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Silva Pinto S, Henriques TS, Teixeira ASC, Monteiro H, Martins C. Appropriateness of prescribing profiles and intake adherence to non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: analysis of a retrospective longitudinal study using real-world data from Northern Portugal (AF-React Study). BMJ Open 2024; 14:e076108. [PMID: 38688672 PMCID: PMC11086444 DOI: 10.1136/bmjopen-2023-076108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 03/04/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES This study aimed to assess the appropriateness of prescribing profiles and intake adherence to non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF). DESIGN Retrospective longitudinal study. SETTING The study was conducted in the Regional Health Administration of Northern Portugal. PARTICIPANTS The authors selected a database of 21 854 patients with prescriptions for NOACs between January 2016 and December 2018 and were classified with AF until December 2018. OUTCOME MEASURES The appropriate dosage of NOAC for patients with AF divided into three categories: contraindicated, inconsistent and consistent, based on the 2020 European Society of Cardiology guidelines for AF. RESULTS Dabigatran had a lower percentage of guideline-consistent doses (n=1657, 50.1%) than other drugs such as rivaroxaban (n=4737, 81.6%), apixaban (n=3830, 78.7%) and edoxaban (n=436, 82.1%). Most patients with an inconsistent dose were prescribed a lower dose than recommended based on their glomerular filtration rate (GFR). Among patients younger than 75 years with GFR >60 mL/min, 59.8% (n=10 028) had an adequate GFR range, while 27.8% (n=7166) of GFR measurements from patients older than 75 years old and 29.4% (n=913) of GFR measurements from patients younger than 75 years with GFR <60 mL/min were within an adequate time range. Adherence to NOACs varied across different drugs, with 59.1% (n=540) adhering to edoxaban, 56.3% (n=5443) to rivaroxaban, 55.3% (n=3143) to dabigatran and 53.3% (n=4211) to apixaban. CONCLUSIONS Dabigatran had the lowest percentage of guideline-consistent doses. Patients younger than 75 years with GFR >60 mL/min had the highest percentage with an adequate GFR range, while other groups who require closer GFR monitoring had lower percentages within an adequate GFR range. Adherence to NOACs differed among different drugs, with greater adherence to treatment with edoxaban and less adherence to apixaban.
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Affiliation(s)
- Susana Silva Pinto
- São Tomé Family Health Unit, Santo Tirso, Portugal
- CINTESIS@RISE, University of Porto, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences, University of Porto, Porto, Portugal
| | - Teresa S Henriques
- CINTESIS@RISE, University of Porto, Porto, Portugal
- CI-IPOP (Health Research Network), Portuguese Oncoloy Institute of Porto, Porto, Portugal
| | - Andreia Sofia Costa Teixeira
- CINTESIS@RISE, University of Porto, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences, University of Porto, Porto, Portugal
- ADiT-LAB, Instituto Politécnico de Viana do Castelo, Viana do Castelo, Portugal
| | - Hugo Monteiro
- Regional Health Administration of Northern Portugal, Ministry of Health, Porto, Portugal
| | - Carlos Martins
- CINTESIS@RISE, University of Porto, Porto, Portugal
- H4A Primary Health Care Research Network, Porto, Portugal
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Svensson MK, Sorio Vilela F, Leósdóttir M, Banefelt J, Lindh M, Dun AR, Norhammar A, Villa G. Effects of lipid-lowering treatment intensity and adherence on cardiovascular outcomes in patients with a recent myocardial infarction: a Swedish register-based study. Ups J Med Sci 2022; 127:8296. [PMID: 35722183 PMCID: PMC9171571 DOI: 10.48101/ujms.v127.8296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 03/03/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Oral lipid-lowering treatment (LLT) is the standard of care for patients with cardiovascular disease (CVD). However, insufficient treatment intensity and poor adherence can lead to suboptimal treatment benefit, rendering patients at increased risk of CVD. AIMS The objective of this study was to evaluate trends in LLT intensity and adherence in Sweden over time, and their association with major adverse cardiovascular events (MACE) after recent myocardial infarction (MI), and also to assess the impact of transition from secondary to primary care on intensity and adherence. METHODS AND RESULTS This retrospective observational cohort study used data from Swedish nationwide patient registers and included patients on LLT after an MI in the years 2010-2016 (n = 50,298; mean age, 68 years; 69% men). LLT intensity was evaluated over time (overall, for 2010-2013 and for 2014-2016) as the proportion of patients prescribed low-, moderate-, and high-intensity LLT. Adherence was assessed as the proportion of days covered. A combined measure of intensity and adherence was also considered. Differences in treatment patterns and MACE were assessed. Initiation of high-intensity LLT increased over the two time periods studied (2010-2013, 32%; 2014-2016, 91%). Adherence varied by LLT intensity and was highest in patients receiving high-intensity LLT (>80%), especially during the first time period. Little change in treatment intensity or the combined measure of intensity and adherence was observed after transition to primary care. There was a significant association between the combined measure of intensity and adherence and MACE reduction (hazard ratio [95% confidence interval] per 10% increase in the combined measure: 0.84 [0.82-0.86]; P < 0.01). CONCLUSION The proportion of post-MI patients with high LLT intensity and adherence has increased in recent years, with little change after transfer from specialist to primary care. The combination of LLT intensity and adherence is important for preventing future cardiovascular events.
