较抗凝剂的使用。

结果

我们纳入了 447,252 名 AF 患者（平均年龄 79 ± 8 岁），其中 82% 为城市患者，9% 为大型农村患者，5% 为小型农村患者，4% 为孤立患者。开始使用抗凝剂的百分比从 2011 年的 34% 上升到 2016 年的 53%，与 DOAC 的吸收平行。在多变量调整分析中，农村地区（与城市相比）的人更有可能开始使用抗凝剂。然而，农村受益人（与城市相比）不太可能发起 DOAC；偏远地区的可能性低 17%（95% 置信区间 [CI] 13-20），小农村地区的可能性低 12%（95% CI 9-15），大农村地区的可能性低 10%不太可能（95% CI 8-12）。

结论

在患有 AF 的 Medicare 受益人中，抗凝药物的使用率较低，但随着 DOAC 的引入而增加。农村受益人不太可能获得 DOAC。