Inequalities in the Incidence and Management of Non-valvular Atrial Fibrillation in England, 2009 to 2019: Cohort Study Using Electronic Health Records from General Practices

Sunday, August 28, 2022

8:30 AM – 8:45 AM CEST

Location: Congress Hall D2

Publication Number: 212

Background
Atrial fibrillation is an important risk factor for ischaemic stroke and AF incidence is expected to increase. Guidelines recommend using oral anticoagulants (OACs) to prevent the development of stroke. However, studies have reported the frequent under-use of OACs in AF patients. The objective of this study is to describe non-valvular atrial fibrillation (NVAF) incidence in England and assess the clinical and socioeconomic factors associated with the under-prescribing OACs.

Methods and findings
We conducted a population-based retrospective cohort study using the UK Clinical Practice Research Datalink (CPRD) database to identify patients with NVAF aged ≥18 years and registered in English general practices between 2009 and 2019. Annual incidence rate of NVAF by age, deprivation quintile, and region was estimated. OAC prescribing status was explored for patients at risk for stroke and classified into: OAC, aspirin-only, or no treatment. We used a multivariable multinomial logistic regression model to estimate relative risk ratios (RRRs) and 95% confidence intervals (CIs) of the factors associated with OAC or aspirin-only prescribing compared to no treatment in patients with NVAF who are recommended to take OAC. The multivariable regression was adjusted for age, sex, comorbidities, socioeconomic status, baseline treatment, frailty, bleeding risk factors, and takes into account clustering by general practice. Between 2009 and 2019, 12,517,191 patients met the criteria for being at-risk of developing NVAF. After a median follow-up of 4.6 years, 192,265 patients had an incident NVAF contributing a total of 647,876 person-years (PYR) of follow-up. The overall age-adjusted incidence of NVAF per 10,000 PYR increased from 20.8 (95% CI: 20.4; 21.1) in 2009 to 25.5 (25.1; 25.9) in 2019. Higher incidence rates were observed for older ages and males. Among NVAF patients eligible for anticoagulation, OAC prescribing rose from 59.8% (95% CI: 59.0; 60.6) in 2009 to 83.2% (95% CI: 83.0; 83.4) in 2019. Several conditions were associated with lower risk of OAC prescribing: dementia [relative risk ratio (RRR) 0.52 (0.47; 0.59)], liver disease 0.58 (0.50; 0.67), malignancy 0.74 (0.72; 0.77), and history of falls 0.82 (0.78; 0.85). Compared to white ethnicity, patients from black and other ethnic minorities were less likely to receive OAC; 0.78 (0.65; 0.94) and 0.76 (0.64; 0.91), respectively. Patients living in the most deprived areas were less likely to receive OAC 0.85 (0.79; 0.91) than patients living in the least deprived areas. practices located in the East of England were associated with higher risk of prescribing aspirin-only over no treatment than practices in London (RRR 1.22; 95% CI 1.02 to 1.45). The main limitation of this study is that these findings depends on accurate recording of conditions by health professionals and the inevitable residual confounding due to lack of data on certain factors that could be associated with under-prescribing of OACs.

Conclusion
The incidence of NVAF increased between 2009 and 2015, before plateauing. Under-prescribing of OACs in NVAF is associated with a range of comorbidities, ethnicity and socioeconomic factors, demonstrating the need for initiatives to reduce inequalities in the care for AF patients.

Presenting Author(s)

Alyaa Ajabnoor

Postgraduate Research Student
Division of Population Health, Health Services Research & Primary Care, University of Manchester
Jeddah, Makkah, Saudi Arabia

Slides

Co-Author(s)

Salwa Zghebi

Dr
Division of Population Health, Health Services Research & Primary Care, University of Manchester
Manchester, Lancashire, United Kingdom
RP

Rosa Parisi

Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester M13 9PL, UK
Manchester, England, United Kingdom
DA

Darren Ashcroft

Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
Manchester, England, United Kingdom
MR

Martin Rutter

Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester M13 9PL, UK, England, United Kingdom
TD

Tim Doran

Department of Health Sciences, Seebohm Rowntree Building, University of York, York, UK, England, United Kingdom
MC

Matthew Carr

Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK, England, United Kingdom
MM

Mamas Mamas

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
Keele, England, United Kingdom
EK

Evangelos Kontopantelis

Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester M13 9PL, UK
Manchester, England, United Kingdom