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Goodman SG, Roy D, Pollack CV, Leblanc K, Kwaku KF, Barnes GD, Bonaca MP, True Hills M, Campello E, Fanikos J, Connors JM, Weitz JI. Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics. Crit Pathw Cardiol 2024; 23:47-57. [PMID: 38381695 DOI: 10.1097/hpc.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by 5 times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a reevaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.
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Affiliation(s)
- Shaun G Goodman
- From the Division of Cardiology, St Michael's Hospital, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
- Canadian VIGOUR Centre and Division of Cardiology, University of Alberta, Edmonton, AB, Canada
| | - Denis Roy
- Department of Medicine and Research Center, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Charles V Pollack
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Kori Leblanc
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Kevin F Kwaku
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Geoffrey D Barnes
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | - Marc P Bonaca
- Division of Cardiology, CPC Clinical Research, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | | | - Elena Campello
- Department of Medicine, General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
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Adusumilli RK, Coca S. Renalism: Avoiding Procedure, More Harm than Good? Interv Cardiol Clin 2023; 12:573-578. [PMID: 37673500 DOI: 10.1016/j.iccl.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Management of patients with chronic kidney disease (CKD) is complex in terms of their disease pathophysiology. Cardiovascular disease is one of the leading causes of death in individuals with CKD. These patients are very prone for developing increase in creatinine usually enough to meet criteria for acute kidney injury spontaneously and after mild insults. The fear of precipitating an acute kidney injury or worsening of CKD (ie, renalism) is preventing current day physicians in providing clinically indicated interventions that have a positive impact on their morbidity and mortality.
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Affiliation(s)
| | - Steven Coca
- Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1243, New York, NY 10029, USA.
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3
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Chen L, McWilliams JM. Chief Residency-More Than Just Teaching and Scheduling-Reply. JAMA Intern Med 2023; 183:1031-1032. [PMID: 37399031 DOI: 10.1001/jamainternmed.2023.2676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Affiliation(s)
- Lucy Chen
- Harvard Medical School, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - J Michael McWilliams
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
- Associate Editor, JAMA Internal Medicine
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Ly DP, Shekelle PG, Song Z. Evidence for Anchoring Bias During Physician Decision-Making. JAMA Intern Med 2023; 183:818-823. [PMID: 37358843 PMCID: PMC10294014 DOI: 10.1001/jamainternmed.2023.2366] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/20/2023] [Indexed: 06/27/2023]
Abstract
Introduction Cognitive biases are hypothesized to influence physician decision-making, but large-scale evidence consistent with their influence is limited. One such bias is anchoring bias, or the focus on a single-often initial-piece of information when making clinical decisions without sufficiently adjusting to later information. Objective To examine whether physicians were less likely to test patients with congestive heart failure (CHF) presenting to the emergency department (ED) with shortness of breath (SOB) for pulmonary embolism (PE) when the patient visit reason section, documented in triage before physicians see the patient, mentioned CHF. Design, Setting, and Participants In this cross-sectional study of 2011 to 2018 national Veterans Affairs data, patients with CHF presenting with SOB in Veterans Affairs EDs were included in the analysis. Analyses were performed from July 2019 to January 2023. Exposure The patient visit reason section, documented in triage before physicians see the patient, mentions CHF. Main Outcomes and Measures The main outcomes were testing for PE (D-dimer, computed tomography scan of the chest with contrast, ventilation/perfusion scan, lower-extremity ultrasonography), time to PE testing (among those tested for PE), B-type natriuretic peptide (BNP) testing, acute PE diagnosed in the ED, and acute PE ultimately diagnosed (within 30 days of ED visit). Results The present sample included 108 019 patients (mean [SD] age, 71.9 [10.8] years; 2.5% female) with CHF presenting with SOB, 4.1% of whom had mention of CHF in the patient visit reason section of the triage documentation. Overall, 13.2% of patients received PE testing, on average within 76 minutes, 71.4% received BNP testing, 0.23% were diagnosed with acute PE in the ED, and 1.1% were ultimately diagnosed with acute PE. In adjusted analyses, mention of CHF was associated with a 4.6 percentage point (pp) reduction (95% CI, -5.7 to -3.5 pp) in PE testing, 15.5 more minutes (95% CI, 5.7-25.3 minutes) to PE testing, and 6.9 pp (95% CI, 4.3-9.4 pp) more BNP testing. Mention of CHF was associated with a 0.15 pp lower (95% CI, -0.23 to -0.08 pp) likelihood of PE diagnosis in the ED, although no significant association between the mention of CHF and ultimately diagnosed PE was observed (0.06 pp difference; 95% CI, -0.23 to 0.36 pp). Conclusions and Relevance In this cross-sectional study among patients with CHF presenting with SOB, physicians were less likely to test for PE when the patient visit reason that was documented before they saw the patient mentioned CHF. Physicians may anchor on such initial information in decision-making, which in this case was associated with delayed workup and diagnosis of PE.
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Affiliation(s)
- Dan P. Ly
- Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Paul G. Shekelle
- Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, California
| | - Zirui Song
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts
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5
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Caddick ZA, Fraundorf SH, Rottman BM, Nokes-Malach TJ. Cognitive perspectives on maintaining physicians' medical expertise: II. Acquiring, maintaining, and updating cognitive skills. Cogn Res Princ Implic 2023; 8:47. [PMID: 37488460 PMCID: PMC10366061 DOI: 10.1186/s41235-023-00497-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/20/2023] [Indexed: 07/26/2023] Open
Abstract
Over the course of training, physicians develop significant knowledge and expertise. We review dual-process theory, the dominant theory in explaining medical decision making: physicians use both heuristics from accumulated experience (System 1) and logical deduction (System 2). We then discuss how the accumulation of System 1 clinical experience can have both positive effects (e.g., quick and accurate pattern recognition) and negative ones (e.g., gaps and biases in knowledge from physicians' idiosyncratic clinical experience). These idiosyncrasies, biases, and knowledge gaps indicate a need for individuals to engage in appropriate training and study to keep these cognitive skills current lest they decline over time. Indeed, we review converging evidence that physicians further out from training tend to perform worse on tests of medical knowledge and provide poorer patient care. This may reflect a variety of factors, such as specialization of a physician's practice, but is likely to stem at least in part from cognitive factors. Acquired knowledge or skills gained may not always be readily accessible to physicians for a number of reasons, including an absence of study, cognitive changes with age, and the presence of other similar knowledge or skills that compete in what is brought to mind. Lastly, we discuss the cognitive challenges of keeping up with standards of care that continuously evolve over time.
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Affiliation(s)
- Zachary A Caddick
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott H Fraundorf
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA.
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Benjamin M Rottman
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothy J Nokes-Malach
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
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Rottman BM, Caddick ZA, Nokes-Malach TJ, Fraundorf SH. Cognitive perspectives on maintaining physicians' medical expertise: I. Reimagining Maintenance of Certification to promote lifelong learning. Cogn Res Princ Implic 2023; 8:46. [PMID: 37486508 PMCID: PMC10366070 DOI: 10.1186/s41235-023-00496-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
Until recently, physicians in the USA who were board-certified in a specialty needed to take a summative test every 6-10 years. However, the 24 Member Boards of the American Board of Medical Specialties are in the process of switching toward much more frequent assessments, which we refer to as longitudinal assessment. The goal of longitudinal assessments is to provide formative feedback to physicians to help them learn content they do not know as well as serve an evaluation for board certification. We present five articles collectively covering the science behind this change, the likely outcomes, and some open questions. This initial article introduces the context behind this change. This article also discusses various forms of lifelong learning opportunities that can help physicians stay current, including longitudinal assessment, and the pros and cons of each.
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Affiliation(s)
- Benjamin M Rottman
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, USA
| | - Zachary A Caddick
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, USA
| | - Timothy J Nokes-Malach
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, USA
| | - Scott H Fraundorf
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA.
- Department of Psychology, University of Pittsburgh, Pittsburgh, USA.
