To determine the use of different anticoagulation therapies in rural Western Australia; to establish whether remoteness from health care services affects the choice of anticoagulation therapy; to gather preliminary data on anticoagulation therapy safety and efficacy. Retrospective cohort study of patients hospitalised with a principal diagnosis of atrial fibrillation/flutter (AF) or venous thromboembolism (VTE) during 2014-2015. Four hospitals serving two-thirds of the rural population of Western Australia. 609 patients with an indication for anticoagulation therapy recorded in their hospital discharge summary for index admission. Prescribing rates of anticoagulation therapies by indication for anticoagulation and distance of patient residence from their hospital. The primary safety outcome was re-hospitalisation with a major or clinically relevant non-major bleeding event; the primary lack-of-efficacy outcome was re-hospitalisation for a thromboembolic event. The overall rates of prescription of NOACs and warfarin were similar (34% v 33%). A NOAC was prescribed more often than warfarin for patients with AF (56.0% v 42.2% of those who received an anticoagulant; P < 0.001), but less often for patients with VTE (29% v 48%; P < 0.001). Warfarin was prescribed for 38% of patients who lived locally, a NOAC for 31% (P = 0.013); for non-local patients, the respective proportions were 29% and 36% (P = 0.08). 69% of patients with AF and a CHA2DS2-VASc score ≥ 1 were prescribed anticoagulation therapy. Patients treated with NOACs had fewer bleeding events than patients treated with warfarin (nine events [4%] v 20 events [10%]; P = 0.027). In rural WA, about one-third of patients with an indication for anticoagulation therapy receive NOACs, but one-third of patients with AF and at risk of stroke received no anticoagulant therapy, and may benefit from NOAC therapy.