Disparities in the care and direct-acting oral anticoagulant (DOAC) management in atrial fibrillation (AF) and chronic kidney disease (CKD) in English primary care between 2018 and 2022: primary care sentinel network database study.

Abstract

Background: In England, most prescribing of direct-acting oral anticoagulants (DOACs) for patients with chronic kidney disease (CKD) and atrial fibrillation (AF) takes place in primary care. The 2024 European Society of Cardiology guidelines introduced the AF-CARE ((C) comorbidities and risk factors; (A) avoid stroke and thromboembolism by appropriate prescription of oral anticoagulants; (R) rate and rhythm control; (E) evaluation and reassessment should be individualised for every patient, with a dynamic approach) framework to address this.

Objective: To describe any health disparities in CKD and AF, including anticoagulation management and correct dosing of DOACs.

Methods: Using English primary care sentinel network data from 2018 to 2022, demographics of AF and CKD including anticoagulation and appropriate DOAC dosing according to creatinine clearance and other factors were assessed. The study also examined disparities in CKD and AF in relation to socioeconomic status and ethnicity. We defined socioeconomic status by Index of Multiple Deprivation (IMD), a weighted composite index combining information from the domains of deprivation including income.

Results: Of 10 513 950 people registered with general practices in the sentinel network, 2.9% (n=304 678) were aged ≥18 years with a diagnosis of AF. The prevalence of CKD in AF was 26.0% (n=79 210) and 63.3% of people eligible for anticoagulation were prescribed a DOAC. Among the 54 897 people with AF and CKD 3 or 4, greater likelihood of DOAC prescribing was associated with higher socioeconomic status. Socioeconomic disparities in anticoagulation increased through the 5 years. No association was identified between ethnicity and likelihood of being anticoagulated.In terms of correct dosing, there was no association with socioeconomic status. Overdosing was more frequent than underdosing. Incorrect dosing was associated with male sex (OR 0.80 (95% CI 0.74, 0.86)), dementia (OR 0.94 (0.83, 1.07)) and frailty (OR 0.42 (0.37, 0.48)).

Conclusions: People in the most deprived IMD quintile were least likely to be anticoagulated. Incorrect DOAC dosing was associated with male sex, increasing frailty and dementia. Socioeconomic and health disparities are apparent in anticoagulation prescribing and should be addressed in line with the AF-CARE framework.