Impact of a practice guideline for patients with atrial fibrillation on medical resource utilization and costs

Sex Differences in High-Cost Users of Healthcare for Atrial Fibrillation

Background

Healthcare resource use for atrial fibrillation (AF) is high, but it may not be equivalent across all patients. We examined whether sex differences exist for AF high-cost users (HCUs), who account for the top 10% of total acute care costs.

Methods

All patients aged ≥ 20 years who presented to the emergency department (ED) or were hospitalized with AF were identified in Alberta, Canada, between 2011 and 2015. The cohort was categorized by sex into HCUs and non-HCUs. Healthcare utilization was defined as ED, hospital, and physician visits, and costs included those for hospitalization, ambulatory care, physician billing, and drugs. All costs were inflated to 2022 Canadian dollars (CAD$).

Results

Among 48,030 AF patients, 45.1% were female. Of these, 31.8% were HCUs, and the proportions of female and male patients were equal (31.9% vs 31.7%). Female HCUs were older, more likely to have hypertension and heart failure, and had a higher stroke risk than male HCUs. Mean healthcare utilization did not differ among HCUs by sex, except for number of ED visits, which was higher in male patients (12.7% vs 9.2%, P < 0.0001). Overall, HCUs accounted for 65.8% of the total costs (CAD$3.4 billion). Almost half of total HCU costs were attributable to female HCUs (CAD$966.1 million). Significant differences were present in the distributions of HCU-related costs (male patients: 74.6% hospitalization, 9.5% ambulatory care, 12.4% physician billing, 3.5% drugs; female patients: 77.7% hospitalization, 7.4% ambulatory care, 11.5% physician billing, 3.5% drugs, P < 0.0001).

Conclusions

Despite having a lower AF prevalence, female patients represent an equal proportion of HCUs, and account for almost half the total HCU costs. Interventions targeted at reducing the number of AF HCU are needed, particularly for female patients.

Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial)

BACKGROUND

Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk.

METHODS

We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California.

DISCUSSION

We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05009225 .  Registered on 17 August 2021.

Effectiveness of an algorithm‐based care pathway for patients with non‐valvular atrial fibrillation presenting to the emergency department

Objective

Atrial fibrillation (AF) carries substantial morbidity and mortality. Evidence‐based guidelines have been synthesized into emergency department (ED) AF care pathways, but the effectiveness and scalability of such approaches are not well established. We thus evaluated the impacts of an algorithmic care pathway for ED management of non‐valvular AF (EDAFMP) on hospital use and care process measures.

Methods

We deployed a voluntary‐use EDAFMP in 4 EDs (1 tertiary hospital, 1 cardiac hospital, 2 community hospitals) of an integrated delivery organization using a multifaceted implementation approach. We compared outcomes between patients with AF treated using the EDAFMP and historical and contemporaneous “usual care” controls, using a propensity‐score adjusted generalized estimating equation. Patients with an index ED encounter for a primary visit reason of non‐valvular AF (and no excluding concurrent diagnoses) were eligible for inclusion.

Results

Preimplementation (January 1, 2016–December 31, 2016), 628 AF patients were eligible; postimplementation (September 1, 2017–June 30, 2019), 1296, including 271 (20.9%) treated with the EDAFMP, were eligible. EDAFMP patients were less likely to be admitted than both historical (adjusted odds ratio [aOR], 95% confidence interval [CI]: 0.45, 0.29–0.71) and contemporaneous controls (aOR, 95%CI: 0.63, 0.46–0.86). ED visits and hospital readmissions over 90 days subsequent to index ED encounters were similar between postimplementation EDAFMP and usual care groups. EDAFMP patients were more likely to be prescribed anticoagulation (38% v. 5%, P < 0.001) and be referred to a cardiologist (93% vs 29%, P < 0.001) versus the comparator group.

Conclusion

EDAFMP use is associated with decreased hospital admission during an index ED encounter for non‐valvular AF, and improved delivery of AF care processes.

Characteristics of patients presenting to emergency department for primary atrial fibrillation or flutter at an academic medical center

OBJECTIVE

In the United States, atrial fibrillation (AF) accounts for over 400,000 hospitalizations annually. Emergency Department (ED) physicians have few resources available to guide AF/AFL (atrial flutter) patient triage, and the majority of these patients are subsequently admitted. Our aim is to describe the characteristics and disposition of AF/AFL patients presenting to the University of North Carolina (UNC) ED with the goal of developing a protocol to prevent unnecessary hospitalizations.

METHODS

We performed a retrospective electronic medical chart review of AF/AFL patients presenting to the UNC ED over a 15-month period from January 2015 to March 2016. Demographic and ED visit variables were collected. Additionally, patients were designated as either having primary or secondary AF/AFL where primary AF/AFL patients were those in whom AF/AFL was the primary reason for ED presentation. These primary AF/AFL patients were categorized by AF symptom severity score according to the Canadian Cardiovascular Society Severity of Atrial Fibrillation (CCS-SAF) Scale.

RESULTS

A total of 935 patients presented to the ED during the study period with 202 (21.5%) having primary AF/AFL. Of the primary AF/AFL patients, 189 (93.6%) had mild-moderate symptom severity (CCS-SAF ≤ 3). The majority of primary AF/AFL patients were hemodynamically stable, with a mean (SD) SBP of 123.8 (21.3), DBP of 76.6 (14.1), and ventricular rate of 93 (21.9). Patients with secondary AF/AFL were older 76 (13.1), p < 0.001 with a longer mean length of stay 6.1 (7.7), p = 0.31. Despite their mild-moderate symptom severity and hemodynamic stability, nearly 2/3 of primary AF/AFL patients were admitted.

CONCLUSION

Developing a protocol to triage and discharge hemodynamically stable AF/AFL patients without severe AF/AFL symptoms to a dedicated AF/AFL clinic may help to conserve healthcare resources and potentially deliver more effective care.

Predictors of Acute Atrial Fibrillation and Flutter Hospitalization across 7 U.S. Emergency Departments: A Prospective Study

INTRODUCTION

International rates of hospitalization for atrial fibrillation and flutter (AFF) from the emergency department (ED) vary widely without clear evidence to guide the identification of high-risk patients requiring inpatient management. We sought to determine (1) variation in hospital admission and (2) modifiable factors associated with hospitalization of AFF patients within a U.S. integrated health system.

METHODS

This multicenter prospective observational study of health plan members with symptomatic AFF was conducted using convenience sampling in 7 urban community EDs from 05/2011 to 08/2012. Prospective data collection included presenting symptoms, characteristics of atrial dysrhythmia, ED physician impression of hemodynamic instability, comorbid diagnoses, ED management, and ED discharge rhythm. All centers had full-time on-call cardiology consultation available. Additional variables were extracted from the electronic health record. We identified factors associated with hospitalization and included predictors in a multivariate Poisson Generalized Estimating Equations regression model to estimate adjusted relative risks while accounting for clustering by physician.