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Affiliation(s)
| | | | - Margrét Leósdóttir
- Skåne University Hospital and Department of Clinical Sciences, Lund University, Malmö, Sweden
| | | | - Maria Lindh
- Quantify Research, Hantverkargatan 8, Stockholm, Sweden
| | | | - Anna Norhammar
- Karolinska Institute, Solnavägen 1, Solna, Sweden
- Capio S:t Görans Hospital, Sankt Görans plan 1, Stockholm, Sweden
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Gebreyohannes EA, Mill D, Salter S, Chalmers L, Bereznicki L, Lee K. Strategies for improving guideline adherence of anticoagulants for patients with atrial fibrillation in primary healthcare: A systematic review. Thromb Res 2021; 205:128-136. [PMID: 34333301 DOI: 10.1016/j.thromres.2021.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/06/2021] [Accepted: 07/22/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clinical guidelines on atrial fibrillation management help optimize the use of oral anticoagulants. However, guideline non-adherence is common, particularly in the primary care setting. The primary aim of this systematic review was to identify effective strategies for improving adherence to guideline-directed thromboprophylaxis to patients with atrial fibrillation in the primary care setting. METHODS A search was conducted on 6 electronic databases (Medline, Embase, ScienceDirect, Scopus, the Cumulative Indexing of Nursing and Allied Health Literature, and Web of Science) supplemented by a Google advanced search. Studies aimed at improving oral thromboprophylaxis guideline adherence in patients with atrial fibrillation, in the primary care setting, were included in the study. RESULTS A total of 33 studies were included in this review. Nine studies employed electronic decision support (EDS), of which 4 reported modest improvements in guideline adherence. Five of 6 studies that utilized local guidelines as quality improvement measures reported improvement in guideline adherence. All 5 studies that employed coordinated care and the use of specialist support and 4 of the 5 studies that involved pharmacist-led interventions reported improvements in guideline adherence. Interventions based mainly on feedback from audits were less effective. CONCLUSIONS Multifaceted interventions, especially those incorporating coordinated care and specialist support, pharmacists, or local adaptations to and implementation of national and/or international guidelines appear to be more consistently effective in improving guideline adherence in the primary care setting than interventions based mainly on EDS and feedback from audits.
