BMJ  2006;332:141-145 (21 January), doi:10.1136/bmj.38698.709572.55 (published 10 January 2006)

Research

Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis

Niteesh K Choudhry, instructor in medicine1, Geoffrey M Anderson, chair in health management strategies2, Andreas Laupacis, chief executive officer3, Dennis Ross-Degnan, associate professor4, Sharon-Lise T Normand, professor of biostatistics5, Stephen B Soumerai, professor4

1 Harvard Medical School and Brigham and Women's Hospital, Boston, USA 02120, 2 Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Canada, 3 Institute of Clinical Evaluative Sciences, Toronto, Canada, 4 Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, USA, 5 Department of Health Care Policy, Harvard Medical School, Boston, USA

Correspondence to: N K Choudhry nchoudhry{at}partners.org

Abstract

Objectives To quantify the influence of physicians' experiences of adverse events in patients with atrial fibrillation who were taking warfarin.

Design Population based, matched pair before and after analysis.

Setting Database study in Ontario, Canada.

Participants The physicians of patients with atrial fibrillation admitted to hospital for adverse events (major haemorrhage while taking warfarin and thromboembolic strokes while not taking warfarin). Pairs of other patients with atrial fibrillation treated by the same physicians were selected.

Main outcome measures Odds of receiving warfarin by matched pairs of a given physician's patients (one treated after and one treated before the event) were compared, with adjustment for stroke and bleeding risk factors that might also influence warfarin use. The odds of prescriptions for angiotensin converting enzyme (ACE) inhibitor before and after the event was assessed as a neutral control.

Results For the 530 physicians who had a patient with an adverse bleeding event (exposure) and who treated other patients with atrial fibrillation during the 90 days before and the 90 days after the exposure, the odds of prescribing warfarin was 21% lower for patients after the exposure (adjusted odds ratio 0.79, 95% confidence interval 0.62 to 1.00). Greater reductions in warfarin prescribing were found in analyses with patients for whom more time had elapsed between the physician's exposure and the patient's treatment. There were no significant changes in warfarin prescribing after a physician had a patient who had a stroke while not on warfarin or in the prescribing of ACE inhibitors by physicians who had patients with either bleeding events or strokes.

Conclusions A physician's experience with bleeding events associated with warfarin can influence prescribing warfarin. Adverse events that are possibly associated with underuse of warfarin may not affect subsequent prescribing.


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