Atrial Fibrillation as an Ischemic Stroke Clinical and Economic Burden Modifier: A 15-Year Nationwide Study

Diagnosis of atrial fibrillation in young patients with ischemic stroke: A systematic review and meta-analysis

INTRODUCTION

The recommended cardiac rhythm evaluation to determine the etiology of ischemic stroke (IS) is similar in all patients regardless of their age and includes an electrocardiogram and at least a 24-hour heart rhythm monitoring. However, it is known that the main causes of IS vary according to patients' age. There is a higher preponderance of arterial dissections and patent foramen ovale in younger patients, while atrial fibrillation (AF) is more common in older patients.

AIMS

To determine the proportion of AF in young IS reported in the literature and determine if young IS patients found to have AF had known structural cardiac pathology.

METHODS

Systematic review of the literature searching PubMed and Embase for articles published since their inception to August 2020. Inclusion criteria were studies including at least 10 patients, aged 14-50 years-old, clinical or radiological diagnosis of IS and quantification of patients found to have AF. We conducted a meta-analysis using a random-effects model and calculated pooled proportions with 95% confidence intervals.

RESULTS

8331 articles were screened, 154 were selected for full-text review. 43 studies were included in our final analysis (902800 patients). The proportion of AF in young IS overall was 3.1% [95%CI 2.4-3.7], I2 93.88%. Sub-analysis revealed a proportion of AF of 3.8% [95% CI 0.3-7.3] in lower-middle-income economies, versus 5.4% [95% CI 3-7.9] in upper-middle-income economies, and 2.2% [95% CI 1.6-2.8] in high-income economies. Only 3 studies mentioned the proportion of patients with AF that had structural cardiac pathology.

CONCLUSION

The proportion of AF in young IS was low. More studies are needed to better understand if young IS patients diagnosed with AF had a priori known structural cardiac pathology that could increase the probability of finding AF. This could lead to a reevaluation of the need for 24 hours cardiac rhythm evaluation in young patients without cardiac pathology.

[Oral Anticoagulation and the Incidence of Stroke Associated with Atrial Fibrillation in Mainland Portugal: A Modelling Study]

INTRODUCTION

Atrial fibrillation is the most prevalent persistent dysrhythmia, contributing to a significant social and economic burden. The main objective of this study was to evaluate the association between oral anticoagulant use and the incidence of stroke associated with atrial fibrillation, in mainland Portugal.

METHODS

The number of episodes of inpatient care with a main diagnosis of stroke and an additional diagnosis of atrial fibrillation, occurring monthly between January 2012 and December 2018, in individuals aged 18 years or over, was extracted from the hospital morbidity database. The number of patients with an atrial fibrillation code documented in this database was used as a proxy for the prevalence of known atrial fibrillation. The number of anticoagulated patients was estimated from total medicine sales of vitamin K antagonists and novel oral anticoagulants (apixaban, dabigatran, edoxaban and rivaroxaban) in mainland Portugal. Descriptive analyses were performed, and seasonal autoregressive integrated moving average (SARIMA) models were built using the R software.

RESULTS

The mean number of episodes of stroke per month was 522 (± 57). The number of anticoagulated patients increased gradually from 68 943 to 180 389 per month. The decreasing trend in the number of episodes has been observed since 2016, along with the increased use of new oral anticoagulants compared to vitamin K antagonists. The final model indicated that the increase in oral anticoagulation use between 2012 and 2018, in mainland Portugal, was associated with a decrease in the number of episodes of stroke associated with atrial fibrillation. It was estimated that the shift in the type of anticoagulation used, between 2016 and 2018, was associated with a reduction of 833 episodes of stroke in patients with atrial fibrillation (4.2%).

CONCLUSION

The use of oral anticoagulation was associated with a reduced incidence of stroke in patients with atrial fibrillation in mainland Portugal. This reduction was more relevant in the period between 2016 and 2018, and is probably related with the introduction of the novel oral anticoagulants.

