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Abstract
Sex disparities within the field of stroke, including subarachnoid hemorrhages (SAHs), have been in focus during the last 2 decades. It is clear that stroke incidence is higher in men, and also that men have their first stroke earlier than women. On the other hand, women have more severe strokes, mainly because cardioembolic strokes are more common in women. This leads to higher case fatality and worse functional outcome in women. It has often been pointed out that women more often have nontraditional stroke symptoms, and therefore may seek medical help later. After discharge from the hospital, female stroke survivors live alone in many cases and are dependent on external care. Therefore, these women frequently rate their quality of life (QoL) lower than men do. Female spouses more often provide help to their male stroke survivors than the reverse, and they accept a heavier burden. These caregivers are at high risk for depression, low QoL, and low psychologic wellbeing. SAH is a special form of stroke, often caused by a ruptured aneurysm. It is about 20% more common in women. The case fatality is high, but does not differ between the sexes.
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Affiliation(s)
- Peter Appelros
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Signild Åsberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Lee P, Chin K, Liew D, Stub D, Brennan AL, Lefkovits J, Zomer E. Economic evaluation of clinical quality registries: a systematic review. BMJ Open 2019; 9:e030984. [PMID: 31843824 PMCID: PMC6924778 DOI: 10.1136/bmjopen-2019-030984] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES The objective of this systematic review was to examine the existing evidence base for the cost-effectiveness or cost-benefit of clinical quality registries (CQRs). DESIGN Systematic review and narrative synthesis. DATA SOURCES Nine electronic bibliographic databases, including MEDLINE, EMBASE and CENTRAL, in the period from January 2000 to August 2019. ELIGIBILITY CRITERIA Any peer-reviewed published study or grey literature in English which had reported on an economic evaluation of one or more CQRs. DATA EXTRACTION AND SYNTHESIS Data were screened, extracted and appraised by two independent reviewers. A narrative synthesis was performed around key attributes of each CQR and on key patient outcomes or changes to healthcare processes or utilisation. A narrative synthesis of the cost-effectiveness associated with CQRs was also conducted. The primary outcome was cost-effectiveness, in terms of the estimated incremental cost-effectiveness ratio (ICER), cost savings or return-on-investment (ROI) attributed to CQR implementation. RESULTS Three studies and one government report met the inclusion criteria for the review. A study of the National Surgical Quality Improvement Programme (NSQIP) in the USA found that the cost-effectiveness of this registry improved over time, based on an ICER of US$8312 per postoperative event avoided. A separate study in Canada estimated the ROI to be US$3.43 per US$1.00 invested in the NSQIP. An evaluation of a post-splenectomy CQR in Australia estimated that registry cost-effectiveness improved from US$234 329 to US$18 358 per life year gained when considering the benefits accrued over the lifetime of the population. The government report evaluating five Australian CQRs estimated an overall return of 1.6-5.5 times the cost of investment. CONCLUSIONS Available data indicate that CQRs can be cost-effective and can lead to significant returns on investment. It is clear that further studies that evaluate the economic and clinical impacts of CQRs are necessary. PROSPERO REGISTRATION NUMBER CRD42018116807.
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Affiliation(s)
- Peter Lee
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ken Chin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Departrment of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Angela L Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ella Zomer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Hellwig S, Grittner U, Audebert H, Endres M, Haeusler KG. Non-vitamin K-dependent oral anticoagulants have a positive impact on ischaemic stroke severity in patients with atrial fibrillation. Europace 2019; 20:569-574. [PMID: 28460024 PMCID: PMC5889015 DOI: 10.1093/europace/eux087] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/08/2017] [Indexed: 11/14/2022] Open
Abstract
Aims Several studies showed reduced stroke severity in patients with atrial fibrillation (AF) if the international normalized ratio (INR) was ≥ 2 at stroke onset. There are no respective data for non-vitamin K-dependent oral anticoagulants (NOACs). The aim of this study was to compare the impact of NOAC or phenprocoumon intake on stroke severity. Methods and results In this single-centre observational study, 3669 patients with acute ischaemic stroke were retrospectively analysed regarding AF status and medication immediately before admission. Using multivariable regression, we analysed the association of pre-admission anticoagulation with severe stroke (National Institutes of Health Stroke Scale score ≥ 11) on admission and poor outcome at discharge (modified Rankin scale score > 2). Before the index stroke, 655 patients had known AF and a CHA2DS2-VASc score ≥ 2. While 325 (49.6%) patients were anticoagulated, 159 (24.3%) were prescribed a NOAC and 75 (11.5%) phenprocoumon patients had an INR ≥ 2 on admission. Compared with AF patients without medical stroke prevention, an INR ≥ 2 [OR 0.23 (95% CI 0.10-0.53)] or NOAC intake [OR 0.48 (95% CI 0.27-0.86)] were associated with a lower probability of severe stroke after adjustment for confounders, while an INR < 2 [OR 0.62 (95% CI 0.33-1.16)] was not. Adjusted odds ratios for poor functional outcome at hospital discharge were 0.47 (95% CI 0.27-0.84) for NOAC patients, 0.33 (95% CI 0.17-0.65) for INR ≥ 2 and 0.61 (95% CI 0.32-1.16) for INR < 2. Conclusion NOAC intake before stroke did reduce the probability of severe stroke on hospital admission and poor functional outcome at hospital discharge as similarly demonstrated for phenprocoumon patients with an INR ≥ 2 on admission.
