RPD118 - Distribution of Stroke and Bleeding Risk Scores among Hospice Patients with Atrial Fibrillation

Key Message : We describe the distributions of CHA₂DS₂-VASc and HAS-BLED scores among hospice patients with atrial fibrillation. Nearly all patients had high stroke risk and one third had high bleeding risk, with scores varying by care location. This an initial step towards developing hospice-specific risk assessment tools to inform antithrombotic decision making.

Abstract:

Background: Atrial fibrillation (AF) is prevalent at the end-of-life and increases stroke risk (1,2). Risk scores can help predict stroke and bleeding risk in patients with AF and guide antithrombotic prescribing, but their distribution in hospice patients remains unknown.

Objective: To describe the distribution of stroke and bleeding risk scores among hospice patients with AF.

Methods: We conducted a cross-sectional study using electronic health record data from adult (age ≥18) decedents with AF in a for-profit hospice chain across 19 U.S. states between January 1, 2017 and December 31, 2019. We calculated CHA₂DS₂-VASc and HAS-BLED scores using International Classification of Diseases, version 10 codes (3,4).

Results: Among 13,233 hospice patients with AF, mean (standard deviation (SD)) age was 84.2 (9.9) years, 65.1% were White, 56.1% were referred from a hospital, and 35.2% received inpatient hospice care. Mean (SD) CHA₂DS₂-VASc scores were 3.8 (1.4) for males and 4.8 (1.3) for females. Most patients had high stroke risk including 97.5% of women (score ≥3) and 95.1% of men (score ≥2). Mean (SD) HAS-BLED score was 2.2 (1.0) with 36.1% at high bleeding risk (≥3). CHA₂DS₂-VASc scores differed by hospice location (p < 0.001) with the highest mean (SD) scores among females in assisted living (5.1 (1.2)) and males in residential care homes (4.0 (1.3)) and the lowest in hospitals for both females (4.4 (1.4)) and males (3.4 (1.5)). HAS-BLED scores were highest in assisted living (2.4 (0.9)) and nursing homes (2.4 (1.0)) and lowest in hospitals (1.9 (1.0)) (p < 0.001).

Conclusion: Almost all hospice patients with AF had high stroke risk and over one-third had high bleeding risk. Scores varied significantly by care setting, with higher scores occurring in assisted living and lower scores in hospitals. Future work should develop risk assessment tools tailored to the hospice setting to inform antithrombotic decision making.

References: 1. Kowalewska CA, Noble BN, Fromme EK, et al. Prevalence and Clinical Intentions of Antithrombotic Therapy on Discharge to Hospice Care. J Palliat Med. 2017;20(11):1225-1230. doi:10.1089/jpm.2016.0487

2. Colilla S, Crow A, Petkun W, et al. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013;112(8):1142-1147. doi:10.1016/j.amjcard.2013.05.063

3. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137(2):263-272. doi:10.1378/chest.09-1584

4. Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;138(5):1093-1100. doi:10.1378/chest.10-0134