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Bhat A, Karthikeyan S, Chen HHL, Gan GCH, Denniss AR, Tan TC. BARRIERS TO GUIDELINE-DIRECTED ANTICOAGULATION IN PATIENTS WITH ATRIAL FIBRILLATION NEW APPROACHES TO AN OLD PROBLEM. Can J Cardiol 2023; 39:625-636. [PMID: 36716858 DOI: 10.1016/j.cjca.2023.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 01/22/2023] [Accepted: 01/22/2023] [Indexed: 01/29/2023] Open
Abstract
Optimising guideline-directed anticoagulation in atrial fibrillation remains a perennial problem despite strong evidence for improved health outcomes with use of guideline-directed anticoagulation. Efforts to improve uptake have been hampered by barriers found at the level of the physician, patient, disease and choices of therapy. Clinician judgement is often clouded by factors such as therapeutic inertia, aversion to bleeding risk and implicit bias. For patients, negative pre-conceptions of therapy, impact of therapy on day-to-day life and the nocebo effect pose significant barriers. Both groups are impacted by poor education. Utility of a single pronged approach directed towards clinicians or patients have demonstrated variable success, with the highest impact appreciated in studies employing shared decision models. Further, there is emerging evidence for use of integrated models of care, which have shown improved efficacy in improving patient outcomes, as well as use of digital platforms such as mobile app-based interventions, which can be of aid to the clinician in improving patient adherence to anticoagulation with translated improved outcomes in clinical trials. Our narrative review article aims to investigate the physician and health system, patient, as well as drug therapy and disease barriers to uptake of guideline-directed anticoagulation in treatment of non-valvular atrial fibrillation.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia.
| | - Sowmiya Karthikeyan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia
| | - A Robert Denniss
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW 2145, Australia
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW 2145, Australia
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8
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Wang AZ, Barnett ML, Cohen JL. Changes in Cancer Screening Rates Following a New Cancer Diagnosis in a Primary Care Patient Panel. JAMA Netw Open 2022; 5:e2222131. [PMID: 35838669 PMCID: PMC9287757 DOI: 10.1001/jamanetworkopen.2022.22131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Although screenings for breast and colorectal cancer are widely recommended, patient screening rates vary greatly and remain below public health targets, and primary care physicians' (PCPs') counseling and referrals play critical roles in patients' use of cancer screenings. Recent adverse events may influence PCPs' decision-making, but it remains unknown whether cancer screening rates of PCPs' patients change after PCPs are exposed to new cancer diagnoses. OBJECTIVE To investigate whether PCPs' exposures to patients with new diagnoses of breast or colorectal cancer were associated with changes in screening rates for other patients subsequently visiting the affected PCPs. DESIGN, SETTING, AND PARTICIPANTS This cohort study used stacked difference-in-differences analyses of all-payer claims data for New Hampshire and Maine in 2009 to 2015. Participants were PCPs caring for patients. Data analysis was performed from June 2020 to May 2022. EXPOSURES New diagnosis of a PCP's patient with breast cancer or colorectal cancer. MAIN OUTCOMES AND MEASURES Patients' breast and colorectal cancer screening rates within 1 year of a PCP visit. RESULTS The sample included 3158 PCPs (1819 male PCPs [57.6%]) caring for 1 920 189 patients (1 073 408 female patients [55.9%]; mean [SD] age, 41.0 [21.9] years) aged 18 to 64 years. During the study period, 898 PCPs had a patient with a new diagnosis of breast cancer and 370 PCPs had a patient with a new diagnosis of colorectal cancer. In the preexposure period, 68 837 female patients (37.3% of those visiting a PCP) underwent breast cancer screening within 1 year of the visit, and 13 137 patients (10.1% of those visiting a PCP) underwent colorectal cancer screening within 1 year of the visit. For both cancer types, after exposure to a new cancer diagnosis, PCPs' cancer screening rates displayed a rapid, sustained increase. Breast cancer screening rates increased by 4.5 percentage points (95% CI, 3.0-6.1 percentage points; P < .001). Colorectal cancer screening rates increased by 1.3 percentage points (95% CI, 0.3-2.2 percentage points; P = .01). Observed breast cancer screening increases were higher for male PCPs than for female PCPs (3.1 percentage points; 95% CI, 0.4-5.8 percentage points; P = .03). CONCLUSIONS AND RELEVANCE This study found significant, sustained increases in cancer screening rates for patients visiting PCPs recently exposed to new breast and colorectal cancer diagnoses. These findings suggest that PCPs may update practice patterns on the basis of recent patient diagnoses. Future work should assess whether salient cues to PCPs about patient diagnoses when clinically appropriate can improve screening practices.
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Affiliation(s)
- Annabel Z. Wang
- Harvard Medical School, Harvard University, Cambridge, Massachusetts
| | - Michael L. Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Farinha JM, Jones ID, Lip GYH. Optimizing adherence and persistence to non-vitamin K antagonist oral anticoagulant therapy in atrial fibrillation. Eur Heart J Suppl 2022; 24:A42-A55. [PMID: 35185408 PMCID: PMC8850710 DOI: 10.1093/eurheartj/suab152] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke, which can be prevented by the use of oral anticoagulation. Although non-vitamin K antagonist oral anticoagulants (NOACs) have become the first choice for stroke prevention in the majority of patients with non-valvular AF, adherence and persistence to these medications remain suboptimal, which may translate into poor health outcomes and increased healthcare costs. Factors influencing adherence and persistence have been suggested to be patient-related, physician-related, and healthcare system-related. In this review, we discuss factors influencing patient adherence and persistence to NOACs and possible problem solving strategies, especially involving an integrated care management, aiming for the improvement in patient outcomes and treatment satisfaction.
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Affiliation(s)
- José Maria Farinha
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Ian D Jones
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- School of Nursing and Allied Health, Liverpool John Moores University, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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10
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Abstract
[Figure: see text].
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Affiliation(s)
- Manasvini Singh
- College of Social and Behavioral Sciences, University of Massachusetts, Amherst, MA, USA
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11
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Ly DP. The Influence of the Availability Heuristic on Physicians in the Emergency Department. Ann Emerg Med 2021; 78:650-657. [PMID: 34373141 DOI: 10.1016/j.annemergmed.2021.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/15/2021] [Accepted: 06/14/2021] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE Heuristics, or rules of thumb, are hypothesized to influence the care physicians deliver. One such heuristic is the availability heuristic, under which assessments of an event's likelihood are affected by how easily the event comes to mind. We examined whether the availability heuristic influences physician testing in a common, high-risk clinical scenario: assessing patients with shortness of breath for the risk of pulmonary embolism. METHODS We performed an event study from 2011 to 2018 of emergency physicians caring for patients presenting with shortness of breath to 104 Veterans Affairs (VA) hospitals. Our measures were physician rates of pulmonary embolism testing (D-dimer and/or computed tomography scan) for subsequent patients after having a patient visit with a pulmonary embolism discharge diagnosis, hypothesizing that physician rates of pulmonary embolism testing would increase after having a recent patient visit with a pulmonary embolism diagnosis due to the availability heuristic. RESULTS The sample included 7,370 emergency physicians who had 416,720 patient visits for shortness of breath. The mean rate of pulmonary embolism testing was 9.0%. For physicians who had a recent patient visit with a pulmonary embolism diagnosis, their rate of pulmonary embolism testing for subsequent patients increased by 1.4 percentage points (95% confidence interval 0.42 to 2.34) in the 10 days after, which is approximately 15% relative to the mean rate of pulmonary embolism testing. We failed to find statistically significant changes in rates of pulmonary embolism testing in the subsequent 50 days following these first 10 days. CONCLUSION After having a recent patient visit with a pulmonary embolism diagnosis, physicians increase their rates of pulmonary embolism testing for subsequent patients, but this increase does not persist. These results provide large-scale evidence that the availability heuristic may play a role in complex testing decisions.
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Affiliation(s)
- Dan P Ly
- VA Greater Los Angeles Healthcare System, Los Angeles, CA; VA Boston Healthcare System, Boston, MA; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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12
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Bhat A, Khanna S, Chen HHL, Gupta A, Gan GCH, Denniss AR, MacIntyre CR, Tan TC. Integrated Care in Atrial Fibrillation: A Road Map to the Future. Circ Cardiovasc Qual Outcomes 2021; 14:e007411. [PMID: 33663224 PMCID: PMC7982130 DOI: 10.1161/circoutcomes.120.007411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice with an epidemiological coupling appreciated with advancing age, cardiometabolic risk factors, and structural heart disease. This has resulted in a significant public health burden over the years, evident through increasing rates of hospitalization and AF-related clinical encounters. The resultant gap in health care outcomes is largely twinned with suboptimal rates of anticoagulation prescription and adherence, deficits in symptom identification and management, and insufficient comorbid cardiovascular risk factor investigation and modification. In view of these shortfalls in care, the establishment of integrated chronic care models serves as a road map to best clinical practice. The expansion of integrated chronic care programs, which include multidisciplinary team care, nurse-led AF clinics, and use of telemedicine, are expected to improve AF-related outcomes in the coming years. This review will delve into current gaps in AF care and the role of integrated chronic care models in bridging fragmentations in its management.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.).,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (A.B., G.C.H.G., C.R.M.)
| | - Shaun Khanna
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.)
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.)
| | - Arnav Gupta
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.)