Stroke: Molecular mechanisms and therapies: Update on recent developments

Stroke, a neurological disease, is one of the leading causes of death worldwide, resulting in long-term disability in most survivors. Annual stroke costs in the United States alone were estimated at $46 billion recently. Stroke pathophysiology is complex, involving multiple causal factors, among which atherosclerosis, thrombus, and embolus are prevalent. The molecular mechanisms involved in the pathophysiology are essential to understanding targeted drug development. Some common mechanisms are excitotoxicity and calcium overload, oxidative stress, and neuroinflammation. In addition, various modifiable and non-modifiable risk factors increase the chances of stroke manifolds. Once a patient encounters a stroke, complete restoration of motor ability and cognitive skills is often rare. Therefore, shaping therapeutic strategies is paramount for finding a viable therapeutic agent. Apart from tPA, an FDA-approved therapy that is applied in most stroke cases, many other therapeutic strategies have been met with limited success. Stroke therapies often involve a combination of multiple strategies to restore the patient's normal function. Certain drugs like Gamma-aminobutyric receptor agonists (GABA), Glutamate Receptor inhibitors, Sodium, and Calcium channel blockers, and fibrinogen-depleting agents have shown promise in stroke treatment. Recently, a drug, DM199, a recombinant (synthetic) form of a naturally occurring protein called human tissue kallikrein-1 (KLK1), has shown great potential in treating stroke with fewer side effects. Furthermore, DM199 has been found to overcome the limitations presented when using tPA and/or mechanical thrombectomy. Cell-based therapies like Neural Stem Cells, Hematopoietic stem cells (HSCs), and Human umbilical cord blood-derived mesenchymal stem cells (HUCB-MSCs) are also being explored as a treatment of choice for stroke. These therapeutic agents come with merits and demerits, but continuous research and efforts are being made to develop the best therapeutic strategies to minimize the damage post-stroke and restore complete neurological function in stroke patients.

Cost-Effectiveness of the CNIC-Polypill Strategy Compared With Separate Monocomponents in Secondary Prevention of Cardiovascular and Cerebrovascular Disease in Portugal: The MERCURY Study

Background: Cardiovascular (CV) diseases remain a leading and costly cause of death globally. Patients with previous CV events are at high risk of recurrence. Secondary prevention therapies improve CV risk factor control and reduce disease costs. Objectives: To assess the cost-effectiveness of a CV polypill strategy (CNIC-Polypill) compared with the loose combination of monocomponents to improve the control of CV risk factors in patients with previous coronary heart disease or stroke. Methods: A Markov model cost-utility analysis was developed using 4 health states, SMART risk equation, and 3-month cycles for year 1 and annual cycles thereafter, over a lifetime horizon from the perspective of the National Health System in Portugal (base case). The NEPTUNO study, Portuguese registries, mortality tables, official reports, and the literature were consulted to define effectiveness, epidemiological costs, and utility data. Outcomes were costs (estimated in 2020 euros) per life-year (LY) and quality-adjusted LY (QALY) gained. A 4% discount rate was applied. Alternative scenarios and one-way and probabilistic sensitivity analyses tested the consistency and robustness of results. Results: The CNIC-Polypill strategy in secondary prevention provides more LY and QALY, at a higher cost, than monocomponents. The incremental cost-utility ratio is €1557/QALY gained. Assuming a willingness-to-pay threshold of €30 000/QALY gained, there is a 79.7% and a 44.4% probability of the CNIC-Polypill being cost-effective and cost-saving, respectively, compared with the loose combination of monocomponents. Results remain consistent in the alternative scenarios and robust in the sensitivity analyses. Discussion: The model reflects increments in the number of years patients would live and in quality of life with the CNIC-Polypill. The clinical effectiveness of the CNIC-Polypill strategy initially demonstrated in the NEPTUNO study has been recently corroborated in the SECURE trial. The incremental cost of the CNIC-Polypill strategy emerges slightly above the comparator, but willingness-to-pay estimates and sensitivity analyses indicate that the CNIC-Polypill strategy is consistently cost-effective compared with monocomponents and remains within acceptable affordability margins. Conclusion: The CNIC-Polypill is a cost-effective secondary prevention strategy. In patients with histories of coronary heart disease or stroke, the CNIC-Polypill more effectively controls CV risk factors compared with monocomponents.

Direct Medical Cost of Stroke and the Cost-Effectiveness of Direct Oral Anticoagulants in Atrial Fibrillation-Related Stroke: A Cross-Sectional Study

BACKGROUND

Stroke has significant direct medical costs, and direct oral anticoagulants (DOACs) are better alternatives to warfarin for stroke prevention in atrial fibrillation (AF). This study aimed to determine the direct medical costs of stroke, with emphasis on AF stroke and the cost-effectiveness of DOACs among stroke patients in a tertiary hospital in Malaysia.