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Affiliation(s)
| | - Deanna Mill
- Division of Pharmacy, School of Allied Health, University of Western Australia, WA, Australia
| | - Sandra Salter
- Division of Pharmacy, School of Allied Health, University of Western Australia, WA, Australia
| | | | - Luke Bereznicki
- School of Pharmacy and Pharmacology, University of Tasmania, TAS, Australia
| | - Kenneth Lee
- Division of Pharmacy, School of Allied Health, University of Western Australia, WA, Australia
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Piccoliori G, Mahlknecht A, Abuzahra ME, Engl A, Breitenberger V, Vögele A, Montalbano C, Sönnichsen A. Quality improvement in chronic care by self-audit, benchmarking and networking in general practices in South Tyrol, Italy: results from an interventional study. Fam Pract 2021; 38:253-258. [PMID: 33184661 DOI: 10.1093/fampra/cmaa123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Systematic strategies promoting quality of care in general practice are yet under-represented in several European countries. OBJECTIVE This interventional study assessed whether a combined intervention (self-audit, benchmarking, quality circles) improved quality of care in Salzburg, Austria and South Tyrol, Italy. The present publication reports the Italian results. METHODS We developed quality indicators for general practice in a consensus process based on pre-existing quality programmes. The indicators addressed diagnosis and treatment regarding eight common chronic conditions. A quality score comprising 91 indicators was calculated (0-5 points per indicator depending on fulfilment, maximum 455 points). We collected anonymous data from the electronic health records of the participating physicians in 2012, 2013 and 2014. Wilcoxon signed-rank tests were used for pre-post analysis. RESULTS Thirty-six GPs participated in the study. The median quality score increased significantly from 177.0 points at baseline to 272.0 points at the second follow-up (P = 0.000). Improvements concerned process and intermediate outcome indicators particularly between baseline and the first follow-up. CONCLUSION Performance was relatively low at baseline and improved considerably, mainly in the first study period. The intervention investigated in this study can serve as a model for future quality programmes. A customized electronic health record for the implementation of this intervention as well as standardized and consistent documentation by GPs is a prerequisite. Use of a limited set of quality indicators (QIs) and regular QI modification is probably advisable to increase the benefits. Long-term prospective studies should investigate the impact of QI-based interventions on end-result outcomes.
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Affiliation(s)
- Giuliano Piccoliori
- South Tyrolean Academy of General Practice, Bolzano, Italy.,Institute of General Practice, College of Health Care Professions, Bolzano, Italy
| | - Angelika Mahlknecht
- Institute of General Practice, College of Health Care Professions, Bolzano, Italy.,Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Muna E Abuzahra
- Institute for General Medicine and Evidence-Based Health Services Research, Medical University of Graz, Graz, Austria
| | - Adolf Engl
- South Tyrolean Academy of General Practice, Bolzano, Italy.,Institute of General Practice, College of Health Care Professions, Bolzano, Italy
| | - Vera Breitenberger
- Institute of General Practice, College of Health Care Professions, Bolzano, Italy
| | - Anna Vögele
- South Tyrolean Academy of General Practice, Bolzano, Italy
| | | | - Andreas Sönnichsen
- Department of General Practice and Family Medicine, Center of Public Health, Medical University of Vienna, Vienna, Austria
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Shi J, Shi L, Geng J, Liu R, Gong X, Bo X, Chen N, Liu Q, Yang Y, Wang Z. Status of evidence-based chronic diseases prevention implementation in Shanghai, China: A qualitative study. Int J Health Plann Manage 2019; 34:912-925. [PMID: 31368209 DOI: 10.1002/hpm.2863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Given the rapid increase in chronic disease epidemics in developing countries and the lagging research and practice in evidence-based chronic diseases prevention (EBCDP), we evaluated the status of public health practitioners' implementation of EBCDP and its impeding factors in China, as well as made a comparison between China and the developed countries to encourage better utilisation of this new field of science in China. METHODS We interviewed health practitioners and patients from various health institutions in China and conducted a literature review to assess the current status of EBCDP practice in developed countries and identify the contextual driving factors. RESULTS China is in its initial stage of EBCDP practice, as it lacks evidence-based interventions. Moreover, health practitioners' awareness of EBCDP is inadequate. The lack of policy support, especially funding, has restricted the efficiency and quality of EBCDP in terms of its adoption, implementation, and maintenance. Currently, EBCDP practice is limited to the practitioners' spontaneous behaviours. The literature review showed that developed countries practising EBCDP did well in evidence development and awareness; however, much has yet to be explored regarding practitioners' adoption and implementation and the maintenance of evidence-based practice. The impeding factors in developed countries were related to individual (patients and physicians) and organisational factors (such as resources, leaders, and climate). CONCLUSION To promote EBCDP practice in China, more evidence for effective chronic disease prevention programmes is needed, and multiple and flexible measures should be implemented for a successful transition to evidence-based practice.