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Affiliation(s)
- Simon Hellwig
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Ulrike Grittner
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Department of Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Heinrich Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Berlin Institute of Health, Kapelle-Ufer 2, 10117 Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Germany.,German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Germany
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Panaich SS, Holmes DR. Who Should Be Referred for Left Atrial Appendage Occlusion Therapy? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:42. [PMID: 28466118 DOI: 10.1007/s11936-017-0540-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OPINION STATEMENT Atrial fibrillation (AF) is the most common cardiac arrhythmia affecting approximately 7 million individuals in USA. It is one of the most significant arrhythmias, which accounts for a majority of embolic strokes, especially in elderly individuals. Although oral anti-coagulation is beneficial in lowering the risk of stroke, 1 in 10 patients have a contra-indication to warfarin therapy. Among patients who do tolerate either warfarin or novel oral anticoagulant (NOAC), major or recurrent bleeding, intracranial bleeds, etc. often lead to interruption of anti-coagulation. Previous studies have reported that >90% of cardioemboli in non-valvular atrial fibrillation (NVAF) originate in the left atrial appendage. Left atrial appendage occlusion (LAAO) is currently covered by the Centers for Medicare & Medicaid Services (CMS) as an alternative for stroke prevention in patients with an elevated stroke risk (CHADS2 ≥2 or CHA2DS2-VASc score ≥3) who have appropriate rational for avoiding long-term oral anticoagulation following a shared-decision making process. In this review, we discuss the currently available LAAO devices and more importantly, appropriate patient selection for this strategy.
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Affiliation(s)
- Sidakpal S Panaich
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA.
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Burton PR, Ooi GJ, Shaw K, Smith AI, Brown WA, Nottle PD. Assessing quality of care in oesophago-gastric cancer surgery in Australia. ANZ J Surg 2016; 88:290-295. [DOI: 10.1111/ans.13752] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/27/2016] [Accepted: 07/28/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Paul R. Burton
- Upper Gastro-intestinal Surgical Unit, Department of General Surgery, Alfred Hospital; Melbourne Victoria Australia
- Department of Surgery, Central Clinical School, Monash University Centre for Obesity Research and Education; Melbourne Victoria Australia
| | - Geraldine J. Ooi
- Department of Surgery, Central Clinical School, Monash University Centre for Obesity Research and Education; Melbourne Victoria Australia
| | - Kalai Shaw
- Upper Gastro-intestinal Surgical Unit, Department of General Surgery, Alfred Hospital; Melbourne Victoria Australia
| | - Andrew I. Smith
- Upper Gastro-intestinal Surgical Unit, Department of General Surgery, Alfred Hospital; Melbourne Victoria Australia
| | - Wendy A. Brown
- Upper Gastro-intestinal Surgical Unit, Department of General Surgery, Alfred Hospital; Melbourne Victoria Australia
- Department of Surgery, Central Clinical School, Monash University Centre for Obesity Research and Education; Melbourne Victoria Australia
| | - Peter D. Nottle
- Upper Gastro-intestinal Surgical Unit, Department of General Surgery, Alfred Hospital; Melbourne Victoria Australia
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Sjölander M, Eriksson M, Asplund K, Norrving B, Glader EL. Socioeconomic Inequalities in the Prescription of Oral Anticoagulants in Stroke Patients With Atrial Fibrillation. Stroke 2015; 46:2220-5. [PMID: 26081841 DOI: 10.1161/strokeaha.115.009718] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/14/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Oral anticoagulants (OACs) are effective against ischemic stroke in patients with atrial fibrillation. Our aim was to investigate differences in the prescribing of OACs after ischemic stroke in patients with atrial fibrillation based on age, sex, country of birth, and socioeconomic status. METHODS Patients with first-ever ischemic stroke and atrial fibrillation without OAC treatment were included from the Swedish stroke register from 2009 to 2012. The outcome was OAC prescribed at discharge. Income, education, country of birth, and risk factors were obtained from official registers. Risk factors and health status were controlled for in multivariable logistic regression. RESULTS Of 12 088 stroke patients, 36.3% were prescribed an OAC. Prescribing was less common with older age and, in patients born in other Nordic countries (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.68-0.98) or countries outside of Europe (OR, 0.65; 95% CI, 0.42-0.99) compared with those born in Sweden. University education (OR, 1.20; 95% CI, 1.05-1.36) and highest income (OR, 1.19; 95% CI, 1.06-1.33) were associated with higher levels of OAC prescribing compared with those with primary school education or lowest income level. CONCLUSION Differences by age, income, education, and country of birth were found in the prescribing of OACs after stroke. Differences were not explained by common risk factors. This indicates socioeconomic inequalities in the prescribing of preventive treatment after stroke.
