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Danny McCormick, MD, MPH; Jerry H. Gurwitz, MD; Robert J. Goldberg, PhD; Richard Becker, MD; Janet P. Tate, MPH; Anne Elwell, RN; Martha J. Radford, MD

Arch Intern Med. 2001;161:2458-2463.

Background  Evidence-based clinical practice guidelines recommend the use of warfarin sodium for stroke prevention in most patients with atrial fibrillation (AF) who do not have risk factors for hemorrhagic complications, irrespective of age.

Methods  The medical records of all residents of a convenience sample of long-term care facilities in Connecticut (n = 21) were reviewed. The percentages of all patients with AF (AF patients) and ideal candidates for warfarin therapy (ie, AF patients with no risk factors for hemorrhage) who received warfarin were determined; for patients receiving warfarin, the percentage of days spent in the therapeutic range of international normalized ratio (INR) values (2.0-3.0) was also assessed. The relationship between receipt of warfarin and the presence of stroke and bleeding risk factors was assessed in multivariate models.

Results  Atrial fibrillation was present in 429 (17%) of the 2587 long-term care residents. Overall, 42% of AF patients were receiving warfarin. However, only 44 (53%) of 83 ideal candidates were receiving this therapy. In residents who received warfarin therapy, the therapeutic range of INR values was maintained only 51% of the time. The odds of receiving warfarin in the study sample decreased with increasing number of risk factors for bleeding and increased (nonsignificant trend) with increasing number of stroke risk factors present.

Conclusions  Atrial fibrillation is very common among residents of long-term care facilities. Even among apparently ideal candidates, warfarin therapy is underused for stroke prevention in patients with AF. Prescribing decisions and monitoring related to warfarin therapy in the long-term care setting warrant improvement.

From the Department of Medicine, Cambridge Hospital, Cambridge, Mass, and Harvard Medical School, Boston, Mass (Dr McCormick); Meyers Primary Care Institute (Drs Gurwitz and Goldberg) and the Department of Cardiology (Drs Goldberg and Becker), University of Massachusetts Medical School, Worcester; the Fallon Healthcare System, Worcester (Drs Gurwitz and Goldberg); Qualidigm Inc, Middletown, Conn (Mss Tate and Elwell and Dr Radford); and the Yale Health System, New Haven, Conn (Dr Radford).

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