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Affiliation(s)
- Jianwei Shi
- School of Public Health, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Yangpu Hospital, Tongji University School of Medicine, Shanghai, China
| | - Leiyu Shi
- Department of Health Policy and Management, Primary Care Policy Center, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jinsong Geng
- Department of Medical Informatics, Evidence-based Medical Center, Medical School of Nantong University, Nantong, China
| | - Rui Liu
- Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xin Gong
- School of Medicine, Tongji University, Shanghai, China
| | - Xiaojie Bo
- School of Medicine, Tongji University, Shanghai, China
| | - Ning Chen
- School of Medicine, Tongji University, Shanghai, China
| | - Qian Liu
- School of Economics and Management, Tongji University, Shanghai, China
| | - Yan Yang
- School of Economics and Management, Tongji University, Shanghai, China
| | - Zhaoxin Wang
- School of Public Health, Shanghai Jiaotong University School of Medicine, Shanghai, China.,General Practice Center, Nanhai Hospital, Southern Medical University, Guangzhou, China
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Fang Y, Wang HHX, Liang M, Yeung MS, Leung C, Chan CH, Cheung W, Huang JLW, Huang J, Sit RWS, Wong SYS, Wong MCS. The adoption of hypertension reference framework: An investigation among primary care physicians of Hong Kong. PLoS One 2018; 13:e0205529. [PMID: 30300397 PMCID: PMC6177174 DOI: 10.1371/journal.pone.0205529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 09/26/2018] [Indexed: 01/19/2023] Open
Abstract
Background The Hong Kong Government released a Reference Framework (RF-HT) for Hypertension Care for Adults in Primary Care Settings since 2010. No studies have evaluated its adoption by primary care physicians (PCPs) since its release. Aim We aimed to evaluate the level of PCPs’ adoption of the RF-HT and the potential barriers of its use in family practice. Design and setting A cross-sectional study was conducted by a self-administered validated survey among all PCPs in Hong Kong through various means. Methods We assessed the level of and factors associated with its adoption by multivariate logistic regression modelling. Result A total of 3,857 invitation episodes were sent to 2,297 PCPs in 2014–2015. We received 383 completed questionnaires. The average score of adoption was 3.43 out of 4.00, and 47.5% of PCPs highly adopted RF-HT in their daily consultations. Male practitioners (adjusted odds ratio [aOR] = 0.524, 95% CI = 0.290–0.948, p = 0.033) and PCPs of public sector (aOR = 0.524, 95% CI = 0.292–0.940, p = 0.030) were significantly less likely to adopt the RF-HT. PCPs with higher training completion or being academic fellow are more likely to adopt RF-HT than those who were “nil to basic training completion” (aOR = 0.479, 95% CI = 0.269–0.853, p = 0.012) or “higher trainee” (aOR = 0.302, 95% CI = 0.093–0.979, p = 0.046). Three most-supported suggestions on RF-HT improvement were simplification of RF-HT, provision of pocket version and promoting in patients. Conclusion Among PCP respondents, the adoption level of the RF-HT was high. These findings also highlighted some factors associated with its adoption that could inform targeted interventions for enhancing its use in clinical practice.