RESULTS

Among 1,942 eligible AFF patients, 1,074 (55.3%) were discharged home and 868 (44.7%) were hospitalized. Hospitalization rates ranged from 37.4% to 60.4% across medical centers. After adjustment, modifiable factors associated with increased hospital admission from the ED included non-sinus rhythm at ED discharge, no attempted cardioversion, and heart rate reduction.

DISCUSSION

Within an integrated health system, we found significant variation in AFF hospitalization rates and identified several modifiable factors associated with hospital admission. Standardizing treatment goals that specifically address best practices for ED rate reduction and rhythm control may reduce hospitalizations.

A combined care model using early access to specialists off-hours to reduce cardiac admissions

Despite the implementation of diagnostic and treatment algorithms for many common cardiovascular (CV) complaints, identifying low- and intermediate-risk cardiac patients presenting to the emergency department (ED) who could be managed without hospital admission remains difficult. We hypothesized that the presence of an attending cardiologist in the ED after normal working hours would decrease the proportion of these patients admitted to the hospital. We conducted a retrospective study of patients seen in the ED with cardiac diagnoses identified by ICD-9 codes during the time period when the cardiologist was available (6 p.m.-midnight) compared with patients seen at other times of the day in the 12 months before and after the consultation program was implemented. The primary outcome was disposition at the time of discharge from the ED. Logistic regression was used to model the primary outcome. A difference-in-differences approach was used as the primary statistical test .Following the start of the consultation program, the odds of discharge home from the ED with or without observation increased (OR 1.69, 95% CI [1.45-1.96]). There was a significant interaction between pre-/post-intervention status and time of day in the odds of discharge home from the ED (P = 0.04) suggesting an association between the consultation program and disposition patterns that is independent of concurrent programs aimed to reduce utilization. An ED-based cardiology consultation program may reduce the need for inpatient stays by identifying low- to intermediate-risk patients safe for discharge from the ED with or without a period of active management/observation.

Impact of a novel protocol for atrial fibrillation management in outpatient gastrointestinal endoscopic procedures: a retrospective cohort study

BACKGROUND

Atrial fibrillation (AF) may result in procedure cancellations and emergency department (ED) referrals for patients presenting for outpatient GI endoscopic procedures. Such cancellations and referrals delay patient care and can lead to inefficient use of resources.

METHODS

All consecutive patients presenting in AF for a colonoscopy or upper endoscopy to the University of Wisconsin Digestive Health Center between October 2013 and September 2014 were defined as the pre-intervention group (Group 1). In 2015, a protocol was initiated for peri-procedural management of patients presenting in AF, new onset or previously known. All consecutive patients after initiation of the protocol from October 2015 to September 2016 were analyzed as the post intervention group (Group 2). Patients with heart failure, hypotension, or chest pain were excluded from the protocol.

RESULTS

One hundred nine and 141 patients were included in Groups 1 and Group 2, respectively. Following protocol initiation, patients were less likely to present to the ED (6.4% Group 1 vs. 1.4% Group 2, RR 0.22, p = 0.04). There was also a trend towards a reduction in procedure cancelations (5.5% Group 1 vs. 1.4% Group 2, RR 0.26, p = 0.08). All attempted procedures were completed and there were no complications in the intervention group.

CONCLUSIONS

Implementation of a standardized protocol for management of atrial fibrillation in patients presenting for outpatient gastrointestinal endoscopic procedures resulted in a significant decrease in emergency department visits with an additional trend toward decreased procedural cancellations without an increased risk of complications.

Management and Disposition of Atrial Fibrillation in the Emergency Department: A Systematic Review

Introduction

Management of atrial fibrillation (AF) and atrial flutter (AFL) in the emergency department (ED) varies greatly, and there are currently no United States guidelines to guide management with regard to patient disposition after ED treatment. The aim of this systematic review was to evaluate the literature for decision aids to guide disposition of patients with AF/AFLin the ED, and assess potential outcomes associated with different management strategies in the ED.

Methods and Results

A systematic review was done using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE, combining the search terms "Atrial Fibrillation", "Atrial Flutter", "Emergency Medicine", "Emergency Service", and "Emergency Treatment". After removal of duplicates, 754 articles were identified. After initial screening of titles and abstracts, 69full text articles were carefully reviewed and 34 articles were ultimately included in the study based on inclusion and exclusion criteria. The articles were grouped into four main categories: decision aids and outcome predictors, electrical cardioversion-based protocols, antiarrhythmic-based protocols, and general management protocols.

Conclusion

This systematic review is the first study to our knowledge to evaluate the optimal management of symptomatic AF/AFLin the ED with a direct impact on ED disposition. There are several viable management strategies that can result in safe discharge from the ED in the right patient population, and decision aids can be utilized to guide selection of appropriate patients for discharge.

Impact of Standardizing Management of Atrial Fibrillation with Rapid Heart Rate in the Emergency Department

CONTEXT

There is substantial variation in the emergency treatment of atrial fibrillation with tachycardia. A standardized treatment approach at an academic center decreased admissions without adverse outcomes, but this approach has not been evaluated in a community Emergency Department (ED).

OBJECTIVE

To evaluate the implementation of a standardized treatment guideline for patients with atrial fibrillation and a rapid heart rate in a community ED.

DESIGN

An observational pre-/postimplementation (August 2013 to July 2014 and August 2014 to July 2015, respectively) study at a community ED. The standardized treatment guideline encouraged early oral treatment with rate control medication, outpatient echocardiogram, and early follow-up. A multiple logistic regression model adjusting for patient characteristics was generated to investigate the association between the intervention and ED discharge rate.

MAIN OUTCOME MEASURES

The primary measure was ED discharge. Secondary measures included stroke or death, ED return visit, hospital readmission, length of stay, and use of oral rate control medications.

RESULTS

A total of 199 (104 pre/95 post) ED encounters were evaluated. The ED discharge rate increased 14% after intervention (57.7% to 71.6%, p = 0.04), and use of rate control medications increased by 19.4% (p < 0.01). Adjusted multivariate results showed a nearly 2-fold likelihood of ED discharge after guideline implementation (odds ratio = 1.97, 95%confidence interval = 1.07-3.63). Length of stay, return visits, and hospital readmissionswere similar.

CONCLUSION

A standardized approach to ED patients with atrial fibrillation and tachycardia is associated with a decrease in hospital admissions without adversely affecting patient safety.

Predictors and clinical outcomes of inpatient versus ambulatory management after an emergency department visit for atrial fibrillation: A population-based study

BACKGROUND

There is substantial variation in the management of atrial fibrillation (AF) in the emergency department (ED), particularly whether these patients are admitted to hospital. We sought to identify factors that predict admission and to examine the relationship between AF admission and outcomes.