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Affiliation(s)
- Maria Sjölander
- From the Department of Statistics (M.S., M.E.), Department of Pharmacology and Clinical Neuroscience (M.S.), and Department of Public Health and Clinical Medicine (K.A., E.-L.G.), Umeå University, Umeå, Sweden; and Department of Clinical Sciences, Section of Neurology, Lund University, Lund, Sweden (B.N.).
| | - Marie Eriksson
- From the Department of Statistics (M.S., M.E.), Department of Pharmacology and Clinical Neuroscience (M.S.), and Department of Public Health and Clinical Medicine (K.A., E.-L.G.), Umeå University, Umeå, Sweden; and Department of Clinical Sciences, Section of Neurology, Lund University, Lund, Sweden (B.N.)
| | - Kjell Asplund
- From the Department of Statistics (M.S., M.E.), Department of Pharmacology and Clinical Neuroscience (M.S.), and Department of Public Health and Clinical Medicine (K.A., E.-L.G.), Umeå University, Umeå, Sweden; and Department of Clinical Sciences, Section of Neurology, Lund University, Lund, Sweden (B.N.)
| | - Bo Norrving
- From the Department of Statistics (M.S., M.E.), Department of Pharmacology and Clinical Neuroscience (M.S.), and Department of Public Health and Clinical Medicine (K.A., E.-L.G.), Umeå University, Umeå, Sweden; and Department of Clinical Sciences, Section of Neurology, Lund University, Lund, Sweden (B.N.)
| | - Eva-Lotta Glader
- From the Department of Statistics (M.S., M.E.), Department of Pharmacology and Clinical Neuroscience (M.S.), and Department of Public Health and Clinical Medicine (K.A., E.-L.G.), Umeå University, Umeå, Sweden; and Department of Clinical Sciences, Section of Neurology, Lund University, Lund, Sweden (B.N.)
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Jespersen SF, Christensen LM, Christensen A, Christensen H. Increasing rate of atrial fibrillation from 2003 to 2011 in patients with ischaemic stroke: results from 55 551 patients in a nationwide registry. Eur J Neurol 2015; 22:839-44. [DOI: 10.1111/ene.12671] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 12/15/2014] [Indexed: 11/30/2022]
Affiliation(s)
- S. F. Jespersen
- Department of Neurology; Copenhagen University Hospital Bispebjerg; Copenhagen NV Denmark
| | - L. M. Christensen
- Department of Neurology; Copenhagen University Hospital Bispebjerg; Copenhagen NV Denmark
| | - A. Christensen
- Department of Radiology; Copenhagen University Hospital Bispebjerg; Copenhagen NV Denmark
| | - H. Christensen
- Department of Neurology; Copenhagen University Hospital Bispebjerg; Copenhagen NV Denmark
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Lewalter T, Kanagaratnam P, Schmidt B, Rosenqvist M, Nielsen-Kudsk JE, Ibrahim R, Albers BA, Camm AJ. Ischaemic stroke prevention in patients with atrial fibrillation and high bleeding risk: opportunities and challenges for percutaneous left atrial appendage occlusion. Europace 2014; 16:626-30. [DOI: 10.1093/europace/euu069] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Pharmacotherapy prior to and in acute ischaemic stroke. The use of pharmacotherapy and drug-associated outcomes in real world practice - findings from the Polish Hospital Stroke Registry. Neurol Neurochir Pol 2014; 47:509-16. [PMID: 24374995 DOI: 10.5114/ninp.2013.39067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Stroke is a preventable disease and acute ischaemic stroke can be effectively treated. Specific pharmacotherapy is recommended in either prevention or acute ischemic stroke treatment. We aimed to evaluate the use and the early and late outcomes impact of drugs administered before and in acute ischaemic stroke in a real world practice. MATERIAL AND METHODS Ischaemic stroke patients hospitalized between 1st March 2007 and 29th February 2008 and reported in Polish Hospital Stroke Registry were analysed. Fully anonymous data were collected with standardized, web-based questionnaire with authorized access. Multivariate regression models were used to adjust for case-mix and evaluate the impact of drugs used prior to or in acute ischaemic stroke on outcomes. The early outcomes were defined as in-hospital mortality or poor outcome (death or dependency - modified Rankin Scale 3) at hospital discharge, while late outcomes covered one-year survival. RESULTS A total number of 26 153 ischaemic stroke patients (mean age: 71.8 years; females: 51.6%) was reported. The ana-lysis of pharmacotherapy showed that preventive use of hypo-tensive agents, anticoagulants in atrial fibrillation, antiplatelets and statins is inadequate. Regression models confirmed some expected drug benefits and additionally revealed that antihypertensive drugs or aspirin used prior to stroke and oral anticoagulants or statins used in hospital were associated with better stroke outcome. CONCLUSIONS The prevention of ischaemic stroke needs to be monitored and improved. Evidence-based treatment of acute ischaemic stroke requires further promotion. The benefits of acute ischaemic stroke treatment with statins require to be confirmed in randomized controlled settings.