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Affiliation(s)
- Yuan Fang
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, Hong Kong Special Administrative Region, China
| | - Harry H. X. Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, People's Republic of China
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Miaoyin Liang
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, Hong Kong Special Administrative Region, China
| | - Ming Sze Yeung
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, Hong Kong Special Administrative Region, China
| | - Colette Leung
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, Hong Kong Special Administrative Region, China
| | - Chun Hei Chan
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, Hong Kong Special Administrative Region, China
| | - Wilson Cheung
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, Hong Kong Special Administrative Region, China
| | - Jason L. W. Huang
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, Hong Kong Special Administrative Region, China
| | - Junjie Huang
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, Hong Kong Special Administrative Region, China
| | - Regina W. S. Sit
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, Hong Kong Special Administrative Region, China
| | - Samuel Y. S. Wong
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, Hong Kong Special Administrative Region, China
| | - Martin C. S. Wong
- School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, Hong Kong Special Administrative Region, China
- * E-mail:
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Mahlknecht A, Abuzahra ME, Piccoliori G, Enthaler N, Engl A, Sönnichsen A. Improving quality of care in general practices by self-audit, benchmarking and quality circles. Wien Klin Wochenschr 2016; 128:706-718. [PMID: 27599700 PMCID: PMC5052301 DOI: 10.1007/s00508-016-1064-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 07/28/2016] [Indexed: 11/27/2022]
Abstract
Guideline adherence of general practitioners (GP) regarding treatment of chronic conditions shows room for improvement. Thus, concepts have to be designed to promote quality of care. The aim of the interventional study “Improvement of Quality by Benchmarking” was to assess whether quality can be improved by self-auditing, benchmarking and quality circles in Salzburg (Austria) and South Tyrol (Italy). In this publication we present the Austrian results. Quality indicators were developed in a consensus process for eight chronic diseases based on pre-existing quality management systems. A quality score consisting of 35 indicators was calculated (0–5 points per indicator depending on fulfilment, maximum 175 points). Data were extracted from the electronic health records of participating practices in 2012, 2013 and 2014. A statistical pre-post analysis was performed using Wilcoxon signed-rank tests. A total of 20 GPs participated in the project. The mean quality score increased from 62.0 at baseline to 84.0 at the second follow-up (p = 0.003). Regarding the individual quality indicators, strong improvements were achieved between baseline and first follow-up, especially in process indicators concerning documentation. Between the first and second follow-up, quality remained in most cases at the same level. The validity of results is limited because of structural and technical problems. Due to the uncontrolled pre-post design we cannot exclude external influences on the results. Nevertheless, the intervention was able to improve measured quality of care. Barriers were detected that should be considered in a possible implementation of quality control programs.
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Affiliation(s)
- Angelika Mahlknecht
- Institut für Allgemein-, Familien- und Präventivmedizin, Paracelsus Medizinische Universität Salzburg, Strubergasse 21, 5020, Salzburg, Austria.
| | - Muna E Abuzahra
- Institut für Allgemeinmedizin und evidenzbasierte Versorgungsforschung, Medizinische Universität Graz, Auenbruggerplatz 2/9, 8036, Graz, Austria.,Institut für Allgemeinmedizin und Familienmedizin, Universität Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Germany
| | - Giuliano Piccoliori
- Südtiroler Akademie für Allgemeinmedizin, Wangergasse 18, 39100, Bolzano, Italy
| | - Nina Enthaler
- Institut für Allgemein-, Familien- und Präventivmedizin, Paracelsus Medizinische Universität Salzburg, Strubergasse 21, 5020, Salzburg, Austria
| | - Adolf Engl
- Südtiroler Akademie für Allgemeinmedizin, Wangergasse 18, 39100, Bolzano, Italy
| | - Andreas Sönnichsen
- Institut für Allgemeinmedizin und Familienmedizin, Universität Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Germany
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YASINZADEH M, POUR SHAFIEE SH, CHARDOLI M, GHAFOURI HB, JAZAYERI SB, RAHIMI-MOVAGHAR V. Overuse of Anticoagulation in Treatment of Atrial Fibrillation Patients in University Hospitals of Tehran. IRANIAN JOURNAL OF PUBLIC HEALTH 2015; 44:593-5. [PMID: 26056682 PMCID: PMC4441976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/10/2015] [Indexed: 10/28/2022]
Affiliation(s)
| | | | - Mojtaba CHARDOLI
- Dept. of Emergency Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Seyed Behzad JAZAYERI
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran,Students Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vafa RAHIMI-MOVAGHAR