METHODS

We performed a retrospective cohort analysis of patients ≥20 years of age who had an index ED visit with a primary diagnosis of AF from between April 1, 2005, and March 31, 2010, in Ontario, Canada. We excluded patients who died during the index ED visit or hospitalization. A hierarchical logistic regression model was used to determine predictors of hospital admission during the index ED visit. A propensity-matched analysis was used to test for associations between hospital admission and 1-year outcomes.

RESULTS

The cohort consisted of 33,699 patients, of whom 16,270 (48.3%) were admitted to hospital. Substantial variation was seen across the 154 hospitals, with admission rates ranging from 3.0% to 91.0%. Admitted patients had higher rates of comorbidities compared to discharged patients. Mortality rates at 1 year were significantly higher in matched admitted versus discharged patients (hazard ratio 1.45, 95% CI 1.33-1.57, P < .001), as were all-cause hospitalizations (hazard ratio 1.18, 95% CI 1.13-1.22, P < .001).

CONCLUSIONS

Wide practice variation was observed between hospitals in terms of the proportion of patients admitted. Our data suggest that selected patients when discharged have similar or improved outcomes compared to those who are initially admitted. Future research is needed to better standardize admission/discharge decisions for AF patients in the ED.

Impact of an Emergency Department Observation Unit Management Algorithm for Atrial Fibrillation

Background

Atrial fibrillation (AF) is a common, growing, and costly medical condition. We aimed to evaluate the impact of a management algorithm for symptomatic AF that used an emergency department observation unit on hospital admission rates and patient outcomes.

Methods and Results

This retrospective cohort study compared 563 patients who presented consecutively in the year after implementation of the algorithm, from July 2013 through June 2014 (intervention group), with 627 patients in a historical cohort (preintervention group) who presented consecutively from July 2011 through June 2012. All patients who consented to have their records used for chart review were included if they had a primary final emergency department diagnosis of AF. We observed no significant differences in age, sex, vital signs, body mass index, or CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke or transient ischemic attack) score between the preintervention and intervention groups. The rate of inpatient admission was significantly lower in the intervention group (from 45% to 36%; P<0.001). The groups were not significantly different with regard to rates of return emergency department visits (19% versus 17%; P=0.48), hospitalization (18% versus 16%; P=0.22), or adverse events (2% versus 2%; P=0.95) within 30 days. Emergency department observation unit admissions were 40% (P<0.001) less costly than inpatient hospital admissions of ≤1 day's duration.

Conclusions

Implementation of an emergency department observation unit AF algorithm was associated with significantly decreased hospital admissions without increasing the rates of return emergency department visits, hospitalization, or adverse events within 30 days.

Development of Standardized Clinical Assessment and Management Plans (SCAMPs) in Plastic and Reconstructive Surgery

Background:

With rising cost of healthcare, there is an urgent need for developing effective and economical streamlined care. In clinical situations with limited data or conflicting evidence-based data, there is significant institutional and individual practice variation. Quality improvement with the use of Standardized Clinical Assessment and Management Plans (SCAMPs) might be beneficial in such scenarios. The SCAMPs method has never before been reported to be utilized in plastic surgery.

Methods:

The topic of immediate breast reconstruction was identified as a possible SCAMPs project. The initial stages of SCAMPs development, including planning and implementation, were entered. The SCAMP Champion, along with the SCAMPs support team, developed targeted data statements. The SCAMP was then written and a decision-tree algorithm was built. Buy-in was obtained from the Division of Plastic Surgery and a SCAMPs data form was generated to collect data.

Results:

Decisions pertaining to “immediate implant-based breast reconstruction” were approved as an acceptable topic for SCAMPs development. Nine targeted data statements were made based on the clinical decision points within the SCAMP. The SCAMP algorithm, and the SDF, required multiple revisions. Ultimately, the SCAMP was effectively implemented with multiple iterations in data collection.

Conclusions:

Full execution of the SCAMP may allow better-defined selection criteria for this complex patient population. Deviations from the SCAMP may allow for improvement of the SCAMP and facilitate consensus within the Division. Iterative and adaptive quality improvement utilizing SCAMPs creates an opportunity to reduce cost by improving knowledge about best practice.

The AFFORD clinical decision aid to identify emergency department patients with atrial fibrillation at low risk for 30-day adverse events

There is wide variation in the management of patients with atrial fibrillation (AF) in the emergency department (ED). We aimed to derive and internally validate the first prospective, ED-based clinical decision aid to identify patients with AF at low risk for 30-day adverse events. We performed a prospective cohort study at a university-affiliated tertiary-care ED. Patients were enrolled from June 9, 2010, to February 28, 2013, and followed for 30 days. We enrolled a convenience sample of patients in ED presenting with symptomatic AF. Candidate predictors were based on ED data available in the first 2 hours. The decision aid was derived using model approximation (preconditioning) followed by strong bootstrap internal validation. We used an ordinal outcome hierarchy defined as the incidence of the most severe adverse event within 30 days of the ED evaluation. Of 497 patients enrolled, stroke and AF-related death occurred in 13 (3%) and 4 (<1%) patients, respectively. The decision aid included the following: age, triage vitals (systolic blood pressure, temperature, respiratory rate, oxygen saturation, supplemental oxygen requirement), medical history (heart failure, home sotalol use, previous percutaneous coronary intervention, electrical cardioversion, cardiac ablation, frequency of AF symptoms), and ED data (2 hours heart rate, chest radiograph results, hemoglobin, creatinine, and brain natriuretic peptide). The decision aid's c-statistic in predicting any 30-day adverse event was 0.7 (95% confidence interval 0.65, 0.76). In conclusion, in patients with AF in the ED, Atrial Fibrillation and Flutter Outcome Risk Determination provides the first evidence-based decision aid for identifying patients who are at low risk for 30-day adverse events and candidates for safe discharge.

The Atrial Fibrillation Therapies after ER visit: Outpatient Care for Patients with Acute AF - The AFTER3 Study

BACKGROUND

Visits to the emergency room (ER) for atrial fibrillation/flutter (AF) are common, but follow-up care is rarely systematically organized and is often delayed.

PURPOSE

We conducted a pilot program to develop a systematic, protocol-based system of care for patients presenting to the ER with a primary diagnosis of AF.

METHODS

Consecutive patients presenting to the ER with ECG-documented AF at an urban teaching hospital were treated according to a guideline-based care protocol, including a patient toolkit at ER discharge, and systematic referral to a rapid access AF clinic. Consenting patients received questionnaires on AF knowledge, patient satisfaction, and the AFEQT questionnaire at first visit and three-month follow-up.

