Impact of Rural Residence on Warfarin Use and Clinical Events in Patients with Non-Valvular Atrial Fibrillation: A Canadian Population Based Study

PLoS One. 2015 Oct 14;10(10):e0140607. doi: 10.1371/journal.pone.0140607. eCollection 2015.

Abstract

Background and purpose: We studied whether anticoagulant use and outcomes differed between rural versus urban Canadian non-valvular atrial fibrillation (NVAF) patients prior to the introduction of direct oral anticoagulant drugs.

Methods: Retrospective cohort study of 25,284 adult Albertans with NVAF between April 1, 1999 and December 31, 2008.

Results: Compared to urban patients, rural patients were older (p = 0.0009) and had more comorbidities but lower bleeding risk at baseline. In the first year after NVAF diagnosis, urban patients were less likely to be hospitalized (aOR 0.82, 95%CI 0.77-0.89) or have an emergency department visit for any reason (aOR 0.61, 95%CI 0.56-0.66) but warfarin dispensation rates (72.2% vs 71.8% at 365 days, p = 0.98) and clinical outcomes were similar: 7.8% died in both groups, 3.2% rural vs. 2.8% urban had a stroke or systemic embolism (SSE) (aOR 0.92, 95%CI 0.77-1.11), and 6.6% vs. 5.7% (aOR 0.93, 95%CI 0.81-1.06) had a bleed. Baseline SSE risk did not impact warfarin dispensation (73.0% in those with high vs. 72.8% in those with low CHADS2 score, p = 0.85) but patients at higher baseline bleeding risk were less likely to be using warfarin (69.2% high vs. 73.6% low HASBLED score, p<0.0001) in the first 365 days after diagnosis. In warfarin users, bleeding was more frequent (7.5% vs 6.2%, aHR 1.51 [95%CI 1.33-1.72]) but death or SSE was less frequent (7.0% vs 18.1%, aHR 0.60 [0.54-0.66]).

Conclusion: Warfarin use and clinical event rates did not differ between rural and urban NVAF patients in a universal access publically-funded healthcare system.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Ambulatory Care Facilities
  • Anticoagulants / therapeutic use*
  • Atrial Fibrillation / complications
  • Atrial Fibrillation / epidemiology*
  • Atrial Fibrillation / mortality
  • Canada / epidemiology
  • Cohort Studies
  • Comorbidity
  • Embolism / epidemiology
  • Embolism / etiology
  • Embolism / prevention & control
  • Female
  • Hospitalization
  • Humans
  • Male
  • Odds Ratio
  • Patient Outcome Assessment
  • Population Surveillance
  • Retrospective Studies
  • Risk
  • Rural Population*
  • Stroke / epidemiology
  • Stroke / etiology
  • Stroke / prevention & control
  • Urban Population
  • Warfarin / therapeutic use*

Substances

  • Anticoagulants
  • Warfarin

Grants and funding

Drs. McAlister and Ezekowitz are supported by salary awards from Alberta Innovates: Health Solutions; Dr. McAlister holds the University of Alberta Chair in Cardiovascular Outcomes Research; Dr. McMurtry receives a salary award from the Heart and Stroke Foundation of Canada. The funding agencies did not have input into study design, data collection, interpretation of results, or write up/approval for submission.