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Eissa A, Krass I, Bajorek BV. Use of medications for secondary prevention in stroke patients at hospital discharge in Australia. Int J Clin Pharm 2014; 36:384-93. [DOI: 10.1007/s11096-013-9908-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Accepted: 12/26/2013] [Indexed: 10/25/2022]
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Jespersen SF, Christensen LM, Christensen A, Christensen H. Use of oral anticoagulation therapy in atrial fibrillation after stroke: results from a nationwide registry. THROMBOSIS 2013; 2013:601450. [PMID: 24349774 PMCID: PMC3855960 DOI: 10.1155/2013/601450] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 09/24/2013] [Accepted: 09/25/2013] [Indexed: 11/22/2022]
Abstract
Background. The knowledge is still sparse about patient related factors, influencing oral anticoagulation therapy (OAC) rates, in stroke patients with atrial fibrillation (AF). Aims. To assess the use of OAC in ischemic stroke patients diagnosed with AF and to identify patient related factors influencing the initiation of OAC. Methods. In the nationwide Danish Stroke Registry we identified 55,551 patients admitted with acute ischemic stroke from 2003 to 2011. Frequency analysis was used to assess the use of OAC in patients with AF, and logistic regression was used to determine independent predictors of OAC. Results. 17.1% (n = 9,482) of ischemic stroke patients had AF. OAC prescription rates were increasing, and in 2011 46.6% were prescribed OAC, 42.5% had a contraindication, and 3.7% were not prescribed OAC without a stated contraindication. Younger age, less severe stroke, and male gender were positive predictors of OAC, while excessive alcohol consumption, smoking, and institutionalization were negative predictors of OAC (P values < 0.05). Conclusions. Advanced age, severe stroke, female gender, institutionalization, smoking, and excessive alcohol consumption were associated with lower OAC rates. Contraindications were generally present in patients not in therapy, and the assumed underuse of OAC may be overestimated.
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Affiliation(s)
- Stine Funder Jespersen
- Department of Neurology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
| | - Louisa M. Christensen
- Department of Neurology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
| | - Anders Christensen
- Department of Radiology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
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Ball J, Carrington MJ, McMurray JJV, Stewart S. Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century. Int J Cardiol 2013; 167:1807-24. [PMID: 23380698 DOI: 10.1016/j.ijcard.2012.12.093] [Citation(s) in RCA: 445] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 12/04/2012] [Accepted: 12/24/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) represents an increasing public health challenge with profound social and economic implications. METHODS A comprehensive synthesis and review of the AF literature was performed. Overall, key findings from 182 studies were used to describe the indicative scope and impact of AF from an individual to population perspective. RESULTS There are many pathways to AF including advancing age, cardiovascular disease and increased levels of obesity/metabolic disorders. The reported population prevalence of AF ranges from 2.3%-3.4% and historical trends reflect increased AF incidence. Estimated life-time risk of AF is around 1 in 4. Primary care contacts reflect whole population trends: AF-related case-presentations increase from less than 0.5% in those aged 40 years or less to 6-12% for those aged 85 years or more. Globally, AF-related hospitalisations (primary or secondary diagnosis) showed an upward trend (from ~35 to over 100 admissions/10,000 persons) during 1996 to 2006. The estimated cost of AF is greater than 1% of health care expenditure and rising with hospitalisations the largest contributor. For affected individuals, quality of life indices are poor and AF confers an independent 1.5 to 2.0-fold probability of death in the longer-term. AF is also closely linked to ischaemic stroke (3- to 5-fold risk), chronic heart failure (up to 50% develop AF) and acute coronary syndromes (up to 25% develop AF) with consistently worse outcomes reported with concurrent AF. Future projections predict at least a doubling of AF cases by 2050. SUMMARY AF represents an evolving, global epidemic providing considerable challenges to minimise its impact from an individual to whole society perspective.
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Affiliation(s)
- Jocasta Ball
- Centre of Research Excellence to Reduce Inequality in Heart Disease, Preventative Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
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Sun MC, Hsiao PJ. In-hospital case management to increase anticoagulation therapy for stroke patients with atrial fibrillation: a hospital-based registry. J Formos Med Assoc 2012; 112:263-8. [PMID: 23660222 DOI: 10.1016/j.jfma.2012.02.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Revised: 02/07/2012] [Accepted: 02/07/2012] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND/PURPOSE Anticoagulation is underused for stroke patients with atrial fibrillation in Taiwan. An effective preventive measure is in great need of improvement. METHODS In-hospital case management was implemented to monitor the diagnosis of atrial fibrillation and the use of warfarin. Timely feedback to treating physicians was made. Change in performance after the implementation was analyzed. RESULTS A total of 2754 patients hospitalized for acute ischemic stroke or transient ischemic attack were included, 1216 before and 1538 after the intervention. The percentage of patients without electrocardiography examination decreased from 8.7% to 2.9% (p < 0.001). The diagnosis of atrial fibrillation increased from 11.5% (n = 140) to 15.9% (n = 244) (p = 0.001). The use of warfarin at discharge increased from 36.9% to 54.7% (p = 0.001). In-hospital case management was significantly related to the use of warfarin (odds ratio = 2.47, p < 0.001). The percentage of warfarin use was still significantly higher in the intervention group at 3 months of follow-up (45.9% vs. 27.8%, p = 0.002) and at 6 months of follow up (49.2% vs. 28.6%, p = 0.004). More patients' international normalized ratio was within the recommended range in the intervention group at 6 months' follow-up (30.5% vs. 9.1%, p = 0.039). CONCLUSION Our study indicates that in-hospital case management may be an effective strategy to improve anticoagulation for eligible stroke patients.
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Affiliation(s)
- Mu-Chien Sun
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan.