RESULTS

Of the 321 patients with AF, 244 (76%) were discharged from the ER and 166 (68%) were referred to the AF clinic for urgent follow-up. Among 166 referred, 144 (87%) were seen, within a median 10.5 days (IQR 6-16.5 days); 128 (89%) patients agreed to participate in the study and 81% received a toolkit in the ER. The mean age of patients seen in AF clinic was 63.6±13.2 years and 59% were male. Eighty-seven percent were aware of their diagnosis, stroke risk (82%), possible complications (90%), treatment options (86%) and benefits of adherence (86%). Severity of Atrial Fibrillation class was > 2 in 51% at baseline; AFEQT scores increased from baseline (56.4±25.5) to three months post-ER visit (76.4±20.0), a moderately large improvement in QOL (p<0.0001). Seventy eight percent of patients with CHA2DS2-VASc score > 1 were treated with an oral anticoagulant.

CONCLUSIONS

A systematic program to improve patient transition of care from the ER to community clinic was associated with prompt, guideline-based care, and high levels of patient disease awareness. Quality of life scores improved substantially between the index ER visit and 3 months post-visit.

Usefulness of a low CHADS2 or CHA2DS2-VASc score to predict normal diagnostic testing in emergency department patients with an acute exacerbation of previously diagnosed atrial fibrillation

International guidelines do not specify what testing should be performed during emergency department (ED) evaluations for patients presenting with an exacerbation of previously diagnosed atrial fibrillation (AF). We hypothesized that low CHADS2 and CHA2DS2-VASc scores predict normal routine diagnostic testing in these patients. We conducted an analysis within a prospective observational cohort study at a university-affiliated hospital. We included patients with previously diagnosed AF and who presented to the ED primarily for an AF-related complaint. Logistic regression was used to analyze the association between CHADS2 and CHA2DS2-VASc scores and abnormal results for blood counts, electrolytes, cardiac markers, thyroid function, and chest x-rays. We included 216 patients in this analysis. The odds ratios (95% confidence interval) for each point increase in CHADS2 for abnormal blood counts, electrolytes, troponin I, brain natriuretic peptide, thyroid function, and chest x-ray were 1.28 (0.99 to 1.65), 1.48 (1.19 to 1.84), 1.42 (1.10 to 1.82), 1.66 (1.15 to 2.41), 0.95 (0.70 to 1.29), and 1.17 (0.94 to 1.44), respectively. The corresponding odds ratios (95% confidence interval) for each point increase in CHA2DS2-VASc were 1.17 (0.96 to 1.42), 1.27 (1.09 to 1.49), 1.30 (1.07 to 1.57), 1.57 (1.18 to 2.10), 0.98 (0.79 to 1.22), and 1.14 (0.97 to 1.33), respectively. Among ED patients with established AF who underwent evaluation for acutely symptomatic AF, nearly 3/4 of routine diagnostic tests return to normal. In conclusion, patients with CHADS2 or CHA2DS2-VASc score of 0 have the lowest likelihood of abnormal studies and may represent an easily identifiable group of patients who need fewer ED tests.

Evaluation and management of the atrial fibrillation patient: a report from the Society of Cardiovascular Patient Care

Atrial fibrillation (AF) is the most common cardiac dysrhythmia, and its prevalence is growing. The care of patients with AF is complex and involves multiple specialties and venues of care. Guideline recommendations are available for AF therapy; however, their implementation can be challenging. The Society of Cardiovascular Patient Care has developed an accreditation program, formulated by an expert committee on AF. Accreditation is based on specific criteria in 7 domains: (1) community outreach, (2) prehospital care, (3) early stabilization, (4) acute care, (5) transitions of care, (6) clinical quality measures, and (7) governance. This document presents the rationale, discussion, and supporting evidence for these criteria, in an effort to maximize effective and efficient AF care.

Predictors of regional variations in hospitalizations following emergency department visits for atrial fibrillation

The emergency department (ED) is often where atrial fibrillation (AF) is first detected and acutely treated and affected patients dispositioned. We used the Nationwide Emergency Department Sample to estimate the percentage of visits resulting in hospitalization and investigate associations between patient and hospital characteristics with hospitalization at the national and regional levels. We conducted a cross-sectional study of adults with AF listed as the primary ED diagnosis in the 2007 to 2009 Nationwide Emergency Department Sample. We performed multivariate logistic regression analyses investigating the associations between prespecified patient and hospital characteristics with hospitalization. From 2007 to 2009, there were 1,320,123 weighted ED visits for AF, with 69% hospitalized nationally. Mean regional hospitalization proportions were: Northeast (74%), Midwest (68%), South (74%), and West (57%). The highest odds ratios for predicting hospitalization were heart failure (3.85, 95% confidence interval [CI] 3.66 to 4.02), chronic obstructive pulmonary disease (2.47, 95% CI 2.34 to 2.61), and coronary artery disease (1.65, 95% CI 1.58 to 1.73). After adjusting for age, privately insured (0.77, 95% CI 0.73 to 0.81) and self-pay (0.77 95% CI 0.66 to 0.90) patients had lower odds compared with Medicare recipients, whereas Medicaid (1.21, 95% CI 1.11 to 1.32) patients tended to have higher odds. Patients living in low-income zip codes (1.18, 95% CI 1.12 to 1.25) and patients treated at large metropolitan hospitals (1.75, 95% CI 1.59 to 1.93) had higher odds. In conclusion, our analysis showed considerable regional variation in the management of patients with AF in the ED and in associations between patient socioeconomic and hospital characteristics with ED disposition; adapting best practices from among these variations in management could reduce hospitalizations and health-care expenses.

Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC Guidelines on atrial fibrillation: primary results of the PREvention oF thromboemolic events--European Registry in Atrial Fibrillation (PREFER in AF)

Aims

We sought to describe the management of patients with atrial fibrillation (AF) in Europe after the release of the 2010 AF Guidelines of the European Society of Cardiology.

Methods and results

The PREFER in AF registry enrolled consecutive patients with AF from January 2012 to January 2013 in 461 centres in seven European countries. Seven thousand two hundred and forty-three evaluable patients were enrolled, aged 71.5 ± 11 years, 60.1% male, CHA₂DS₂VASc score 3.4 ± 1.8 (mean ± standard deviation). Thirty per cent patients had paroxysmal, 24.0% had persistent, 7.2% had long-standing persistent, and 38.8% had permanent AF. Oral anticoagulation was used in the majority of patients: 4799 patients (66.3%) received a vitamin K antagonist (VKA) as mono-therapy, 720 patients a combination of VKA and antiplatelet agents (9.9%), 442 patients (6.1%) a new oral anticoagulant drugs (NOAC). Antiplatelet agents alone were given to 808 patients (11.2%), no antithrombotic therapy to 474 patients (6.5%). Of 7034 evaluable patients, 5530 (78.6%) patients were adequately rate controlled (mean heart rate 60–100 bpm). Half of the patients (50.7%) received rhythm control therapy by electrical cardioversion (18.1%), pharmacological cardioversion (19.5%), antiarrhythmic drugs (amiodarone 24.1%, flecainide or propafenone 13.5%, sotalol 5.5%, dronedarone 4.0%), and catheter ablation (5.0%).