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.).,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (A.B., G.C.H.G., C.R.M.)
| | - A Robert Denniss
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.).,Department of Cardiology, Westmead Hospital, Australia (A.R.D., T.C.T.)
| | - C Raina MacIntyre
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (A.B., G.C.H.G., C.R.M.)
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Australia (A.B., S.K., H.H.L.C., A.G., G.C.H.G., A.R.D., T.C.T.).,Department of Cardiology, Westmead Hospital, Australia (A.R.D., T.C.T.)
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13
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Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia in the general population. In western countries with aging populations, atrial fibrillation poses a significant health concern, as it is associated with a high risk of thromboembolism, stroke, congestive heart failure, and myocardial infarction. Thrombi are generated in the left atrial appendage, and subsequent embolism into the cerebral circulation is a major cause of ischemic stroke. Therefore, patients have a lifetime risk of stroke, and those at high risk, defined as a CHA2DS2-VASc2 (congestive heart failure, hypertension, age >75 years, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease, age 65-74 yrs, sex category) ≥2, are usually placed on oral anticoagulants. Unfortunately, long-term anticoagulation poses bleeding risks, of which intracranial hemorrhage (ICH) is the most feared and deadly complication.In patients who survive an ICH, the question of oral anticoagulation resumption arises. It is a therapeutic dilemma in which clinicians must decide how to manage the risk of thromboembolism versus recurrent hemorrhage. Although there is a substantial amount of retrospective data on the topic of resumption of anticoagulation, there are, at this time, no randomized controlled trials addressing the issue. We therefore sought to address ICH risk and management, summarize high quality existing evidence on restarting oral anticoagulation, and suggest an approach to clinical decision-making.
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14
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Minué-Lorenzo S, Fernández-Aguilar C, Martín-Martín JJ, Fernández-Ajuria A. [Effect of the use of heuristics on diagnostic error in Primary Care: Scoping review]. Aten Primaria 2020; 52:159-175. [PMID: 30711287 PMCID: PMC7063144 DOI: 10.1016/j.aprim.2018.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/12/2018] [Accepted: 11/03/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To assess the use of representativeness, availability, overconfidence, anchoring and adjustment heuristics in clinical practice, specifically in Primary Care setting. DESIGN Panoramic review (scope review). DATA SOURCES OvidMedline, Scopus, PsycoINFO, Cochrane Library and PubMed databases. Each one of the selected studies was reviewed applying TIDIER criteria (Template for Description of the Intervention and Replication) to facilitate their understanding and replicability. SELECTION OF STUDIES A total of 48 studies were selected that analyzed availability heuristics (26), anchoring and adjustment (9), overconfidence (9) and representativeness (8). RESULTS From the 48 studies selected, 26 analyzed availability heuristics, 9 anchoring and adjustment, 9 overconfidence; and 8 representativeness. The study population included physicians (35.4%), patients (27%), trainees (20.8%), nurses (14.5%) and students (14.5%). The studies conducted in clinical practice setting were 17 (35.4%). In 33 of the 48 studies (68,7%) it was observed heuristic use in the population studied. Heuristics use on diagnostic process was found in 27 studies (54.1%); 5 of them (18%) were carried out in clinical practice setting. Of the 48 studies, 6 (12,5%) were performed in Primary Care, 3 of which studied diagnostic process: only one of them analyzed the use of heuristics in clinical practice setting, without demonstrating bias as consequence of the use of heuristic. CONCLUSION The evidence about heuristic use in diagnostic process on clinical practice setting is limited, especially in Primary Care.
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Affiliation(s)
- Sergio Minué-Lorenzo
- Integrated Health Services based on Primary Health Care WHO Collaborating Centre. Escuela Andaluza de Salud Pública, Granada, España.
| | - Carmen Fernández-Aguilar
- Integrated Health Services based on Primary Health Care WHO Collaborating Centre. Escuela Andaluza de Salud Pública, Granada, España
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McNamara K, O'Donoghue K. The perceived effect of serious adverse perinatal events on clinical practice. Can it be objectively measured? Eur J Obstet Gynecol Reprod Biol 2019; 240:267-272. [PMID: 31344666 DOI: 10.1016/j.ejogrb.2019.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/20/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Obstetrics involves a high degree of clinical risk. While serious adverse events resulting in substantial maternal or neonatal morbidity or mortality are relatively rare it has been shown that exposure to a such an event can have a predominantly negative personal and professional impact on the healthcare professionals who are involved. There is little in the published literature to show an objective change in clinical practice as a result of an adverse event. The aim of this study was to identify if it was feasible to design a study that could objectively demonstrate if a change in labour ward clinical activity occurred in the 28 days following a serious adverse perinatal event. If this proved possible, the second aim was to identify if these changes could be attributed to the preceding adverse event. STUDY DESIGN This study was conducted in a large tertiary teaching hospital in Ireland. This was a retrospective observational study conducted using data from a 25-month period from August 2013 to September 2015. Six of the most serious adverse perinatal events that occurred over that time period were identified from the hospital's clinical risk register. Various outcome variables in the form of aggregate data on all deliveries that occurred in CUMH for the 28 days preceding and succeeding the events were collected by the lead author. The medical records for each severe adverse perinatal event were reviewed and the clinical case details recorded. Based on these clinical details individual hypotheses were created for each event. Data was analysed using IBM-SPSS. RESULTS Aggregate data relating to 6180 deliveries was collected and analysed. Data analysis revealed some statistically significant changes in clinical activity in the 28 days following five of the six adverse events. These changes in clinical activity did not, however, always match what we had expected from our original hypotheses. CONCLUSION This novel study aimed to identify if it was possible to objectively demonstrate this practice change. We identified some statistically significant changes in clinical activity in the 28 days following five of the six adverse events but were unable to definitively conclude if the change in activity was a direct result of each event.
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Affiliation(s)
- Karen McNamara
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Ireland.
| | - Keelin O'Donoghue
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Ireland; The Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Ireland
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16
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Jiyad Z, Akhras V. Incidence of melanoma and outcomes of longitudinal melanonychia in a cohort of cases referred to a London dermatology department. Br J Dermatol 2019; 181:204-205. [PMID: 30609019 DOI: 10.1111/bjd.17607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Z Jiyad
- Department of Dermatology, St George's Hospital, Blackshaw Road, London, SW17 0QT, U.K
| | - V Akhras
- Department of Dermatology, St George's Hospital, Blackshaw Road, London, SW17 0QT, U.K
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17
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Najafzadeh M, Schneeweiss S, Choudhry NK, Avorn J, Gagne JJ. General Population vs. Patient Preferences in Anticoagulant Therapy: A Discrete Choice Experiment. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2018; 12:235-246. [DOI: 10.1007/s40271-018-0329-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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18
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Krumme AA, Glynn RJ, Schneeweiss S, Choudhry NK, Tong AY, Gagne JJ. Defining Exposure in Observational Studies Comparing Outcomes of Treatment Discontinuation. Circ Cardiovasc Qual Outcomes 2018; 11:e004684. [DOI: 10.1161/circoutcomes.118.004684] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/21/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Alexis A. Krumme
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
- Harvard TH Chan School of Public Health, Boston, MA (A.A.K., S.S., J.J.G.)
| | - Robert J. Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
- Harvard TH Chan School of Public Health, Boston, MA (A.A.K., S.S., J.J.G.)
| | - Niteesh K. Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
| | - Angela Y. Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
| | - Joshua J. Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
- Harvard TH Chan School of Public Health, Boston, MA (A.A.K., S.S., J.J.G.)
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Jones NR, Hobbs FR, Taylor CJ. Atrial fibrillation and stroke prevention: where we are and where we should be. Br J Gen Pract 2018; 68:260-261. [PMID: 29853572 PMCID: PMC6001982 DOI: 10.3399/bjgp18x696257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Nicholas R Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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20
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Cook B, Creedon T, Wang Y, Lu C, Carson N, Jules P, Lee E, Alegría M. Examining racial/ethnic differences in patterns of benzodiazepine prescription and misuse. Drug Alcohol Depend 2018; 187:29-34. [PMID: 29626743 PMCID: PMC5959774 DOI: 10.1016/j.drugalcdep.2018.02.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 02/09/2018] [Accepted: 02/13/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Benzodiazepines (BZDs) are widely prescribed during psychiatric treatment. Unfortunately, their misuse has led to recent surges in overdose emergency visits and drug-related deaths. METHODS Electronic health record data from a large healthcare system were used to describe racial/ethnic, sex, and age differences in BZD use and dependence. Among patients with a BZD prescription, we assessed differences in the likelihood of subsequently receiving a BZD dependence diagnosis, number of BZD prescriptions, receiving only one BZD prescription, and receiving 18 or more BZD prescriptions. We also estimated multivariate hazard models and generalized linear models, assessing racial/ethnic differences after adjustment for covariates. RESULTS In both unadjusted and adjusted analyses, Whites were more likely than Blacks, Hispanics, and Asians to have a BZD dependence diagnosis and to receive a BZD prescription. Racial/ethnic minority groups received fewer BZD prescriptions, were more likely to have only one BZD prescription, and were less likely to have 18 or more BZD prescriptions. We identified greater BZD misuse among older patients but no sex differences. CONCLUSIONS Findings from this study add to the emerging evidence of high relative rates of prescription drug abuse among Whites. There is a concern, given their greater likelihood of having only one BZD prescription, that Blacks, Hispanics, and Asians may be discontinuing BZDs before their clinical need is resolved. Research is needed on provider readiness to offer racial/ethnic minorities BZDs when indicated, patient preferences for BZDs, and whether lower prescription rates among racial/ethnic minorities offer protection against the progression from prescription to addiction.