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Haeusler KG, Konieczny M, Endres M, Villringer A, Heuschmann PU. Impact of anticoagulation before stroke on stroke severity and long-term survival. Int J Stroke 2011; 7:544-50. [PMID: 22111868 DOI: 10.1111/j.1747-4949.2011.00672.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Therapeutic anticoagulation by vitamin K antagonists is highly effective in reducing stroke risk in patients with atrial fibrillation. Vitamin K antagonist treatment before stroke reduces stroke severity and short-term mortality. AIMS This study analyses vitamin K antagonists, used in patients with atrial fibrillation diagnosed before the index stroke. We also focus on the impact of preadmission antithrombotic medication on long-term survival. METHODS We analyzed 2390 stroke patients consecutively admitted to the Department of Neurology, Charité Berlin, Germany between 2003 and 2004. Mean follow-up was 38 months (range 0-68). Using univariable and multivariable regression models, we identified factors for preadmission anticoagulation in patients with known atrial fibrillation and analyzed the impact of antithrombotic therapy preadmission on functional disability and long-term survival after stroke. RESULTS Atrial fibrillation was diagnosed in 534 (22·3%) of the 2390 stroke patients. In 348 (65·2%) of all atrial fibrillation patients, atrial fibrillation was already known before the index stroke. Three hundred twenty-five (93·4%) atrial fibrillation patients were amenable to anticoagulation, according to guidelines, 75 (23·1%) received vitamin K antagonists, and 20 (6·2%) had an international normalized ratio of 2-3 at the time of stroke onset. Males and younger patients were more likely to receive anticoagulation preadmission, while previous stroke had no significant impact on vitamin K antagonist prescription. Age (odds ratio 1·02 (95% confidence interval 1·00-1·04) per year), history of coronary artery disease (odds ratio 1·51 (95% confidence interval 1·01-2·26)), and therapeutic anticoagulation (odds ratio 0·28 (0·09-0·84)) were independent predictors of stroke severity. Age (hazard rates 3·11 (95% confidence interval 1·47-6·59), 4·65 (95% confidence interval 2·27-9·57), and 11·1 (95% confidence interval 4·90-25·1) for age categories 65-74, 75-84, and ≥85 years), preadmission antiplatelet therapy (hazard rate 1·85 (95% confidence interval 1·21-2·82)), and stroke severity on admission (hazard rate 1·60 (95% confidence interval 1·03-2·46) and hazard rate 3·23 (95% confidence interval 1·88-5·55) for National Institutes of Health Stroke Scale categories 6-15 and >15 points) were associated with risk of death during follow-up. CONCLUSIONS In patients in which atrial fibrillation was diagnosed prior to the index stroke, about 23% received anticoagulation according to guideline recommendations. Therapeutic anticoagulation at stroke onset significantly decreased the risk of moderate to severe stroke on admission but showed no significant association with long-term survival.
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Affiliation(s)
- Karl Georg Haeusler
- Department of Neurology, Charité-University Medicine Berlin, Berlin, Germany.
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Evans SM, Scott IA, Johnson NP, Cameron PA, McNeil JJ. Development of clinical-quality registries in Australia: the way forward. Med J Aust 2011; 194:360-3. [PMID: 21470087 DOI: 10.5694/j.1326-5377.2011.tb03007.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2010] [Accepted: 12/22/2010] [Indexed: 11/17/2022]
Abstract
Australia is developing a national performance framework aimed at measuring health outcomes across the health system. Clinical registries provide a clinically credible means of monitoring health care processes and outcomes, yet only five Australian registries currently have national coverage. At a national level, clinical registry development should be prioritised to target conditions or procedures that are suspected of being associated with large variations in processes or outcomes of care and that impact significantly on health care costs and patient morbidity. Registries should also aim to capture information across care interfaces and to monitor the medium and long-term safety and effectiveness of specific devices, procedures and drugs.
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Affiliation(s)
- Sue M Evans
- NHMRC Centre of Research Excellence in Patient Safety, Monash University, Melbourne, VIC, Australia.
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16
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Lin YJ, Po HL. Use of Oral Anticoagulant for Secondary Prevention of Stroke in Very Elderly Patients With Atrial Fibrillation: An Observational Study. INT J GERONTOL 2011. [DOI: 10.1016/j.ijge.2011.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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17
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Grau AJ, Eicke M, Biegler MK, Faldum A, Bamberg C, Haass A, Hardt R, Hufschmidt A, Lowitzsch K, Marx J, Schmitt E, Schoenemann H, von Arnim W, Weiss H, Dienlin S. Quality Monitoring of Acute Stroke Care in Rhineland-Palatinate, Germany, 2001–2006. Stroke 2010; 41:1495-500. [DOI: 10.1161/strokeaha.110.582239] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Quality monitoring projects are useful tools to improve the quality and to assess temporal trends of stroke care in larger populations.
Methods—
In Rhineland-Palatinate, Germany, a statewide, hospital-based, acute stroke care quality monitoring project was started in 2001. Initially, participation was mandatory for all hospitals with dedicated stroke units and from 2006 onward was mandatory for all hospitals. Quality monitoring included a structured data assessment and quality indicators for procedural measures.
Results—
Between 2001 and 2006, the numbers of patients registered annually (N=6389 vs N=10 610), admission <3 hours after stroke onset (28.2% vs 34.6%), admission via emergency medical systems (38.1% vs 50.3%), and treatment in stroke units (44.3% vs 59.5%) increased significantly (
P
<0.0001, respectively). In ischemic stroke, use of thrombolytic therapy increased (for patients admitted <3 hours after onset, 6.5% vs 14.1%), whereas therapy with high-dose heparin declined (24.5% vs 6.0%,
P
<0.0001). Several quality indicators (performance of neuroimaging and Doppler/duplex sonography, neuroimaging <3 hours after admission) showed stable results at a high level; more patients received echocardiography (62.2% vs 74.0%), but fewer patients were rapidly examined by extracranial Doppler/duplex sonography (68.7% vs 62.8%,
P
<0.0001). Diagnosis and treatment of hypertension and hyperlipidemia, use of aspirin and combined aspirin/dipyridamole, and diagnosis of atrial fibrillation increased (
P
<0.0001, respectively). Use of oral anticoagulation remained stable at ≈38% of patients with cardioembolism.