Conclusion

The management of AF patients in 2012 has adapted to recent evidence and guideline recommendations. Oral anticoagulant therapy with VKA (majority) or NOACs is given to over 80% of eligible patients, including those at risk for bleeding. Rate is often adequately controlled, and rhythm control therapy is widely used.

A multidisciplinary atrial fibrillation clinic

BACKGROUND

Reports in the literature indicate that specialty clinics focusing on management of patients with specific chronic disorders have a significant positive impact on patient outcomes. Atrial fibrillation (AF), one of the most common forms of cardiac arrhythmia, affects millions of patients. Outcome data regarding the impact of managing patients with AF are limited. We established a specialty clinic focusing on management of patients with AF. The objective of our study was to evaluate the outcomes of treating AF patients in this clinic.

METHODS

A team consisting of electrophysiologists and pharmacists designed a specific plan for managing and educating patients. This plan consisted of evaluation, implementation of an individualized treatment plan, patient education, medication management, and follow-up care. We reviewed the outcomes of patients who had clinic visits between November 2011 and March 2012. The primary outcome was the incidence of AF-related hospitalizations and stroke.

RESULTS

Seventy one patients were included in the analysis. Out of 71 patients, we identified 17 (23.9%) patients who were hospitalized. Two of these 17 hospitalized patients had ischemic stroke events.

CONCLUSION

When compared to published data in the existing literature, managing AF patients in specialty clinics reduces the incidence of AF-related hospitalizations and stroke.

What are the costs of atrial fibrillation?

The costs of atrial fibrillation (AF) are linked to the general cost of managing AF patients in different health-care systems, as well as the cost of managing AF-related complications (e.g. hospitalizations and long-term complications, such as stroke). In addition, indirect medical costs, such as care for patients who do not recuperate fully from a vascular event, and non-medical costs such as loss of work force add to the costs of AF. All estimations for cost of AF and cost of AF therapy are based on assumptions and markedly influenced by these cost determinants. This urges for extreme caution not to take cost estimates at their absolute values. In fact, even relative comparisons between interventions may have different consequences in terms of direct and indirect costs in different health-care settings. While newer therapeutic options appear to increase the cost of AF management, newer antithrombotic substances and adequate rhythm control therapy also carry the promise of preventing the two major drivers of AF-related cost, hospitalizations and AF-related complications. Formal assessment of the cost of AF requires adjustment to local practice, and more data are clearly needed especially from primary care to better estimate the 'real' cost impact of AF.

Atrial fibrillation and flutter outcomes and risk determination (AFFORD): design and rationale

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia affecting over 700,000 individuals in Japan and 2.2 million in the USA. The proper management of patients with AF is critical due to the well-documented association with heart failure and stroke. A strategy to better define the emergency department (ED) management, admission decisions, and spectrum of risk from low to high is needed.

METHODS AND SUBJECTS

The atrial fibrillation and flutter outcomes and risk determination investigation is a prospective, observational cohort study to develop a multivariable clinical prediction rule that accurately estimates risk for adverse outcomes in patients presenting to the ED with symptomatic AF. We will enroll 430 patients at 2 sites who present to the ED with symptomatic AF defined as a new or established diagnosis of AF or atrial flutter that require ED evaluation for a complaint thought related to their rhythm disturbance. The study's endpoint is to develop an accurate, objective, internally validated, reliable clinical prediction rule to risk-stratify ED patients presenting with AF exacerbations. The rule will incorporate patient history and examination findings and laboratory studies obtained upon ED presentation, as well as trends over the first 2 h of care. This investigation's primary outcome is the incidence of any AF-related adverse event at 5 days and 30 days. We expect to complete the study by the end of 2014. The study was registered at Clinicaltrials.gov NCT01138644.

[Atrial fibrillation in 2010: an increasing morbidity and mortality burden]

AF, a frequent and banal arrhythmia, is a debilitating and costly disease. The majority of patients with AF are aged 60 to 80 years, but the prevalence is as high as 10% after 80 years and the incidence increases in recent years in an "epidemic" way. AF is responsible for an excess of mortality with an relative risk between 2 and 4 depending of age and sex, especially as cardiovascular risk factors are associated. The morbidity is also important, with cerebral systemic embolism (2-3% per year), heart failure (1 patient for 3), and a total risk of hospitalization from 20 to 30% per year for AF patients with high cardiovascular risks. Whatever be the reasons for hospitalization, cardiovascular or not, in connection with AF or not, these reasons must be well analyzed, so that the risk of occurrence of hospitalization should reflect the efficacy of anti-arrhythmic drugs, or of their complications, or of the comorbidities associated with AF, so common in these older subjects. This morbidity-mortality composite endpoint should now be used in AF randomized trials, as occurring more frequently than mortality (4% per year) or embolic or hemorrhagic usual endpoints. Medico-economic consequences are significant and AF cost is almost 1% of total health spending, with 20% to 30% of the cost for anti-arrhythmic or anti-thrombotic drugs, and 50 to 60% for hospitalizations. Prevention of hospitalizations related to atrial fibrillation may represent a therapeutic target priority on the medico-economic ground.

Resource utilization after introduction of a standardized clinical assessment and management plan

INTRODUCTION

A Standardized Clinical Assessment and Management Plan (SCAMP) is a novel quality improvement initiative that standardizes the assessment and management of all patients who carry a predefined diagnosis. Based on periodic review of systemically collected data the SCAMP is designed to be modified to improve its own algorithm. One of the objectives of a SCAMP is to identify and reduce resource utilization and patient care costs.

METHODS

We retrospectively reviewed resource utilization in the first 93 arterial switch operation (ASO) SCAMP patients and 186 age-matched control ASO patients. We compared diagnostic and laboratory testing obtained at the initial SCAMP clinic visit and control patient visits. To evaluate the effect of the SCAMP over time, the number of clinic visits per patient year and echocardiograms per patient year in historical control ASO patients were compared to the projected rates for ASO SCAMP participants.

RESULTS

Cardiac magnetic resonance imaging (MRI), stress echocardiogram, and lipid profile utilization were higher in the initial SCAMP clinic visit group than in age-matched control patients. Total echocardiogram and lung scan usage were similar. Chest X-ray and exercise stress testing were obtained less in SCAMP patients. ASO SCAMP patients are projected to have 0.5 clinic visits and 0.5 echocardiograms per year. Historical control patients had more clinic visits (1.2 vs. 0.5 visits/patient year, P<.01) and a higher echocardiogram rate (0.92 vs. 0.5 echocardiograms/patient year, P<.01)

CONCLUSION

Implementation of a SCAMP may initially lead to increased resource utilization, but over time resource utilization is projected to decrease.

A clinical prediction model to estimate risk for 30-day adverse events in emergency department patients with symptomatic atrial fibrillation

STUDY OBJECTIVE

Atrial fibrillation affects more than 2 million people in the United States and accounts for nearly 1% of emergency department (ED) visits. Physicians have little information to guide risk stratification of patients with symptomatic atrial fibrillation and admit more than 65%. Our aim is to assess whether data available in the ED management of symptomatic atrial fibrillation can estimate a patient's risk of experiencing a 30-day adverse event.