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Affiliation(s)
- Benjamin Cook
- Health Equity Research Lab, Cambridge Health Alliance and Harvard Medical School, 1035 Cambridge St., Cambridge, MA, 02141, USA.
| | - Timothy Creedon
- Health Equity Research Lab, Cambridge Health Alliance and Harvard Medical School, 1035 Cambridge St., Cambridge, MA, 02141, USA
| | - Ye Wang
- Department of Psychiatry, Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA
| | - Chunling Lu
- Harvard School of Public Health 677 Huntington Ave., Boston, MA 02115, USA
| | - Nicholas Carson
- Health Equity Research Lab, Cambridge Health Alliance and Harvard Medical School, 1035 Cambridge St., Cambridge, MA, 02141, USA
| | - Piter Jules
- Health Equity Research Lab, Cambridge Health Alliance and Harvard Medical School, 1035 Cambridge St., Cambridge, MA, 02141, USA
| | - Esther Lee
- Health Equity Research Lab, Cambridge Health Alliance and Harvard Medical School, 1035 Cambridge St., Cambridge, MA, 02141, USA
| | - Margarita Alegría
- Department of Psychiatry, Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA
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Cloutier JM, Khoo C, Hiebert B, Wassef A, Seifer CM. Physician decision making in anticoagulating atrial fibrillation: a prospective survey of a physician notification system for atrial fibrillation detected on cardiac implantable electronic devices of patients at increased risk of stroke. Ther Adv Cardiovasc Dis 2018; 12:113-122. [PMID: 29528778 PMCID: PMC5941669 DOI: 10.1177/1753944717749739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/14/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The objectives of this study were to evaluate the effectiveness of a physician notification system for atrial fibrillation (AF) detected on cardiac devices, and to assess predictors of anticoagulation in patients with device-detected AF. METHODS In 2013, a physician notification system for AF detected on a patient's CIED [including pacemakers, implantable cardioverter defibrillators (ICD) or cardiac resynchronization therapy (CRT) devices] was implemented, with a recommendation to consider oral anticoagulation in high-risk patients. We prospectively investigated the effectiveness of this system, and evaluated both patient and physician predictors of anticoagulation, as well as factors influencing physician decision making in prescribing anticoagulation. Both uni- and multivariable analysis as well as descriptive statistics were used in the analysis. RESULTS We identified 177 patients with device-detected AF, 126 with a CHADS2 ⩾2. Only 41% were prescribed anticoagulation at any point within 12 months. On multivariable analysis, stroke risk as predicted by CHADS2 was not a predictor of anticoagulation. ASA use predicted a lower rate of anticoagulation (OR 0.39, 95% CI 0.16-0.97, p = 0.04); physicians in practice for <20 years were more likely to prescribe anticoagulation (OR 3.39, 95% CI 1.28-8.93, p = 0.01); and physicians who believed both cardiologist and family doctor should be involved in managing anticoagulation were more likely to prescribe anticoagulation (OR 3.28, 95% CI 1.02-10.5, p = 0.05). CONCLUSIONS Patients on aspirin were less likely to be anticoagulated. Physicians in practice for <20 years and who believed that both the general practitioner and cardiologist should be involved in managing anticoagulants were more likely to prescribe anticoagulation.
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Affiliation(s)
- Justin M. Cloutier
- Section of Cardiology, University of Manitoba, Winnipeg, MB, Canada Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, MB, Canada
| | - Clarence Khoo
- Section of Cardiology, University of Manitoba, Winnipeg, MB, Canada Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, MB, Canada
| | - Brett Hiebert
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, MB, Canada
| | - Anthony Wassef
- Division of Cardiology, University of Toronto, Toronto, ON, Canada
| | - Colette M. Seifer
- WRHA Cardiac Sciences Program, Section of Cardiology, University of Manitoba and Cardiac Sciences Program, St. Boniface Hospital, Y3019 St Boniface Hospital, Winnipeg, Manitoba, R2H 2A6, Canada
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Peek N, Rodrigues PP. Three controversies in health data science. INTERNATIONAL JOURNAL OF DATA SCIENCE AND ANALYTICS 2018; 6:261-269. [PMID: 30957010 PMCID: PMC6413491 DOI: 10.1007/s41060-018-0109-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 02/24/2018] [Indexed: 12/18/2022]
Abstract
The routine operation of modern healthcare systems produces a wealth of data in electronic health records, administrative databases, clinical registries, and other clinical systems. It is widely acknowledged that there is great potential for utilising these routine data for health research to derive new knowledge about health, disease, and treatments. However, the reuse of routine healthcare data for research is not beyond debate. In this paper, we discuss three issues that have stirred considerable controversy among health data scientists. First, we discuss van der Lei's 1st Law of Medical Informatics, which states that data shall be used only for the purpose for which they were collected. Then, we discuss to which extent routine data sources and innovations in analytical methods alleviate the need to conduct randomised clinical trials. Finally, we address questions of governance, privacy, and trust when routine health data are made available for research. While we don't think that there is a definite "right answer" for any of these issues, we argue that data scientists should be aware of the arguments for different viewpoints, respect their validity, and contribute constructively to the debate. The three controversies discussed in this paper relate to core challenges for research with health data and define an essential research agenda for the health data science community.
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Affiliation(s)
- Niels Peek
- Division of Informatics, Imaging, and Data Science, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Pedro Pereira Rodrigues
- Centre for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
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Cowie MR, Zakeri R. Preventing stroke in patients with heart failure: why are patients losing out? BRITISH HEART JOURNAL 2018; 104:1050-1052. [PMID: 29437887 DOI: 10.1136/heartjnl-2017-312862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Martin R Cowie
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Rosita Zakeri
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Cavallari I, Ruff CT, Nordio F, Deenadayalu N, Shi M, Lanz H, Rutman H, Mercuri MF, Antman EM, Braunwald E, Giugliano RP. Clinical events after interruption of anticoagulation in patients with atrial fibrillation: An analysis from the ENGAGE AF-TIMI 48 trial. Int J Cardiol 2018; 257:102-107. [PMID: 29395361 DOI: 10.1016/j.ijcard.2018.01.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 01/09/2018] [Accepted: 01/15/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) who interrupt anticoagulation are at high risk of thromboembolism and death. METHODS AND RESULTS Patients enrolled in the ENGAGE AF-TIMI 48 trial (randomized comparison of edoxaban vs. warfarin) who interrupted study anticoagulant for >3 days were identified. Clinical events (ischemic stroke/systemic embolism, major cardiac and cerebrovascular events [MACCE]) were analyzed from day 4 after interruption until day 34 or study drug resumption. During 2.8 years median follow-up, 13,311 (63%) patients interrupted study drug for >3 days. After excluding those who received open-label anticoagulation during the at-risk window, the population for analysis included 9148 patients. The rates of ischemic stroke/systemic embolism and MACCE post interruption were substantially greater than in patients who never interrupted (15.42 vs. 0.26 and 60.82 vs. 0.36 per 100 patient-years, respectively, padj < .001). Patients who interrupted study drug for an adverse event (44.1% of the cohort), compared to those who interrupted for other reasons, had an increased risk of MACCE (HRadj 2.75; 95% CI 2.02-3.74, p < .0001), but similar rates of ischemic stroke/systemic embolism. Rates of clinical events after interruption of warfarin and edoxaban were similar. CONCLUSION Interruption of study drug was frequent in patients with AF and was associated with a substantial risk of major cardiac and cerebrovascular events over the ensuing 30 days. This risk was particularly high in patients who interrupted as a result of an adverse event; these patients deserve close monitoring and resumption of anticoagulation as soon as it is safe to do so.