Conclusions—
Although these results reflect high standards of acute stroke care and improvements regarding early admission, thrombolytic therapy, and several secondary preventive measures, there is still the potential for further improvement regarding thrombolysis, use of oral anticoagulation and statins, and admission to stroke units, for example.
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Affiliation(s)
- Armin J. Grau
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Martin Eicke
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Marcel K. Biegler
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Andreas Faldum
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Christian Bamberg
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Anton Haass
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Roland Hardt
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Andreas Hufschmidt
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Klaus Lowitzsch
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Jürgen Marx
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Eberhard Schmitt
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Hartmut Schoenemann
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Wolf von Arnim
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Hagen Weiss
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
| | - Sieghard Dienlin
- From the Department of Neurology (A.J.G., K.L.), Klinikum Ludwigshafen, Ludwigshafen am Rhein; Department of Neurology (M.E., W.v.A.), Klinikum Idar-Oberstein, Idar-Oberstein, Germany; SQMed GmbH, Mainz (M.K.B., S.D.); Institute of Medical Biostatistics, Epidemiology and Informatics (A.F.), University Medical Center, Mainz; Department of Neurology (C.B.), Rhein-Mosel Fachklinik Andernach, Andernach, Germany; Department of Neurology (A. Haass), University of Homburg, Homburg; Catholic Hospital/St
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Sloma A, Backlund LG, Strender LE, Skånér Y. Knowledge of stroke risk factors among primary care patients with previous stroke or TIA: a questionnaire study. BMC FAMILY PRACTICE 2010; 11:47. [PMID: 20550690 PMCID: PMC2894756 DOI: 10.1186/1471-2296-11-47] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Accepted: 06/15/2010] [Indexed: 11/30/2022]
Abstract
Background Survivers of stroke or transient ischaemic attacks (TIA) are at risk of new vascular events. Our objective was to study primary health care patients with stroke/TIA regarding their knowledge about risk factors for having a new event of stroke/TIA, possible associations between patient characteristics and patients' knowledge about risk factors, and patients' knowledge about their preventive treatment for stroke/TIA. Methods A questionnaire was distributed to 240 patients with stroke/TIA diagnoses, and 182 patients (76%) responded. We asked 13 questions about diseases/conditions and lifestyle factors known to be risk factors and four questions regarding other diseases/conditions ("distractors"). The patients were also asked whether they considered each disease/condition to be one of their own. Additional questions concerned the patients' social and functional status and their drug use. The t-test was used for continuous variables, chi-square test for categorical variables, and a regression model with variables influencing patient knowledge was created. Results Hypertension, hyperlipidemia and smoking were identified as risk factors by nearly 90% of patients, and atrial fibrillation and diabetes by less than 50%. Few patients considered the distractors as stroke/TIA risk factors (3-6%). Patients with a family history of cardiovascular disease, and patients diagnosed with carotid stenosis, atrial fibrillation or diabetes, knew these were stroke/TIA risk factors to a greater extent than patients without these conditions. Atrial fibrillation or a family history of cardiovascular disease was associated with better knowledge about risk factors, and higher age, cerebral haemorrhage and living alone with poorer knowledge. Only 56% of those taking anticoagulant drugs considered this as intended for prevention, while 48% of those taking platelet aggregation inhibitors thought this was for prevention. Conclusions Knowledge about hypertension, hyperlipidemia and smoking as risk factors was good, and patients who suffered from atrial fibrillation or carotid stenosis seemed to be well informed about these conditions as risk factors. However, the knowledge level was low regarding diabetes as a risk factor and regarding the use of anticoagulants and platelet aggregation inhibitors for stroke/TIA prevention. Better teaching strategies for stroke/TIA patients should be developed, with special attention focused on diabetic patients.
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Affiliation(s)
- Andrzej Sloma
- Centre for Family and Community Medicine, Karolinska Institutet, Alfred Nobels allé 12, SE-141 83 Huddinge, Sweden
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19
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Ghatnekar O, Glader EL. The effect of atrial fibrillation on stroke-related inpatient costs in Sweden: a 3-year analysis of registry incidence data from 2001. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2008; 11:862-868. [PMID: 18489491 DOI: 10.1111/j.1524-4733.2008.00359.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Atrial fibrillation (AF) is an important risk factor for stroke. It is prevalent in approximately one-fourth of stroke patients, and predictive of worse outcomes. This study aimed to analyze the effect of AF on stroke-related inpatient costs among first-ever stroke patients in Sweden. METHODS Hospitalizations and death records were monitored for 3 years in 6611 first-ever stroke patients. For stroke as primary diagnosis, inpatient costs were calculated on the basis of length of stay at different wards. For stroke as secondary diagnosis, costs were based on diagnosis-related groups. RESULTS Patients with AF (24% of all patients) were older (80 years vs. 73 years), had a higher prevalence of hypertension (49% vs. 41%) and/or diabetes (22% vs. 19%), higher risk of experiencing a restroke, and higher case fatality rate (43% vs. 25%) than patients without AF. The average cost per patient over 3 years was 9004 euros, with no statistically significant difference between AF and non-AF patients. However, a multiple regression analysis showed that the presence of AF resulted in higher costs after considering a number of background factors. Among patients surviving the index event, AF patients had on average 818 euros higher inpatient costs over 3 years than non-AF patients (10,192 euros vs. 9374 euros, P < 0.01). The difference in costs was highest for patients aged <65 years, with a difference of 4412 euros (P < 0.01). CONCLUSION AF-related strokes are associated with higher 3-year inpatient costs than non-AF strokes when controlling for factors such as case fatality rates, other risk factors for stroke, and age.