METHODS

We systematically reviewed the electronic medical records of all ED patients presenting with symptomatic atrial fibrillation between August 2005 and July 2008. Predefined adverse outcomes included 30-day ED return visit, unscheduled hospitalization, cardiovascular complication, or death. We performed multivariable logistic regression to identify predictors of 30-day adverse events. The model was validated with 300 bootstrap replications.

RESULTS

During the 3-year study period, 914 patients accounted for 1,228 ED visits. Eighty patients were excluded for non-atrial-fibrillation-related complaints and 2 patients had no follow-up recorded. Of 832 eligible patients, 216 (25.9%) experienced at least 1 of the 30-day adverse events. Increasing age (odds ratio [OR] 1.20 per decade; 95% confidence interval [CI] 1.06 to 1.36 per decade), complaint of dyspnea (OR 1.57; 95% CI 1.12 to 2.20), smokers (OR 2.35; 95% CI 1.47 to 3.76), inadequate ventricular rate control (OR 1.58; 95% CI 1.13 to 2.21), and patients receiving β-blockers (OR 1.44; 95% CI 1.02 to 2.04) were independently associated with higher risk for adverse events. C-index was 0.67.

CONCLUSION

In ED patients with symptomatic atrial fibrillation, increased age, inadequate ED ventricular rate control, dyspnea, smoking, and β-blocker treatment were associated with an increased risk of a 30-day adverse event.

Optimizing the management of atrial fibrillation: focus on current guidelines and the impact of new agents on future recommendations

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in everyday clinical practice. It affects ~2.3 million individuals in the United States, and the prevalence is expected to increase ~2.5-fold over the next 40 years. Atrial fibrillation accounts for more than 2 million hospitalizations each year and contributes to nearly 67 000 deaths. Our understanding of the pathophysiology of AF has increased dramatically over the past few decades. Recent treatment guidelines have heightened our awareness of the challenges involved in the treatment of AF and provided useful recommendations for its diagnosis and management. Because AF is usually associated with multiple comorbid conditions, greater emphasis must be placed on individualizing treatment. This review focuses on current treatment guidelines for patients with AF, assessing the benefits and shortcomings of current pharmacologic options and discussing new agents and trials that may provide better opportunities to improve and individualize patient management.

Atrial fibrillation and ethnicity: the known, the unknown and the paradox

Current understanding of the pathophysiology and epidemiology of atrial fibrillation (AF) is based primarily on studies in White populations of European ancestry with limited data on the non-White populations. Many traditional and novel risk factors for AF have been already established. However, little is known about the differential impact of these AF risk factors in non-White versus White populations. Few studies have compared the prevalence and incidence of AF in Black versus White individuals, and still fewer extended this comparison to other races and ethnicities. These few studies consistently reported that Black individuals have lower AF burden compared with their White counterparts. These findings are not consistent with the reported high stroke rates in Black populations and the strong association between stroke and AF. In this perspective we argue that differential AF underascertainment among different racial and ethnic groups may be the key in explaining this paradox of racial/ethnic distribution of AF. Results from recent publications suggest that Black individuals would have higher rates of AF if more sensitive AF detection methods are used. Although these findings do not reach the level of definitive evidence, they may support the need for rethinking the epidemiology of AF across races and ethnicities in the context of the limited methodology available to detect AF, as well as the questionable assumption that the ability to diagnose AF across different racial/ethnic groups is the same.

Cost of atrial fibrillation in United States managed care organizations

INTRODUCTION

Atrial fibrillation (AF) has been shown to be associated with high healthcare costs; however, limited data are available from large-scale studies quantifying the overall cost burden of AF in the USA. We therefore aimed to provide an up to date estimate of the overall per-patient costs of AF in managed care organizations across the USA.

METHODS

This retrospective cohort study used claims data from the Integrated Healthcare Information Systems National Managed Care Benchmark Database from January 2005 to December 2006. Patients included in the analysis were aged > or =20 years and had at least two outpatient AF-related claims without hospitalization, or a hospitalization with a primary or secondary discharge diagnosis of AF in 2005. AF-related inpatient and outpatient costs over 12 months from the initial outpatient claim or first hospitalization were examined. For secondary AF hospitalizations, incremental costs associated with AF were measured by comparing costs for patients with AF with a group of matched controls hospitalized without AF.

RESULTS

In total, 35,255 patients diagnosed as having AF (5008 with a primary AF diagnosis, 10,776 with a secondary AF diagnosis, 19,471 with outpatient-managed AF), and 20,571 controls without AF, were included in the analysis. Over 12 months, for primary AF hospitalization patients, inpatient costs were $11,306.53 and outpatient costs were $2826.78 (total $14,133.30) per patient. For hospitalized patients with secondary AF, incremental AF-related inpatient costs were $5181.19 and outpatient costs were $1376.33 (total $6557.52). For AF patients with outpatient management in 2005, 12-month AF-related costs were $2177.30 ($175.47 for AF hospitalizations in 2006 and $2001.85 for outpatient costs).

CONCLUSIONS

Overall costs of AF in the US managed care organizations are high. Costs are primarily due to inpatient expenses. Improved disease management strategies to reduce AF-related hospitalizations and decrease the overall cost burden of AF are needed.

Outcomes of adoption: measuring evidence uptake by individuals and organizations

BACKGROUND

The translation and diffusion of findings into health care validate the potential of evidence-based innovation to improve clinical practice and affirm the benefits of society's investment in advancing science.

AIMS

This article briefly reviews key concepts in the knowledge use process, considers theoretical implications for measuring outcomes and uptake of innovation, discusses issues to consider in planning for measurement of adoption, and provides an example of confronting those challenges from a project now in progress. THEORETICAL PERSPECTIVES AND TRANSLATION OUTCOMES: Four principal conceptual frameworks related to translational science, Lewin, Rogers, Havelock, and Promoting Action on Research Implementation in Health Services (PARIHS), explicate a process that catalyzes new knowledge adoption and use by individuals and systems to solve problems. Each conceptual perspective suggests that translation is not complete until the extent and impact of use is examined and understood. Most perspectives support evaluation of impact of evidence-based practice using process measures that integrate clinician knowledge, actual performance of the practice, and patient/clinician outcomes. Based on the Agency for Healthcare Research and Quality (AHRQ) framework, additional measures might include changes in patterns of care and changes in policies, procedures, or protocols. CASE EXAMPLE: A description of process and outcome measures used in an in-progress quality improvement demonstration project, California Nursing Outcomes Coalition (CalNOC) Partners in Quality Translating Research into Practice to Reduce Patient Falls Project, is presented. IMPLICATION(S) FOR PRACTICE, RESEARCH, AND POLICY: Since the adoption of evidence-based innovation is a process that is often described along a continuum, investigators seeking to measure the impact of an evidence-based innovation must gather evidence that uptake of the innovation has occurred. The theoretical perspective and practical measurement issues of a given project will drive selection of process and outcome measures.