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Affiliation(s)
- Ilaria Cavallari
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Department of Cardiovascular Science, Campus Bio-Medico University of Rome, Rome, Italy
| | - Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Francesco Nordio
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Naveen Deenadayalu
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Minggao Shi
- Daiichi Sankyo Pharma Development, Edison, NJ, United States
| | - Hans Lanz
- Daiichi Sankyo Pharma Development, Edison, NJ, United States
| | | | | | - Elliott M Antman
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
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Savarese G, Sartipy U, Friberg L, Dahlström U, Lund LH. Reasons for and consequences of oral anticoagulant underuse in atrial fibrillation with heart failure. Heart 2018; 104:1093-1100. [DOI: 10.1136/heartjnl-2017-312720] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/19/2017] [Accepted: 12/22/2017] [Indexed: 12/15/2022] Open
Abstract
ObjectiveAtrial fibrillation (AF) is common in patients with heart failure (HF), and oral anticoagulants (OAC) are indicated. The aim was to assess prevalence of, predictors of and consequences of OAC non-use.MethodsWe included patients with AF, HF and no previous valve replacement from the Swedish Heart Failure Registry. High and low CHA2DS2-VASc and HAS-BLED scores were defined as above/below median. Multivariable logistic regressions were used to assess the associations between baseline characteristics and OAC use and between CHA2DS2-VASc and HAS-BLED scores and OAC use. Multivariable Cox regressions were used to assess associations between CHA2DS2-VASc and HAS-BLED scores, OAC use and two composite outcomes: all-cause death/stroke and all-cause death/major bleeding.ResultsOf 21 865 patients, only 12 659 (58%) received OAC. Selected predictors of OAC non-use were treatment with platelet inhibitors, less use of HF treatments, paroxysmal AF, history of bleeding, no previous stroke, planned follow-up in primary care, older age, living alone, lower income and variables associated with more severe HF. For each 1-unit increase in CHA2DS2-VASc and HAS-BLED, the ORs (95% CI) of OAC use were 1.24 (1.21–1.27) and 0.32 (0.30–0.33), and the HRs for death/stroke were 1.08 (1.06–1.10) and for death/major bleeding 1.18 (1.15–1.21), respectively. For high versus low CHA2DS2-VASc and HAS-BLED, the ORs of OAC use were 1.23 (1.15–1.32) and 0.20 (0.19–0.21), and the HRs for death/stroke were 1.25 (1.19–1.30) and for death/major bleeding 1.28 (1.21–1.34), respectively.ConclusionsPatients with AF and concomitant HF do not receive OAC on rational grounds. Bleeding risk inappropriately affects decision-making more than stroke risk.
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Cloutier JM, Khoo C, Hiebert B, Wassef A, Seifer CM. Physician decision making in anticoagulating atrial fibrillation: a prospective survey of a physician notification system for atrial fibrillation detected on cardiac implantable electronic devices of patients at increased risk of stroke. Ther Adv Cardiovasc Dis 2018:1753944718749739. [PMID: 29320931 DOI: 10.1177/1753944718749739] [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: 11/16/2022] Open
Abstract
OBJECTIVES The objectives of this study were to evaluate the effectiveness of a physician notification system for atrial fibrillation (AF) detected on cardiac devices, and to assess predictors of anticoagulation in patients with device-detected AF. METHODS In 2013, a physician notification system for AF detected on a patient's CIED [including pacemakers, implantable cardioverter defibrillators (ICD) or cardiac resynchronization therapy (CRT) devices] was implemented, with a recommendation to consider oral anticoagulation in high-risk patients. We prospectively investigated the effectiveness of this system, and evaluated both patient and physician predictors of anticoagulation, as well as factors influencing physician decision making in prescribing anticoagulation. Both uni- and multivariable analysis as well as descriptive statistics were used in the analysis. RESULTS We identified 177 patients with device-detected AF, 126 with a CHADS2 ⩾2. Only 41% were prescribed anticoagulation at any point within 12 months. On multivariable analysis, stroke risk as predicted by CHADS2 was not a predictor of anticoagulation. ASA use predicted a lower rate of anticoagulation (OR 0.39, 95% CI 0.16-0.97, p = 0.04); physicians in practice for <20 years were more likely to prescribe anticoagulation (OR 3.39, 95% CI 1.28-8.93, p = 0.01); and physicians who believed both cardiologist and family doctor should be involved in managing anticoagulation were more likely to prescribe anticoagulation (OR 3.28, 95% CI 1.02-10.5, p = 0.05). CONCLUSIONS Patients on aspirin were less likely to be anticoagulated. Physicians in practice for <20 years and who believed that both the general practitioner and cardiologist should be involved in managing anticoagulants were more likely to prescribe anticoagulation.
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Affiliation(s)
- Justin M Cloutier
- Section of Cardiology, University of Manitoba, Winnipeg, MB, Canada Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, MB, Canada
| | - Clarence Khoo
- Section of Cardiology, University of Manitoba, Winnipeg, MB, Canada Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, MB, Canada
| | - Brett Hiebert
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, MB, Canada
| | - Anthony Wassef
- Division of Cardiology, University of Toronto, Toronto, ON, Canada
| | - Colette M Seifer
- WRHA Cardiac Sciences Program, Section of Cardiology, University of Manitoba and Cardiac Sciences Program, St. Boniface Hospital, Y3019 St Boniface Hospital, Winnipeg, Manitoba, R2H 2A6, Canada
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Jones NR, Hobbs FDR, Taylor CJ. Sous-utilisation de l’anticoagulothérapie dans la fibrillation auriculaire. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2017; 63:e510-e511. [PMID: 29237646 PMCID: PMC5729154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Nicholas R Jones
- Boursier en formation clinique et universitaire au Département Nuffield des sciences de la santé de première ligne à l'Université d'Oxford, en Angleterre
| | - F D Richard Hobbs
- Chef de service au Département Nuffield des sciences de la santé de première ligne à l'Université d'Oxford, en Angleterre
| | - Clare J Taylor
- Chargée d'enseignement clinique au Département Nuffield des sciences de la santé de première ligne à l'Université d'Oxford, en Angleterre.
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28
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Jones NR, Hobbs FDR, Taylor CJ. Underuse of anticoagulation therapy for atrial fibrillation: Are we failing our patients? CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2017; 63:943-944. [PMID: 29237637 PMCID: PMC5729145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Nicholas R Jones
- Academic Clinical Fellow in the Nuffield Department of Primary Care Health Sciences at University of Oxford in England
| | - F D Richard Hobbs
- Head of Department in the Nuffield Department of Primary Care Health Sciences at University of Oxford in England
| | - Clare J Taylor
- Academic Clinical Lecturer in the Nuffield Department of Primary Care Health Sciences at University of Oxford in England.
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Renjen PN, Chaudhari D. Re-initiation of oral-anticoagulants in survivors of hemorrhagic stroke. APOLLO MEDICINE 2017. [DOI: 10.1016/j.apme.2017.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Barrios V, Egocheaga-Cabello M, Gállego-Culleré J, Ignacio-García E, Manzano-Espinosa L, Martín-Martínez A, Mateo-Arranz J, Polo-García J, Vargas-Ortega D. Healthcare resources and needs in anticoagulant therapy for patients with nonvalvular atrial fibrillation. SAMOA Study. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.rceng.2016.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Zheng HJ, Ouyang SK, Zhao Y, Lu K, Luo SX, Xiao H. The use status of anticoagulation drugs for inpatients with nonvalvular atrial fibrillation in Southwest China. Int J Gen Med 2017; 10:69-77. [PMID: 28293117 PMCID: PMC5345993 DOI: 10.2147/ijgm.s128047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Oral anticoagulants (OACs) are effective for the prophylaxis of stroke in patients with atrial fibrillation (AF). This cross-sectional study aimed to investigate the status of anticoagulation treatment for hospitalized AF patients in Southwest China. Methods A total of 4760 hospitalized patients with AF were enrolled from 21 hospitals in Chongqing city from January 1 to December 31, 2013. Results Among the enrolled patients, 3785 were diagnosed with nonvalvular AF. These patients had a mean age of 74.4±10.1 years. The mean CHADS2 score of all subjects was 2.60±1.34, and 80.7% of the patients had CHADS2 ≥2. The use rate of OACs was only 11.5% for patients with a high risk for stroke (CHADS2 ≥2) and was much lower in patients from the second-level hospitals than in patients from the third-level hospitals (5.8% vs. 16.9%, P<0.001). The leading reason for the underuse of OACs in high-risk patients was physician’s nonfeasance. Conclusion This study demonstrated that the underuse of anticoagulation therapy in hospitalized patients with nonvalvular AF was particularly serious in Southwest China, especially in the second-level hospitals. Urgent and effective measures are desperately needed to improve this alarming situation in China.