METHODS

This study utilised in-patient data from the case mix unit of Universiti Kebangsaan Malaysia Medical Centre (UKMMC) between 2011 and 2018. Direct medical costs of stroke were determined using a top-down costing approach and factors associated with costs were identified. Incremental cost effectiveness ratio (ICER) was calculated to compare the cost-effectiveness between DOACs and warfarin.

RESULTS

The direct medical cost of stroke was MYR 11,669,414.83 (n = 3689). AF-related stroke cases had higher median cost of MYR 2839.73 (IQR 2269.79-3101.52). Regression analysis showed that stroke type (AF versus non-AF stroke) (p = 0.013), stroke severity (p = 0.010) and discharge status (p < 0.001) significantly influenced stroke costs. DOACs were cost-effective compared to warfarin with an ICER of MYR 19.25.

CONCLUSIONS

The direct medical cost of stroke is substantial, with AF-stroke having a higher median cost per stroke care. DOACs were cost effective in the treatment of AF-related stroke in UKMMC.

A network meta-analysis of non-vitamin K antagonist oral anticoagulants versus warfarin in patients with atrial fibrillation and diabetes mellitus

PURPOSE

With the aim of recommending proper anticoagulation for patients with atrial fibrillation (AF) and diabetes mellitus, we performed the network meta-analysis comparing the non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in terms of efficacy (stroke or systemic embolism) and safety (major bleeding) outcome.

METHODS

A systematic search of PubMed, EMBASE, Web of Science and Cochrane Library was performed with the items "dabigatran, edoxaban, apixaban, rivaroxaban, warfarin, AF and diabetes mellitus". On the basis of R (version 3.5.1, R Foundation for Statistical Computing) and JAGS (version 4.3.0) to perform the network meta-analysis, our work was also conducted with the help of NetMetaXL (version1.6.1) and winBUGS (version1.4.3) to obtain the cumulative ranking curve (SUCRA) of treatments.

RESULTS

With respect to the most effective drug for preventing systemic embolism or stroke, there was a high probability that dabigatran150 (SUCRA 0.88) would ranked first, followed by apixaban (SUCRA 0.63), dabigatran110 (SUCRA 0.59) and rivaroxaban (SUCRA 0.51). In comparison, probability of ranking the safest drug for preventing major bleeding was edoxaban (SUCRA 0.94), followed by dabigatran110 (SUCRA 0.59) and rivaroxaban (SUCRA 0.52).

CONCLUSION

In patients suffering from AF and diabetes, dabigatran 110 mg (bid) was more likely to become the choice for its performance on preventing systemic embolism or stroke and major bleeding, followed by rivaroxaban 20 mg (QD).

Analysis of root causes of problems affecting the quality of hospital administrative data: A systematic review and Ishikawa diagram

INTRODUCTION

Administrative hospital databases represent an important tool for hospital financing in many national health systems and are also an important data source for clinical, epidemiological and health services research. Therefore, the data quality of such databases is of utmost importance. This paper aims to present a systematic review of root causes of data quality problems affecting administrative hospital data, creating a catalogue of potential issues for data quality analysts to explore.

METHODS

The MEDLINE and Scopus databases were searched using inclusion criteria based on two following concept blocks: (1) administrative hospital databases and (2) data quality. Studies' titles and abstracts were screened by two reviewers independently. Three researchers independently selected the screened studies based on their full texts and then extracted the potential root causes inferred from them. These were subsequently classified according to the Ishikawa model based on 6 categories: "Personnel", "Material", "Method", "Machine", "Mission" and "Management".

RESULTS

The result of our investigation and the contribution of this paper is a classification of the potential (105) root causes found through a systematic review of the 77 relevant studies we have identified and analyzed. The result was represented by an Ishikawa diagram. Most of the root causes (25.7%) were associated with the category "Personnel" - people's knowledge, preferences, education and culture, mostly related to clinical coders and health care providers activities. The quality of hospital documentation, within category "Material", and aspects related to financial incentives or disincentives, within category "Mission", were also frequently cited in the literature as relevant root causes for data quality issues.

CONCLUSIONS

The resultant catalogue of root causes, systematized using the Ishikawa framework, provides a compilation of potential root causes of data quality issues to be considered prior to reusing these data and that can point to actions aimed at improving data quality.