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran,Corresponding Author:
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Díez-Manglano J, Gomes-Martín J, Al-Cheikh-Felices P, Pérez SIDI, Díez-Angulo R, Clemente-Sarasa C. Adherence to guidelines and mortality in atrial fibrillation. Int J Cardiol 2014; 176:430-6. [PMID: 25127960 DOI: 10.1016/j.ijcard.2014.07.098] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 06/24/2014] [Accepted: 07/26/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Determining the adherence to ACC/AHA/ESC 2006 guidelines and its influence on the survival of patients with atrial fibrillation. METHODS Prospective observational study of patients discharged during 2007 from an Internal Medicine department with a main or secondary diagnose of atrial fibrillation. The stroke risk was estimated with the CHADS2 score. The follow-up was carried out in outpatient medical office or via telephone. RESULTS We included 259 patients (mean age 80.9 years); 73% of them had a high risk of stroke. Oral anticoagulants were administered to 134 (51.7%), and antiplatelet drugs to 71 (27%) patients. A rate control strategy was chosen for 155 (59.8%) patients and a rhythm control one for 28 (10.8%). In 100 (38.6%) patients, treatment was adherent to the guidelines. Adherence to the guidelines was associated with age (0.95 95%CI 0.92-0.99; p=0.03), contraindication to the use of oral anticoagulants (0.38 95%CI 0.18-0.81; p=0.01) and mitral valve heart disease/valvular prosthesis (2.10 95%CI 1.04-4.25; p=0.04). The median follow-up was 727 days, and 191 patients died. Patients treated according to the guidelines had a higher rate of survival during the first three years (0.47 vs. 0.36; p=0.049). The use of oral anticoagulants was associated with a higher probability of survival over a 5 year period (0.34 vs 0.21; p=0.001) and the rate control strategy during the first year (0.69 vs 0.57; p=0.04). CONCLUSIONS In the real world, the treatment of atrial fibrillation according to the guidelines is associated with improved survival for up to three years during follow-up.
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Affiliation(s)
- Jesús Díez-Manglano
- Internal Medicine Department, Hospital RoyoVillanova, Zaragoza, Spain; Research Group on Comorbidity and Polypathology in Aragón, Aragón Health Sciences Institute, Zaragoza, Spain; Department of Medicine, Dermatology and Psychiatry, University of Zaragoza School of Medicine, Spain.
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Valentinis A, Ivers N, Bhatia S, Meshkat N, Leblanc K, Ha A, Morra D. Atrial fibrillation anticoagulation care in a large urban family medicine practice. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2014; 60:e173-e179. [PMID: 24627401 PMCID: PMC3952782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To determine the proportion of patients with atrial fibrillation (AF) in primary care achieving guideline-concordant stroke prevention treatment based on both the previous (2010) and the updated (2012) Canadian guideline recommendations. DESIGN Retrospective chart review. PARTICIPANTS Primary care patients (N = 204) with AF. The mean age was 71.3 years and 53.4% were women. SETTING Large urban community family practice in Toronto, Ont. MAIN OUTCOME MEASURES Patient demographic characteristics such as sex and age; a list of current cardiac medications including anticoagulants and antiplatelets; the total number of medications; relevant current and past medical history including presence of diabetes, stroke or transient ischemic attack, hypertension, and vascular disease; number of visits to the family physician and cardiologist in the past year and past 5 years, and how many of these were for AF; the number of visits to the emergency department or hospitalizations for AF, congestive heart failure, or stroke; if patients were taking warfarin, how often their international normalized ratios were recorded, and how many times they were in the reference range; CHADS2 (congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, and stroke or transient ischemic attack) score, if recorded; and reason for not taking oral anticoagulants when they should have been, if recorded. RESULTS Among those who had CHADS2 scores of 0, 64 patients (97.0%) were receiving appropriate stroke prevention in AF (SPAF) treatment according to the 2010 guidelines. When the 2012 guidelines were applied, 39 patients (59.1%) were receiving appropriate SPAF treatment (P < .001). For those with CHADS2 scores of 1, 88.4% of patients had appropriate SPAF treatment according to the 2010 guidelines, but only 55.1% were adequately treated according to the 2012 guidelines (P < .001). Of the patients at the highest risk (CHADS2 score > 1), 68.1% were adequately treated with anticoagulation and an additional 8.7% (6 of 69) had documented reasons why they were not taking anticoagulants. CONCLUSION When assessed using the 2012 Canadian Cardiovascular Society AF guidelines, the proportion of patients receiving appropriate SPAF therapy in this primary care setting decreased substantially. All patients with CHADS2 scores of 0 or 1 should be reassessed to ensure that they are receiving optimal stroke prevention treatment.
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Affiliation(s)
- Alissia Valentinis
- Taddle Creek Family Health Team, 790 Bay St, Suite 522, Box 58/59, Toronto, ON M5G 1N8.
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