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Affiliation(s)
- Huan Jie Zheng
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Shu Kun Ouyang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yue Zhao
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Kai Lu
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Su Xin Luo
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Hua Xiao
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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Barrios V, Egocheaga-Cabello MI, Gállego-Culleré J, Ignacio-García E, Manzano-Espinosa L, Martín-Martínez A, Mateo-Arranz J, Polo-García J, Vargas-Ortega D. Healthcare resources and needs in anticoagulant therapy for patients with nonvalvular atrial fibrillation. SAMOA Study. Rev Clin Esp 2017; 217:193-200. [PMID: 28213993 DOI: 10.1016/j.rce.2016.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/19/2016] [Accepted: 12/29/2016] [Indexed: 12/01/2022]
Abstract
INTRODUCTION AND OBJECTIVES To determine, in the various medical specialties, the healthcare process for anticoagulated patients with nonvalvular atrial fibrillation, to determine the available and necessary resources and to identify potential areas of improvement in the care of these patients. METHODS We performed a cross-sectional survey of primary care and specialised physicians involved in the care of anticoagulated patients. The questionnaires referred to the healthcare process, the indication and prescription of anticoagulant therapy and the barriers and deficiencies present for these patients. RESULTS A total of 893 physicians participated in the study, 437 of whom worked in primary care and 456 of whom were specialists (mostly cardiologists). Forty-two percent of the family doctors indicated that they assessed and prescribed anticoagulant therapy, and 66% performed the regular follow-up of these patients. In both healthcare settings, the physicians noted the lack of standardised protocols. There was also a lack of quality control in the treatment. CONCLUSIONS The role of primary care in managing anticoagulated patients has grown compared with previous reports. The responses of the participating physicians suggest marked gaps in the standardisation of the healthcare process and several areas for improvement in these patients' follow-up. The promotion of training in direct-acting anticoagulant drugs remains pivotal.
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Affiliation(s)
- V Barrios
- Servicio de Cardiología, Hospital Ramón y Cajal, Madrid, España.
| | | | - J Gállego-Culleré
- Servicio de Neurología, Complejo Hospitalario de Navarra, Pamplona, España
| | - E Ignacio-García
- Gestión Sanitaria y Calidad Asistencial, Universidad de Cádiz, Cádiz, España
| | | | - A Martín-Martínez
- Servicio de Urgencias, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
| | - J Mateo-Arranz
- Departamento de Hematología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | - D Vargas-Ortega
- Centro Hospitalario de Alta Resolución (CHARE) El Toyo, Almería, España
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Sheldrick RC, Breuer DJ, Hassan R, Chan K, Polk DE, Benneyan J. A system dynamics model of clinical decision thresholds for the detection of developmental-behavioral disorders. Implement Sci 2016; 11:156. [PMID: 27884203 PMCID: PMC5123221 DOI: 10.1186/s13012-016-0517-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 10/27/2016] [Indexed: 12/18/2022] Open
Abstract
Background Clinical decision-making has been conceptualized as a sequence of two separate processes: assessment of patients’ functioning and application of a decision threshold to determine whether the evidence is sufficient to justify a given decision. A range of factors, including use of evidence-based screening instruments, has the potential to influence either or both processes. However, implementation studies seldom specify or assess the mechanism by which screening is hypothesized to influence clinical decision-making, thus limiting their ability to address unexpected findings regarding clinicians’ behavior. Building on prior theory and empirical evidence, we created a system dynamics (SD) model of how physicians’ clinical decisions are influenced by their assessments of patients and by factors that may influence decision thresholds, such as knowledge of past patient outcomes. Using developmental-behavioral disorders as a case example, we then explore how referral decisions may be influenced by changes in context. Specifically, we compare predictions from the SD model to published implementation trials of evidence-based screening to understand physicians’ management of positive screening results and changes in referral rates. We also conduct virtual experiments regarding the influence of a variety of interventions that may influence physicians’ thresholds, including improved access to co-located mental health care and improved feedback systems regarding patient outcomes. Results Results of the SD model were consistent with recent implementation trials. For example, the SD model suggests that if screening improves physicians’ accuracy of assessment without also influencing decision thresholds, then a significant proportion of children with positive screens will not be referred and the effect of screening implementation on referral rates will be modest—results that are consistent with a large proportion of published screening trials. Consistent with prior theory, virtual experiments suggest that physicians’ decision thresholds can be influenced and detection of disabilities improved by increasing access to referral sources and enhancing feedback regarding false negative cases. Conclusions The SD model of clinical decision-making offers a theoretically based framework to improve understanding of physicians’ behavior and the results of screening implementation trials. The SD model is also useful for initial testing of hypothesized strategies to increase detection of under-identified medical conditions. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0517-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- R Christopher Sheldrick
- Department of Pediatrics, Tufts Medical Center, 800 Washington Street #854, Boston, MA, 02111, USA.
| | - Dominic J Breuer
- Healthcare Systems Engineering Institute, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
| | - Razan Hassan
- Healthcare Systems Engineering Institute, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
| | - Kee Chan
- Department of Health Policy and Administration, University of Illinois, Chicago, School of Public Health, 1603 West Taylor Street, Chicago, IL, USA
| | - Deborah E Polk
- Dental Public Health and Information Management, University of Pittsburg, 381 Salk Hall, Pittsburgh, PA, 15261, USA
| | - James Benneyan
- Healthcare Systems Engineering Institute, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
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Raparelli V, Proietti M, Cangemi R, Lip GYH, Lane DA, Basili S. Adherence to oral anticoagulant therapy in patients with atrial fibrillation. Focus on non-vitamin K antagonist oral anticoagulants. Thromb Haemost 2016; 117:209-218. [PMID: 27831592 DOI: 10.1160/th16-10-0757] [Citation(s) in RCA: 129] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 10/07/2016] [Indexed: 01/11/2023]
Abstract
Oral anticoagulation is pivotal in the management of thromboembolic risk in non-valvular atrial fibrillation (NVAF) patients. Effective anticoagulation is important to avoid major adverse events and medication adherence is central to achieve good anticoagulation control. Non-vitamin K antagonist oral anticoagulants (NOACs) are as effective and safe as vitamin K antagonist (VKAs) in NVAF patients. Due to the absence of routine anticoagulation monitoring with NOACs treatment, concerns have been raised about patient's adherence to NOACs and real-life data demonstrates variability in adherence and persistence. A multi-level approach, including patients' preferences, factors determining physicians' prescribing habits and healthcare system infrastructure and support, is warranted to improve initiation and adherence of anticoagulants. Adherence to NOACs is paramount to achieve a clinical benefit. Implementation of educational programs and easy-to-use tools to identify patients most likely to be non-adherent to NOACs, are central issues in improving the quality of NVAF anticoagulation management.
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Affiliation(s)
| | | | | | | | | | - Stefania Basili
- Prof. Stefania Basili, I Clinica Medica, Viale del Policlinico 155, Roma, 00161, Italy, Tel.: +39 06 49974678, Fax: +39 06 49974678, E-mail:
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Habert JS. Minimizing bleeding risk in patients receiving direct oral anticoagulants for stroke prevention. Int J Gen Med 2016; 9:337-347. [PMID: 27785089 PMCID: PMC5066855 DOI: 10.2147/ijgm.s109104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Many primary care physicians are wary about using direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (AF). Factors such as comorbidities, concomitant medications, and alcohol misuse increase concerns over bleeding risk, especially in elderly and frail patients with AF. This article discusses strategies to minimize the risk of major bleeding events in patients with AF who may benefit from oral anticoagulant therapy for stroke prevention. The potential benefits of the DOACs compared with vitamin K antagonists, in terms of a lower risk of intracranial hemorrhage, are discussed, together with the identification of reversible risk factors for bleeding and correct dose selection of the DOACs based on a patient’s characteristics and concomitant medications. Current bleeding management strategies, including the new reversal agents for the DOACs and the prevention of bleeding during preoperative anticoagulation treatment, in addition to health care resource use associated with anticoagulation treatment and bleeding, are also discussed. Implementing a structured approach at an individual patient level will minimize the overall risk of bleeding and should increase physician confidence in using the DOACs for stroke prevention in their patients with nonvalvular AF.