The effect of a case-finding app on the detection rate of atrial fibrillation compared with opportunistic screening in primary care patients: protocol for a cluster randomized trial

Background

Atrial fibrillation is a cardiac arrhythmia commonly encountered in a primary care setting. Current screening is limited to pulse palpation and ECG confirmation when an irregular pulse is found. Paroxysmal atrial fibrillation will, however, still be difficult to pick up. With the advent of smartphones, screening could be more cost-efficient by making use of simple applications, lowering the need for intensive screening to discover (paroxysmal) atrial fibrillation.

Methods/design

This cluster randomized trial will examine the effect of using a smartphone-based application such as FibriCheck® on the detection rate of atrial fibrillation in a Flemish general practice population. This study will be conducted in 22 primary care practices across the Flanders region of Belgium and will last 12 months. Patients above 65 years of age will be divided in control and intervention groups on the practice level. The control group will be subjected to standard opportunistic screening only, while the intervention group will be prescribed the FibriCheck® app on top of this opportunistic screening. The difference in detection rate between control and intervention groups will be calculated at the end of the study.

We will use the online platform INTEGO for pseudonymized data collection and analysis, and risk calculation.

Discussion

Smartphone applications might offer a way to cost-effectively screen for (paroxysmal) atrial fibrillation in a primary care setting. This could open the door for the update of future screening guidelines.

Trial registration

ClinicalTrials.gov NCT04545723. Registered on September 10, 2020.

A Heart Rate Monitoring App (FibriCheck) for Atrial Fibrillation in General Practice: Pilot Usability Study

Background

Atrial fibrillation (AF) is a major risk factor for stroke. The current opportunistic screening procedure consists of pulse palpation and an electrocardiogram when an irregular rhythm is found. Smartphone apps that measure heart rhythm could be useful in increasing the detection of AF in a primary care setting.

Objective

We conducted a pilot study with the smartphone app FibriCheck to assess whether the introduction of such an app is feasible.

Methods

Four general practices across Flanders provided patient data for the study. Inclusion criteria for participants were aged 65 or older and a CHARGE-AF score of at least 10%. We excluded patients with known AF or a pacemaker. Participants were asked to measure at least twice a day with FibriCheck (for at least 14 days). They were provided the 36-Item Short Form Survey (SF-36) questionnaire both before and after the study, as well as different surveys concerning their user experience and general perception of technology.

Results

There were 92 participants (36 women and 56 men). The study population was relatively homogenous concerning risk factors and medication use at baseline. During the study period, 5/86 (6%) participants were found to have AF (6 dropouts). The average study period was 23 days and the average number of measurements per day was 2.1. Patient compliance was variable, but high. On the whole, there were no appreciable changes in quality of life. The overall user experience and satisfaction were very high.

Conclusions

FibriCheck is a relatively easy-to-use smartphone app to complement AF screening in primary care. Its implementation in this setting is certainly achievable, and one can expect high rates of patient compliance. Based on these results, a planned cluster randomized trial will be going ahead.

Trial Registration

ClinicalTrials.gov NCT03509493; https://clinicaltrials.gov/ct2/show/NCT03509493

Hospitalization trends of the Inflammatory Bowel Disease landscape: A nationwide overview of 16 years

INTRODUCTION

In this study, we aimed to determine the hospitalization rates of Inflammatory Bowel Disease (IBD) in a southern-european country and its associated charges over a period of 16 years.

METHODS

We identified all discharges with a primary diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) between 2000 and 2015 in data provided by the Central Administration of Health Services (ACSS). National estimates of hospitalization rates were assessed and adjusted to gender, age, population, and hospitalizations. Hospitalization charges were also assessed.

RESULTS

There were an estimated 31 358 and 16 669 discharges for CD and UC, respectively. From 2000 to 2015, hospitalization rates per 100000 habitants increased for CD (8.4-11.2) and remained stable for UC (4.4-4.9). The hospitalization rate for IBD increased slightly over time (12.8 per 100 000 habitants in 2000 and 16.1 in 2015). Annual total hospitalization charges amounted to 4.0M€ in 2000 and 5.7M€ in 2015. This increase was mainly due to a rise in the total expenses of CD-related hospitalizations.

CONCLUSION

CD hospitalization rates per 100000 inhabitants increased over time while remaining constant for UC. Hospitalization charges for IBD increased approximately 2.0M€ during the study period, representing an important burden in the national healthcare system.

Health records as the basis of clinical coding: Is the quality adequate? A qualitative study of medical coders' perceptions

BACKGROUND

Health records are the basis of clinical coding. In Portugal, relevant diagnoses and procedures are abstracted and categorised using an internationally accepted classification system and the resulting codes, together with the administrative data, are then grouped into diagnosis-related groups (DRGs). Hospital reimbursement is partially calculated from the DRGs. Moreover, the administrative database generated with these data is widely used in research and epidemiology, among other purposes.

