1077 — Impact of Mental Health Conditions on use of Anticoagulants in Veterans with Atrial Fibrillation

Lead/Presenter: Veena Manja,  COIN - Palo Alto
All Authors: Manja V ((Ci2i, Palo Alto)), Ciaran Phibbs, PhD (Center for Innovation to Implementation, VA Palo Alto) Lakshmi Ananth (Center for Innovation to Implementation, VA Palo Alto) Fay Saechao (Center for Innovation to Implementation, VA Palo Alto) Susan Frayne, MD (Center for Innovation to Implementation, VA Palo Alto)

Objectives:
Stroke risk in atrial fibrillation (AF) can be mitigated by treatment with oral anticoagulants (OAC): warfarin or Direct OAC (DOAC). However, OACs are underutilized. Work demonstrating lower rates of warfarin prescription in OAC eligible veterans with Mental Health Conditions (MHC) was conducted before the current wide availability of DOACs, which are an easier to use alternative than Warfarin, potentially reducing MHC-related gaps in OAC prescribing. We examined whether current use of OAC for AF is lower among veterans with MHC compared to veterans without MHC.

Methods:
We identified veterans with a diagnosis of atrial fibrillation in FY18 national VA administrative data and classified them based on presence or absence of a diagnosis of a MHC (depression, anxiety-disorder, acute stress-disorder, bipolar-disorder, schizophrenia, psychotic-disorder, PTSD, alcohol-use-disorder, drug-use-disorder). From VA national pharmacy data, Veterans with two OAC prescriptions at least 30-days apart were considered to be on long-term OAC. We present descriptive statistics, and results of a logistic regression examining OAC receipt as a function of MHC, first unadjusted and then controlling for sex and age.

Results:
We identified 244,499 Veterans with AF in FY18 active in the FY19 VA pharmacy file. Veterans with MHC (N = 94,243) were younger, more often female, more often African-American, and more often had Cardiovascular comorbidities (p < 0.05 for all). OAC prescribing was significantly lower in Veterans with MHC vs those without MHC (women: 64.6% vs 81%, p < 0.00001; men: 72.3% vs 85.4%, p < 0.00001; unadjusted OR 0.44 [0.44-0.45]; adjusted OR 0.45 [0.44-0.46]) and in women Veterans (adjusted OR-0.82; 0.76-0.88). Prescribing increased with age: >80% of Veterans >65-years were on an OAC, although even in this age group, the odds of OAC prescribing for those with MHC was lower than that for those without MHC.

Implications:
Our results reveal that even in the DOAC era, a significant disparity in OAC prescribing persists for Veterans with a MHC.

Impacts:
These results should prompt investigations into potential causes for this disparity such as safety concerns, drug interactions or unconscious bias, and strategies to promote equitable prescribing.