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Affiliation(s)
- Jeffrey Steven Habert
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Simianu VV, Basu A, Alfonso-Cristancho R, Thirlby RC, Flaxman AD, Flum DR. Assessing surgeon behavior change after anastomotic leak in colorectal surgery. J Surg Res 2016; 205:378-383. [PMID: 27664886 DOI: 10.1016/j.jss.2016.06.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/28/2016] [Accepted: 06/27/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recency effect suggests that people disproportionately value events from the immediate past when making decisions, but the extent of this impact on surgeons' decisions is unknown. This study evaluates for recency effect in surgeons by examining use of preventative leak testing before and after colorectal operations with anastomotic leaks. MATERIALS AND METHODS Prospective cohort of adult patients (≥18 y) undergoing elective colorectal operations at Washington State hospitals participating in the Surgical Care and Outcomes Assessment Program (2006-2013). The main outcome measure was surgeons' change in leak testing from 6 mo before to 6 mo after an anastomotic leak occurred. RESULTS Across 4854 elective colorectal operations performed by 282 surgeons at 44 hospitals, there was a leak rate of 2.6% (n = 124). The 40 leaks (32%) in which the anastomosis was not tested occurred across 25 surgeons. While the ability to detect an overall difference in use of leak testing was limited by small sample size, nine (36%) of 25 surgeons increased their leak testing by 5% points or more after leaks in cases where the anastomosis was not tested. Surgeons who increased their leak testing more frequently performed operations for diverticulitis (45% versus 33%), more frequently began their cases laparoscopically (65% versus 37%), and had longer mean operative times (195 ± 99 versus 148 ± 87 min), all P < 0.001. CONCLUSIONS Recency effect was demonstrated by only one-third of eligible surgeons. Understanding the extent to which clinical decisions may be influenced by recency effect may be important in crafting quality improvement initiatives that require clinician behavior change.
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Affiliation(s)
- Vlad V Simianu
- Department of Surgery, University of Washington, Seattle, Washington.
| | - Anirban Basu
- Department of Health Services, University of Washington, Seattle, Washington
| | - Rafael Alfonso-Cristancho
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, Washington
| | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Abraham D Flaxman
- Department of Global Health, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, Washington; Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, Washington.
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Proietti M, Mairesse GH, Goethals P, Scavee C, Vijgen J, Blankoff I, Vandekerckhove Y, Lip GYH. A population screening programme for atrial fibrillation: a report from the Belgian Heart Rhythm Week screening programme. Europace 2016; 18:1779-1786. [PMID: 27170000 DOI: 10.1093/europace/euw069] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/23/2016] [Indexed: 11/13/2022] Open
Abstract
AIMS Despite the increased prevalence of atrial fibrillation (AF), data for the implementation of nationwide screening programmes are limited. The aim of this national screening study was to increase nationwide awareness about AF and stroke risk, to determine the prevalence of AF in Belgian general population using an ECG handheld machine and its feasibility to identify new AF cases. METHODS AND RESULTS We analysed data obtained from 5 years of the 'Belgian Heart Rhythm Week' screening programme. All subjects were screened using a one-lead ECG handheld machine. Among 65 747 subjects screened, AF was recorded in 911, with an overall prevalence of 1.4% [95% confidence interval (CI) 1.2-1.6%]. High thrombo-embolic risk, as assessed by CHA2DS2-VASc score ≥2, was recorded in 69% of AF subjects. In subjects with high thrombo-embolic risk, only 5.4% were treated with oral anticoagulant (OAC) and 5.8% were treated with OAC and antiplatelet drugs. Among recorded AF cases, the use of the ECG handheld machine allowed identification of 603 new AF patients (1.1%, 95% CI 0.9-1.3%). Factors associated with incident AF were chronic heart failure (P < 0.001), age (P < 0.001), diabetes mellitus (P < 0.001), previous stroke (P < 0.001), vascular disease (P < 0.001), and male sex (P < 0.001). CONCLUSION In this Belgian national screening programme, prevalence of AF was 1.4%. The use of an ECG handheld machine is feasible to identify a significant number of new AF cases, most with a high thrombo-embolic risk. Given the low OAC use recorded, greater efforts in AF detection and treatment are urgently needed to reduce the burden of stroke associated with this common arrhythmia.
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Affiliation(s)
- Marco Proietti
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
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Goodman SG. Prior bleeding, future bleeding and stroke risk with oral anticoagulation in atrial fibrillation: What new lessons can ARISTOTLE teach us? Am Heart J 2016; 175:168-71. [PMID: 27179736 DOI: 10.1016/j.ahj.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 02/10/2016] [Indexed: 10/22/2022]
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Defensive medicine due to different fears by patients and physicians in geriatric atrial fibrillation patients and second victim syndrome. Int J Cardiol 2016; 212:251-2. [PMID: 27054498 DOI: 10.1016/j.ijcard.2016.03.093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 03/19/2016] [Indexed: 11/20/2022]
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Abstract
Atrial fibrillation (AF) is a major risk factor for ischemic stroke. Guidelines recommend anticoagulation for patients with intermediate and high stroke risk (CHA2DS2-VASc score ≥ 2). Underuse of anticoagulants among eligible patients remains a persistent problem. Evidence demonstrates that the psychology of the fear of causing harm (omission bias) results in physicians' hesitancy to initiate anticoagulation and an inaccurate estimation of stroke risk. The American Heart Association (AHA) initiated the Get With The Guidelines-AFIB (GWTG-AFIB) module in June 2013 to enhance guideline adherence for treatment and management of AF. Better quality of care for AF patients can be provided by increasing adherence to anticoagulation guidelines and improving patient compliance with anticoagulation therapy through education and established protocols. Nonvitamin K antagonist oral anticoagulants may facilitate better patient adherence due to ease of administration and reduced monitoring burden. In this review, we discuss the reasons for underuse, omission bias contributing to underuse, and different strategies to address this issue.
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Affiliation(s)
- Ajay Vallakati
- a Division of Cardiovascular Diseases , Metrohealth Medical Center , Cleveland , OH , USA
| | - William R Lewis
- a Division of Cardiovascular Diseases , Metrohealth Medical Center , Cleveland , OH , USA
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Alonso‐Coello P, Montori VM, Díaz MG, Devereaux PJ, Mas G, Diez AI, Solà I, Roura M, Souto JC, Oliver S, Ruiz R, Coll‐Vinent B, Gich I, Schünemann HJ, Guyatt G. Values and preferences for oral antithrombotic therapy in patients with atrial fibrillation: physician and patient perspectives. Health Expect 2015; 18:2318-27. [PMID: 24813058 PMCID: PMC5810657 DOI: 10.1111/hex.12201] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Exploration of values and preferences in the context of anticoagulation therapy for atrial fibrillation (AF) remains limited. To better characterize the distribution of patient and physician values and preferences relevant to decisions regarding anticoagulation in patients with AF, we conducted interviews with patients at risk of developing AF and physicians who manage patients with AF. METHODS We interviewed 96 outpatients and 96 physicians in a multicenter study and elicited the maximal increased risk of bleeding (threshold risk) that respondents would tolerate with warfarin vs. aspirin to achieve a reduction in three strokes in 100 patients over a 2-year period. We used the probabilistic version of the threshold technique. RESULTS The median threshold risk for both patients and physicians was 10 additional bleeds (10 P = 0.7). In both groups, we observed large variability in the threshold number of bleeds, with wider variability in patients than clinicians [patient range: 0-100, physician range: 0-50]. We observed one cluster of patients and physicians who would tolerate <10 bleeds and another cluster of patients, but not physicians, who would accept more than 35. CONCLUSIONS Our findings suggest wide variability in patient and physician values and preferences regarding the trade-off between strokes and bleeds. Results suggest that in individual decision making, physician and patient values and preferences will often be discordant; this mandates tailoring treatment to the individual patient's preferences.
