GUIDE AF: Guiding Anticoagulation Decisions for Atrial Fibrillation in Long-Term Care
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PROJECT SUMMARY Oral anticoagulation (OAC) reduces the risk of ischemic stroke in patients with atrial fibrillation (AF) but also increases the risk of bleeding, especially as patients age and their health status declines. Therefore, OAC strategies require ongoing reassessment to account for changes in risk, benefit, and patient preferences. Among 8 million older adults in the U.S. with AF, approximately 1 in 4 patients transition to long-term care (LTC) during their remaining lifetime. This transition is a sentinel event—a critical change in a person’s health, cognition, and function that necessitates a reassessment of the risks and benefits of OAC. For new LTC residents with AF, the median life expectancy is 1.5 years, and the disability burden is high. Yet, evidence to guide the decisions to continue, discontinue, or initiate OAC at the time of LTC admission remains limited. The objective of the proposed research is to generate real-world evidence on the benefits and harms of continuing, discontinuing, or initiating OAC LTC and to develop a decision aid to support individualized care. Leveraging the Long-Term Care Data Cooperative electronic health records linked to Medicare fee-for-service, Medicare Advantage, and Minimum Data Set assessments, the study will: 1) conduct pharmacoepidemiologic studies to determine the benefits and harms of continuing vs. stopping OAC and initiating vs. staying off OAC when transitioning to LTC; 2) develop and validate models to predict individualized estimates of OAC effects among new LTC residents with AF; and 3) develop, refine, and field test an OAC decision aid. The proposal leverages a nationwide, linked database that integrates multiple real-world data sources, including electronic health records that provide rich clinical data unavailable in Medicare data and Minimum Data Set assessments. The decision aid will incorporate multiple rounds of input from residents, care partners, and clinicians to ensure the decision aid addresses the end-users’ decisional needs. The decision aid developed from this research will be prepared for a future pilot randomized controlled trial, followed by a full-scale, efficacy randomized clinical trial in enhancing individualized informed decision-making.