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Affiliation(s)
- Ola Ghatnekar
- The Swedish Institute for Health Economics, Lund, Sweden.
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20
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Eriksson M, Norrving B, Terént A, Stegmayr B. Functional outcome 3 months after stroke predicts long-term survival. Cerebrovasc Dis 2008; 25:423-9. [PMID: 18349536 DOI: 10.1159/000121343] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Accepted: 11/02/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND When reporting stroke survival and prognostic factors with a possible effect on outcome, the starting point for the observation of a clinical cohort usually is the onset of stroke or the acute admission of a patient. Thus, acute and early mortality inflict prognosis on long-term outcome. In order to give a more robust analysis of long-term survival after the acute period we chose to start our observation with 3-month survivors. METHODS We used data from Riks-Stroke, the Swedish quality register for stroke care, together with survival information from the Swedish population register to explore the influence of disability level 3 months after stroke on long-term survival. The main analysis included 15,959 stroke patients, registered during 2001-2002, who had been independent in primary activities of daily living before stroke, had suffered an ischaemic or a haemorrhagic stroke and reported no previous stroke. RESULTS Impaired functional outcome after stroke was an independent predictor of poor survival. Patients with modified Rankin scale (mRS) grades 3, 4 and 5 had hazard ratios of 1.7, 2.5 and 3.8, respectively, as compared with patients with lower mRS grades. In addition to high mRS, male sex, high age, diabetes, smoking, hypertension therapy at stroke onset, atrial fibrillation and depressed mood were also recognized as significant predictors of poor survival using a multiple Cox regression model. CONCLUSION The influence of disability on survival is stronger than that of several other well-known prognostic factors. This finding indicates that any intervention in the acute phase that may improve functional status at 3 months will also have favourable secondary effects on survival in the long term.
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Affiliation(s)
- Marie Eriksson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
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21
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Martignoni A, Sartori M, Lanzarini L, Negri M, Martino I, Benedicti E, Marchesi E, Bertone G, Tinelli C, Falaschi F. Improved aetiological diagnosis of ischaemic stroke in a Vascular Medicine Unit--the significance of transesophageal echocardiogram. Int J Clin Pract 2008; 62:394-9. [PMID: 18261074 DOI: 10.1111/j.1742-1241.2007.01672.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The TOAST study estimates that 34% of ischaemic strokes are of undetermined aetiology. Improvements in the diagnosis of the pathogenetic mechanism of ischaemic stroke would translate into a better care, in analogy to other fields of vascular and internal medicine. OBJECTIVE To measure the reduction of undetermined aetiology strokes performing a set of additional diagnostic tests. DESIGN Consecutive case series with historical controls. SETTING Internal Medicine Ward with a stroke area (SA) admitting most stroke patients of a large hospital in Italy. SUBJECTS A total of 179 ischaemic stroke patients admitted to SA in 2004-2005 compared with 105 ischaemic stroke patients admitted to the whole department in 2001. INTERVENTION To perform more diagnostic tests, including transesophageal echocardiography (TEE), in the greatest possible number of ischaemic stroke inpatients admitted in SA of the Internal Medicine Department, in the years 2004-2005. RESULTS More diagnostic tests were performed during the study period than in 2001, especially TEE (56% of patients in 2004-2005 vs. 3% of patients in 2001). We observed a significant reduction of undetermined aetiology from 38% in 2001 to 16% in 2004-2005 (p < 0.0001), largely for an increased identification of cases of cardio-embolic mechanism (from 18% to 40%, p = 0.0002). In the years 2004-2005 the fraction of patients on anticoagulant treatment at discharge was 21% vs. 12% in 2001 (p = 0.041). CONCLUSION Performing more tests, particularly TEE, brought improvements in the aetiological diagnosis of stroke, increasing cardio-embolism diagnosis and anticoagulant treatment.