OBJECTIVE

To explore the perceptions of medical coders (medical doctors) regarding possible problems with health records that may affect the quality of coded data.

METHOD

A qualitative design using four focus groups sessions with 10 medical coders was undertaken between October and November 2017. The convenience sample was obtained from four public hospitals in Portugal. Questions related to problems with the coding process were developed from the literature and authors' expertise. The focus groups sessions were taped, transcribed and analysed to elicit themes.

RESULTS

There are several problems, identified by the focus groups, in health records that influence the coded data: the lack of or unclear documented information; the variability in diagnosis description; "copy & paste"; and the lack of solutions to solve these problems.

CONCLUSION AND IMPLICATIONS

The use of standards in health records, audits and physician awareness could increase the quality of health records, contributing to improvements in the quality of coded data, and in the fulfilment of its purposes (e.g. more accurate payments and more reliable research).

Economic burden of thromboembolic and hemorrhagic complications in non-valvular atrial fibrillation in Algeria (the ELRAGFA study)

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac arrhythmia, with substantial public health and economic impact on healthcare systems due to the prevention and management of thromboembolic and hemorrhagic complications. In Algeria, stroke is a leading cause of death, representing 15.6% of all deaths in 2012. Current data on the epidemiology and costs associated with non-valvular AF (NVAF) in Algeria are not available.

METHODS

A three-step approach was undertaken to estimate the economic burden of NVAF in Algeria. First, a literature review identified the epidemiological burden of the disease. Second, expert clinicians practicing in Algerian hospitals were surveyed on consumed resources and unit costs of treatment and management of complications and prevention. Finally, these data were combined with event probabilities in an economic model to estimate the annual cost of NVAF prevention and complications for the Algerian healthcare system.

RESULTS

Based on literature and demographics data, it was estimated that there are currently 187,686 subjects with NVAF in Algeria. Seventy per cent of this population was treated for prevention, half of which were controlled. Cost of prevention was estimated at 203 million DZD (€1.5 million) for drugs and 349 million DZD (€2.6 million) for examinations. Mean hospitalization costs for complications ranged between 123,500 and 435,500 DZD (€910-3,209), according to the type and severity of complications. Hospitalization costs for thromboembolic and hemorrhagic complications were estimated at 8,313 million DZD (€62 million), half of which was for untreated patients. Finally, the economic burden of NVAF was estimated at 8,865 million DZD (>€65 million) annually.

CONCLUSION

The economic burden of NVAF is important in Algeria, largely driven by untreated and INR-uncontrolled patients. There is a lack of information on the Algerian healthcare system that could increase uncertainty around this assessment, but it clearly establishes the importance of NVAF as a public health concern.

Trends and costs of pertussis hospitalizations in Portugal, 2000 to 2015: from 0 to 95 years old

BACKGROUND

Pertussis has caused several outbreaks and concern worldwide. Despite high vaccination coverage, people of all ages are still affected with significant morbidity and mortality. We aimed to analyse all pertussis hospitalizations in Portugal to help to delineate preventive policies.

METHODS

Data were collected from a Portuguese administrative database, which contains all registered hospitalizations in mainland Portugal. Cases were identified using the ICD-9-CM code 033.x (whooping cough) as principal or secondary diagnosis, with hospital discharges between 2000 and 2015. Data were analysed by age groups.

RESULTS

Of 2281 hospitalizations, 94% occurred in infants (<1 year). The mean and median ages were 20 and 2 months, respectively. A seasonal pattern was observed, with higher number of hospitalizations during the winter for infants, and during the summer for other age groups. Higher hospitalization rates were registered in the Southern regions. The mean and median lengths of hospital stay were 8 and 6 days, respectively. The main complications were acute respiratory failure and pneumonia. Invasive or non-invasive ventilation, or both, was required in 2.4, 1.8 and 0.6% of hospitalized cases, respectively. The overall inpatient case fatality rate was 0.7%; 0.8, 11.5 and 17.4% for the age groups 0-1 months, 18-64 years and ≥65 years, respectively. Total hospitalization costs were estimated to be 2,698,995€.

CONCLUSION

Our study emphasizes the need to adopt new preventive strategies mainly focused on infants, to reduce morbidity and costs of hospitalizations related to pertussis.