CONCLUSIONS

Efforts to change practice in order to enhance evidence-based patient care must integrate monitoring and evaluation of specific target outcomes of adoption as the basis for validating the impact of the change.

Increasing US Emergency Department Visit Rates and Subsequent Hospital Admissions for Atrial Fibrillation from 1993 to 2004

STUDY OBJECTIVE

Atrial fibrillation is a significant public health problem that is becoming increasingly prevalent. The clinical epidemiology of US emergency department (ED) visits for atrial fibrillation is uncertain. This study seeks to describe recent trends in ED visits for atrial fibrillation.

METHODS

ED visits with a primary diagnosis of atrial fibrillation were analyzed using data from the US National Hospital Ambulatory Medical Care Survey, 1993 to 2004.

RESULTS

During the 12-year period, there were approximately 2.7 million (95% confidence interval [CI] 2.4 to 3.0 million) ED visits for atrial fibrillation in the United States, and the population-adjusted visit rate increased from 0.6 to 1.2 per 1,000 US population (P for trend=.02). Similarly, the absolute number of visits increased 88%, from 300,000 (95% CI 209,000 to 392,000) in 1993 to 1994 to 564,000 (95% CI 423,000 to 705,000) in 2003 to 2004. Approximately 64% (95% CI 59% to 69%) of these patients were admitted to the hospital, a rate that remained constant throughout the 12-year period (P for trend=.73). Admission rates were significantly lower in the western region of the United States (48%; 95% CI 36% to 60% versus 76%; in the Northeast, 95% CI 68% to 84%). Patient characteristics and ED management did not materially differ by admission status. In a multivariate model, congestive heart failure was the only predictor of admission but accounted for only 14% of admissions.

CONCLUSION

From 1993 to 2004, the population-adjusted rate of ED visits for atrial fibrillation increased, whereas the proportion admitted to the hospital remained stable. Patient characteristics and ED management were similar regardless of admission status, and there were relatively few predictors of admission.

Economic evaluation of enoxaparin for anticoagulation in early cardioversion of persisting nonvalvular atrial fibrillation: a statutory health insurance perspective from Germany

OBJECTIVE

To estimate, from the perspective of Statutory Health Insurance (SHI, third-party payer) in Germany, the economic consequences of using the subcutaneous low-molecular-weight heparin (LMWH) enoxaparin instead of intravenous unfractionated heparin followed by oral phenprocoumon (UFH/PPC) for anticoagulation in patients undergoing transesophageal echocardiography (TEE)-guided early electrical cardioversion (ECV) of persisting nonvalvular atrial fibrillation (AF) without intracardiac clot.

DESIGN AND SETTING

The incremental cost for the enoxaparin-based regimen versus the UFH/PPC-based regimen was chosen as the target variable. A decision-analytic model considering the in- and outpatient sectors was used to quantify the target variable. Resource use during in- and outpatient treatment was taken from the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial and from expert interviews with cardiologists in Germany in order to reflect the day-to-day conditions of clinical practice. Costs were given by SHI expenses for inpatient treatment and for medical services, drugs, disposables, and laboratory tests during outpatient treatment. These costs were determined by multiplying utilized resource items by the price or tariff of each item based on German healthcare regulations for the reference period of 2003/2004. According to the ACE trial, the evaluation encompassed 28 (26-30) treatment days with two consecutive phases. Phase I with 5 (3-12) days comprised diagnostics, start of anticoagulation, and ECV. Phase II with the remaining days consisted of continued anticoagulation and patient monitoring. The dosage of enoxaparin was 1 mg/kg bodyweight twice daily in treatment phase I followed by 40 mg twice daily with a bodyweight <65 kg or 60 mg twice daily with a BW > or =65 kg in treatment phase II. The daily dosages of UFH by continuous infusion and overlapping PPC were adjusted to an International Normalized Ratio of 2.0-3.0 in treatment phase I followed by 2.25mg PPC once daily in treatment phase II. Patients with any comorbidity and complication level (CCL) and those with low comorbidity and complications expected to occur in rare cases only (low-risk patients) were analyzed separately. In each base-case analysis, exclusively point estimates of all respective model parameters were applied.

MAIN OUTCOME MEASURES AND RESULTS

There were savings of 339 euro and 579 euro per patient receiving the enoxaparin-based regimen versus the UFH/PPC-based regimen in the case of patients with any CCL and of low-risk patients, respectively (1 euro approximate, equals $US1.25; first quarter 2004 values). In comprehensive sensitivity analyzes, the robustness of the model and its results was shown. First, the impact of the model parameters on the target variable for each patient group was quantified in a deterministic model. Secondly, the dependency of the target variable on random variables was described for each patient group using Monte Carlo simulation. Irrespective of the patient group, the cost weight and the base rate of hospitals for inpatient ECV in phase I turned out to have the greatest impact on the savings obtained by the enoxaparin-based regimen. In the case of patients with any CCL, this impact was about 1.4-fold of that of the probability of enoxaparin patients undergoing outpatient ECV in phase I. In the case of low-risk patients, the impact of the cost weight and the base rate of hospitals for inpatient ECV in phase I was about 4.1-fold of that of the price of enoxaparin 60 mg prefilled syringes in the outpatient sector. In 79% and 93% of 10,000 simulated comparisons each versus the UFH/PPC-based regimen, there were savings obtained by the enoxaparin-based regimen in patients with any CCL and in low-risk patients, respectively.

CONCLUSIONS

Results of this evaluation showed that an enoxaparin-based regimen for TEE-guided ECV of AF in patients without intracardiac clot offers SHI in Germany a considerable saving potential when used instead of an UFH/PPC-based regimen.

Healthcare resource utilization and costs associated with recurrent episodes of atrial fibrillation: the FRACTAL registry

INTRODUCTION

Drivers of cost in the atrial fibrillation (AF) population are not fully understood. We sought to characterize the resource utilization and costs of treating new-onset AF, with emphasis on the incremental costs associated with recurrent episodes of AF over time.

METHODS AND RESULTS

An inception cohort of 973 AF patients was followed at 3-6 month intervals in an observational registry over a mean of 24 +/- 9 months. AF therapies, clinical outcomes, and both inpatient and outpatient medical resource utilization were tracked at each follow-up interval. Registry patients were managed primarily with cardioversion and pharmacological therapy. Direct healthcare costs were calculated from a U.S. perspective by multiplying measures of resource utilization by representative price weights. Costs were compared among patients in whom the initial episode of AF became permanent and patients who initially achieved sinus rhythm and had either 0, 1-2, or > or = 3 documented recurrences during follow-up. Mean annual costs for these four groups were $2,372, $3,385, $6,331, and $10,312 per patient per year, respectively (P < 0.001 for trend), with the largest variation related to hospital costs. In multivariable analysis controlling for demographic characteristics and baseline cardiac and comorbid conditions, each documented recurrence of AF was found to increase annual healthcare costs by approximately $1,600.