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Affiliation(s)
- A Martignoni
- Department of Internal Medicine, Vascular and Metabolic Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
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22
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Fornari LS, Calderaro D, Nassar IB, Lauretti C, Nakamura L, Bagnatori R, Ageno W, Caramelli B. Misuse of antithrombotic therapy in atrial fibrillation patients: frequent, pervasive and persistent. J Thromb Thrombolysis 2007; 23:65-71. [PMID: 17186395 DOI: 10.1007/s11239-006-9012-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE To assess the use of antithrombotic therapy among atrial fibrillation (AF) patients in a Brazilian University Heart Hospital (InCor). METHODS AND RESULTS In a cross-sectional study we analyzed the charts of all patients treated at InCor in five separate days of 2002 (Phase 1). To assess the impact of admission to a cardiology hospital, a follow-up of the AF patients selected in Phase 1 was carried out after 1 year (Phase 2). The prevalence of AF in the 3,764 assessed charts was 8.0% (301 patients). In Phase 1, antiplatelets were prescribed to 21.2% and anticoagulant therapy (ACT) to 46.5% of AF patients; in Phase 2, to 19.9 and 57.8%, respectively. Thus, 32.2% (Phase 1) and 22.2% (Phase 2) of AF patients were not receiving any antithrombotic drug. Among AF patients with previous ischemic stroke (17.6%), only 49% (Phase 1) and 60.4% (Phase 2) were receiving ACT. As many as 34 and 22.6%, respectively, were not receiving any antithrombotic drug. After follow-up, a new acute embolic event was documented in 5.6% of patients, 17% died. CONCLUSIONS Anticoagulation is underused in AF patients and neither the fact of being treated by cardiologists in a University Hospital, nor the learning time-window of 1 year seemed to improve the antithrombotic care significantly.
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Affiliation(s)
- Luciana S Fornari
- Heart Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil.
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23
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Deplanque D, Leys D, Parnetti L, Schmidt R, Ferro J, de Reuck J, Mas JL, Gallai V. Secondary Prevention of Stroke in Patients with Atrial Fibrillation: Factors Influencing the Prescription of Oral Anticoagulation at Discharge. Cerebrovasc Dis 2006; 21:372-9. [PMID: 16490950 DOI: 10.1159/000091546] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2005] [Accepted: 11/25/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Oral anticoagulation (OAC) is the only treatment that has shown a significant benefit to reduce the risk of recurrence in patients with ischemic stroke and nonvalvular atrial fibrillation (NVAF). However, OAC is still underused, even at discharge from neurological centers. The objective of this study was to identify the reasons underlying the prescription of OAC at discharge after an ischemic stroke in patients with NVAF. METHODS We investigated the reasons why ischemic stroke patients with NVAF were not treated with OAC at discharge from 40 centers located in 5 European countries (Austria, Belgium, France, Italy, and Portugal). RESULTS Of 320 ischemic stroke survivors at discharge, 186 (58.1%) received OAC, while 260 (81.3%) patients were theoretically eligible according to guidelines and the absence of contraindications. There were significant differences between countries and the logistic regression analysis found being already under OAC before stroke, having no leukoaraiosis, having no potential contraindication, being younger than 75 years, being married and suffering from angina pectoris as independent predictors of being discharged under OAC. CONCLUSION This study suggests that besides patient-related factors, the prescription of OAC is also significantly influenced by the social environment and national practices.
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Affiliation(s)
- Dominique Deplanque
- Department of Pharmacology, University of Lille II, Lille, France, and Department of Neurosciences and Mental Health, Hospital Santa Maria, Lisbon, Portugal.
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24
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Indredavik B, Rohweder G, Lydersen S. Frequency and effect of optimal anticoagulation before onset of ischaemic stroke in patients with known atrial fibrillation. J Intern Med 2005; 258:133-44. [PMID: 16018790 DOI: 10.1111/j.1365-2796.2005.01512.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aims of the study were (i) to examine which antithrombotic therapy patients with known atrial fibrillation use at the point of time when they suffer an ischaemic stroke, (ii) to evaluate the effects of optimal antithrombotic treatment on outcome and severity of the stroke. METHODS Patients with known atrial fibrillation before onset of acute ischaemic stroke, and age >60 years were included. Antithrombotic therapy on admission was classified into four groups: no antithrombotic therapy, aspirin, sub-optimal anticoagulation (warfarin and international normalized ratio, INR<2.0) and optimal anticoagulation (warfarin and INR>or=2.0). PRIMARY OUTCOME modified Rankin Scale (mRS) 5 or 6 at day 7 poststroke. SECONDARY OUTCOMES (i) death or discharge to a nursing home, (ii) death, (iii) stroke severity on admission assessed by Scandinavian Stroke Scale. RESULTS A total of 394 patients were included. On admission 109 (28%) patients used no antithrombotic therapy, 169 (43%) aspirin, 52 (13%) warfarin and had an INR<2.0, and 64 (16%) used warfarin and had an INR>or=2.0. The proportion of patients with an mRS 5 or 6 and the corresponding odds ratios were: in the warfarin group with INR<2.0, 16 (31%), OR 3.1 (CI: 1.2-8.0), (P=0.019), in the group with no antithrombotic therapy 29 (27%), 2.5 (1.1-5.9), (P=0.034), and in the aspirin group 41(24%), 2.2 (1.0-5.1) (P=0.054), compared with the warfarin group with INR>or=2.0, where eight (13%) patients had a poor outcome. A significantly higher proportion of patients died or were discharged to a nursing home in the warfarin group with an INR<2.0 (P=0.014), in the aspirin group (P=0.018) and in the no-treatment group (P=0.035), compared with the warfarin group with an INR>or=2.0. No significant differences were found regarding death alone and stroke severity on admission. DISCUSSION Few patients with known atrial fibrillation who suffer an ischaemic stroke receive optimal antithrombotic therapy prior to the onset of stroke. Optimal anticoagulation does not only reduce the risk of ischaemic stroke, but also appears to reduce death and severe dependency as well as the need for nursing home care, if an ischaemic stroke occurs.
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Affiliation(s)
- B Indredavik
- Stroke Unit, Department of Medicine, University Hospital of Trondheim, Trondheim, Norway.
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