CONCLUSION

Following initial diagnosis, patients with AF treated with traditional therapies incur $4,000-$5,000 in annual direct healthcare costs. Costs are markedly higher in patients with multiple AF recurrences. These data may be helpful in evaluating the economic impact of new technologies for treating AF.

The worldwide social burden of atrial fibrillation: what should be done and where do we go?

Atrial fibrillation represents the most common arrhythmia in clinical practice and is associated with poor clinical outcome. Due to the aging of the population, the number of patients with atrial fibrillation will increase approximately 2.5-fold by the year 2050. Comparison studies between rhythm control and rate control strategies in management of atrial fibrillation have been biased by the limited efficacy of antiarrhythmic drugs in keeping an actual rhythm control, while their adverse effects may offset their antiarrhythmic benefits. In patients who are candidates for anti-bradycardia pacing atrial and dual chamber pacing have been demonstrated to be superior to single chamber ventricular pacing in reducing atrial fibrillation recurrences and in preventing progression to permanent atrial fibrillation. Algorithms aimed either to prevent atrial fibrillation relapsing or to interrupt new onset tachycardias early have been demonstrated to be safe and effective, but clinical studies which investigated their impact on clinical end points showed inconsistent results. Multifunction devices capable of delivering atrial shock have been demonstrated useful in patients who were candidates for ICD implantation because of life-threatening ventricular arrhythemias. Preliminary studies suggested a potential role of these devices in selected patients with brady-tachy syndrome without prior ventricular arrhythmias. Radiofrequency catheter ablation techniques of atrial fibrillation have been increasingly used in the last years. Both pulmonary vein ablation and left atrial circumferential ablation showed encouraging clinical results with 70-80% of patients free from atrial fibrillation with or without prior ineffective antiarrhythmic drugs. In the future, strategies to deal with the huge worldwide burden of atrial fibrillation will include a wider application of non pharmacological therapies as well as a big investment in basic and clinical research. New and more effective antiarrhythmic drugs are needed. Genetic studies will deeply change understanding and therapy of atrial fibrillation.

The Accident and Emergency Department Virtual Consulting Room

The goal was to describe the development of the Virtual Consulting Room (VcR), a unique intranet-based guidance application providing direct access to local specialist knowledge, and to evaluate its usability and whether it has the potential to educate staff while working in the Accident and Emergency (A&E) department. Duty staff of the A&E Department, The Royal Free Hospital, London, participated in a prospective observational study. Two hundred and twenty consecutive patients were identified from the triage section of their casualty card as having a presenting complaint that featured in the VcR. These casualty cards were highlighted with a red sticker alert and a short questionnaire attached. Members of staff were invited to consult with the VcR after assessing each patient by clicking on an icon located on the department's computer desktops. No prior training was provided. The questionnaire was completed in 103 of 220 (46.8%) patients. The VcR was used in the management of 38 of 220 (17.3%) patients. In 21 of 38 (55.3%), users reported the VcR supported clinical decision making, in 20 of 38 (52.6%) the VcR improved knowledge and in 11 of 38 (28.9%) the VcR helped directly influence the decision to discharge the patient. In 2 of 38 (5.3%) users changed their decision to refer and in 1 of 38 (2.6%) investigations were altered. This evaluation indicates that A&E clinicians accessing the VcR found it easy to use and educational in the workplace.

Assessing the direct costs of treating nonvalvular atrial fibrillation in the United States

OBJECTIVE

To determine the health-care resource use and costs attributable to treating atrial fibrillation (AF) in the United States.

METHODS

Retrospective analyses of three federally funded US databases (2001 data): 1) hospital inpatient stays (the Healthcare Cost and Utilization Project [HCUP]); 2) physician office visits (the National Ambulatory Medical Care Survey [NAMCS]); and 3) emergency department (ED) and hospital outpatient department visits (OPD) (the National Hospital Ambulatory Medical Care Survey [NHAMCS]). Identification of AF medical encounters was based on occurrence of AF-specific International Classification of Diseases (9th Edition)--Clinical Modification (ICD-9-CM) diagnosis code 427.31 (principal discharge diagnosis for inpatient setting; any diagnosis field for other settings). For the 10 most common principal discharge diagnoses in the inpatient setting, case-control comparison analyses were performed to estimate annual incremental costs of AF as a comorbid discharge diagnosis for hospital stays. Regression models were used to assess the impact of AF on hospitalization costs. Costs were estimated in year 2005 US dollars.

RESULTS

Approximately 350,000 hospitalizations, 5.0 million office visits, 276,000 ED visits, and 234,000 OPD were attributable to AF annually within the United States. Total annual costs for treatment of AF were estimated at $6.65 billion, including $2.93 billion (44%) for hospitalizations with a principal discharge diagnosis of AF, $1.95 billion (29%) for the incremental inpatient cost of AF as a comorbid diagnosis, $1.53 billion (23%) for outpatient treatment of AF, and $235 million (4%) for prescription drugs. In all regressions, AF was a significant contributor to hospital cost.

CONCLUSIONS

Treatment of AF represents a significant health-care burden with the costs of treating AF in the inpatient setting outweighing the costs of treating AF in the office, emergency room or hospital outpatient settings. Further research is needed to fully capture the costs of treating AF.

Clinical practice guidelines: a critical review

PURPOSE

Clinical practice guidelines (CPGs) have been developed for many years with the aim of improving the quality of care. A review of the use of CPGs and assessments of CPG compliance among practitioners so far would aid the understanding of factors influencing CPG compliance. This study seeks to provide this.

DESIGN/METHODOLOGY/APPROACH

A general review and discussion of CPGs in areas of their attributes, benefits and pitfalls were carried out. Articles concerning the assessment of CPG compliance were also reviewed to understand the kind of data collected for such assessments (qualitative vs quantitative), the methods used to collect data (objective versus subjective), and the assessment measures employed (process versus outcome).

FINDINGS

A total of 57 CPG compliance assessment studies were reviewed. Almost two-thirds employed objective methods. Of the subjective assessments, 47 per cent analysed solely quantitative data, 32 per cent analysed solely qualitative information and 21 per cent analysed both. More than four-fifths of all studies used process measures to determine CPG compliance and only 5 per cent used solely outcome measures.

PRACTICAL IMPLICATIONS

Depending on the methods used, assessments can help identify various factors influencing CPG compliance. Such factors may be related to the physician, guidelines, health system or patient. A good understanding of these factors and their role in influencing compliance behaviour will help health regulators and administrators plan better and more effective strategies to improve doctors' CPG compliance.

ORIGINALITY/VALUE

This review looks at the various aspects of CPGs to understand how these influence practitioners' compliance.