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Affiliation(s)
- Pablo Alonso‐Coello
- Iberoamerican Cochrane CentreBiomedical Research Institute Sant Pau‐CIBER of Epidemiology and Public Health (CIBERESP‐ IIB Sant Pau)BarcelonaSpain
| | | | - M. Gloria Díaz
- Unidad Docente de Medicina Familiar y ComunitariaHospital DonostiaDonostiaSpain
| | - Philip J. Devereaux
- Department of Clinical Epidemiology & BiostatisticsCLARITY Research GroupMcMaster University Medical Centre 2C9HamiltonONCanada
| | - Gemma Mas
- Iberoamerican Cochrane CentreBiomedical Research Institute Sant Pau‐CIBER of Epidemiology and Public Health (CIBERESP‐ IIB Sant Pau)BarcelonaSpain
| | - Ana I. Diez
- Centro de Salud de BeraunErrenteriaSan SebastiánSpain
| | - Ivan Solà
- Iberoamerican Cochrane CentreBiomedical Research Institute Sant Pau‐CIBER of Epidemiology and Public Health (CIBERESP‐ IIB Sant Pau)BarcelonaSpain
| | | | - Juan C. Souto
- Unitat d'Hemostàsia i TrombosiHospital de la Santa Creu i Sant PauBarcelonaSpain
| | - Sven Oliver
- Unidad Formadora de Medicina Familiar y Comunitaria de A CoruñaCoruñaSpain
| | | | | | - Ignasi Gich
- Iberoamerican Cochrane CentreBiomedical Research Institute Sant Pau‐CIBER of Epidemiology and Public Health (CIBERESP‐ IIB Sant Pau)BarcelonaSpain
| | - Holger J. Schünemann
- Department of Clinical Epidemiology & BiostatisticsCLARITY Research GroupMcMaster University Medical Centre 2C9HamiltonONCanada
| | - Gordon Guyatt
- Department of Clinical Epidemiology & BiostatisticsCLARITY Research GroupMcMaster University Medical Centre 2C9HamiltonONCanada
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Wasfy JH, Singal G, O'Brien C, Blumenthal DM, Kennedy KF, Strom JB, Spertus JA, Mauri L, Normand SLT, Yeh RW. Enhancing the Prediction of 30-Day Readmission After Percutaneous Coronary Intervention Using Data Extracted by Querying of the Electronic Health Record. Circ Cardiovasc Qual Outcomes 2015; 8:477-85. [PMID: 26286871 DOI: 10.1161/circoutcomes.115.001855] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 06/22/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Early readmission after percutaneous coronary intervention is an important quality metric, but prediction models from registry data have only moderate discrimination. We aimed to improve ability to predict 30-day readmission after percutaneous coronary intervention from a previously validated registry-based model. METHODS AND RESULTS We matched readmitted to non-readmitted patients in a 1:2 ratio by risk of readmission, and extracted unstructured and unconventional structured data from the electronic medical record, including need for medical interpretation, albumin level, medical nonadherence, previous number of emergency department visits, atrial fibrillation/flutter, syncope/presyncope, end-stage liver disease, malignancy, and anxiety. We assessed differences in rates of these conditions between cases/controls, and estimated their independent association with 30-day readmission using logistic regression conditional on matched groups. Among 9288 percutaneous coronary interventions, we matched 888 readmitted with 1776 non-readmitted patients. In univariate analysis, cases and controls were significantly different with respect to interpreter (7.9% for cases and 5.3% for controls; P=0.009), emergency department visits (1.12 for cases and 0.77 for controls; P<0.001), homelessness (3.2% for cases and 1.6% for controls; P=0.007), anticoagulation (33.9% for cases and 22.1% for controls; P<0.001), atrial fibrillation/flutter (32.7% for cases and 28.9% for controls; P=0.045), presyncope/syncope (27.8% for cases and 21.3% for controls; P<0.001), and anxiety (69.4% for cases and 62.4% for controls; P<0.001). Anticoagulation, emergency department visits, and anxiety were independently associated with readmission. CONCLUSIONS Patient characteristics derived from review of the electronic health record can be used to refine risk prediction for hospital readmission after percutaneous coronary intervention.
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Affiliation(s)
- Jason H Wasfy
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.H.W., C.O'B., D.M.B., R.W.Y.), Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (L.M.), Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (G.S.), Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.B.S.), Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., J.A.S.); and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (S.-L.T.N.)
| | - Gaurav Singal
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.H.W., C.O'B., D.M.B., R.W.Y.), Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (L.M.), Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (G.S.), Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.B.S.), Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., J.A.S.); and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (S.-L.T.N.)
| | - Cashel O'Brien
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.H.W., C.O'B., D.M.B., R.W.Y.), Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (L.M.), Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (G.S.), Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.B.S.), Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., J.A.S.); and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (S.-L.T.N.)
| | - Daniel M Blumenthal
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.H.W., C.O'B., D.M.B., R.W.Y.), Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (L.M.), Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (G.S.), Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.B.S.), Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., J.A.S.); and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (S.-L.T.N.)
| | - Kevin F Kennedy
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.H.W., C.O'B., D.M.B., R.W.Y.), Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (L.M.), Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (G.S.), Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.B.S.), Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., J.A.S.); and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (S.-L.T.N.)
| | - Jordan B Strom
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.H.W., C.O'B., D.M.B., R.W.Y.), Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (L.M.), Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (G.S.), Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.B.S.), Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., J.A.S.); and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (S.-L.T.N.)
| | - John A Spertus
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.H.W., C.O'B., D.M.B., R.W.Y.), Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (L.M.), Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (G.S.), Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.B.S.), Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., J.A.S.); and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (S.-L.T.N.)
| | - Laura Mauri
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.H.W., C.O'B., D.M.B., R.W.Y.), Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (L.M.), Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (G.S.), Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.B.S.), Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., J.A.S.); and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (S.-L.T.N.)
| | - Sharon-Lise T Normand
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.H.W., C.O'B., D.M.B., R.W.Y.), Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (L.M.), Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (G.S.), Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.B.S.), Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., J.A.S.); and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (S.-L.T.N.)
| | - Robert W Yeh
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.H.W., C.O'B., D.M.B., R.W.Y.), Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (L.M.), Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (G.S.), Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.B.S.), Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO (K.F.K., J.A.S.); and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (S.-L.T.N.).
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Okumura K, Inoue H, Yasaka M, Gonzalez JM, Hauber AB, Levitan B, Yuan Z, Baptiste Briere J. Japanese Patients' and Physicians' Preferences for Anticoagulant Use in Atrial Fibrillation: Results from a Discrete-choice Experiment. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2015; 2:207-220. [PMID: 37663581 PMCID: PMC10471371 DOI: 10.36469/9904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Background: Anticoagulants are recommended for stroke prevention in patients with atrial fibrillation (AF), but are associated with an increased risk of bleeding; therefore, physicians face benefit-risk tradeoffs when prescribing anticoagulants to AF patients. Although the unmet medical need for safer anticoagulants has been well-documented, there is limited information about the importance that patients and physicians place on cardiovascular events. Objectives: The aim of this study was to quantify patients' and physicians' willingness to accept tradeoffs between the benefits and risks of anticoagulants in order to 1) document the potential differences between patients' and physicians' perceptions of benefits and risks and 2) support physicians' clinical decision making. Methods: Preferences from Japanese AF patients and board-eligible or board-certified physicians were elicited using a discrete-choice experiment. Random-parameters logit models were used to estimate importance weights for treatment-related changes in the annual risk of stroke, myocardial infarction, embolism, and bleeding. Results: Japanese patients (N=152) and physicians (N=164) showed different preferences. In particular, among non-fatal outcomes, patients considered disabling stroke to be 16 times more important than non-major clinically relevant bleeding and 2.6 times more important than extra-cranial major bleeding. In contrast, physicians considered the same stroke risk to be 2.7 times more important than non-major clinically relevant bleeding and equally important as major bleeding. Conclusions: Results suggest that Japanese patients are willing to tolerate a greater risk of bleeding in exchange for stroke prevention than are Japanese physicians. The findings demonstrate the importance of physician-patient communication in treatment decisions involving stroke preventative therapies.
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Affiliation(s)
- Ken Okumura
- Division of Cardiology Hirosaki University Graduate School of Medicine, Hirosaki-shi, Aomori, Japan
| | - Hiroshi Inoue
- Second Department of Internal Medicine University of Toyama School of Medicine, Toyama-shi, Toyama, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Disease National Kyushu Medical Center, Fukuoka-shi, Fukuoka, Japan
| | | | - A Brett Hauber
- RTI Health Solutions Research Triangle Park, North Carolina, USA
| | | | - Zhong Yuan
- Janssen Research & Development, LLC, Titusville, New Jersey
| | - Jean Baptiste Briere
- Global Health Economics & Outcomes Research Department Bayer Pharma AG, Berlin, Germany
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44
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Janzic A, Kos M. Cost effectiveness of novel oral anticoagulants for stroke prevention in atrial fibrillation depending on the quality of warfarin anticoagulation control. PHARMACOECONOMICS 2015; 33:395-408. [PMID: 25512096 DOI: 10.1007/s40273-014-0246-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Vitamin K antagonists, such as warfarin, are standard treatments for stroke prophylaxis in patients with atrial fibrillation. Patient outcomes depend on quality of warfarin management, which includes regular monitoring and dose adjustments. Recently, novel oral anticoagulants (NOACs) that do not require regular monitoring offer an alternative to warfarin. The aim of this study was to evaluate whether cost effectiveness of NOACs for stroke prevention in atrial fibrillation depends on the quality of warfarin control. METHODS We developed a Markov decision model to simulate warfarin treatment outcomes in relation to the quality of anticoagulation control, expressed as percentage of time in the therapeutic range (TTR). Standard treatment with adjusted-dose warfarin and improved anticoagulation control by genotype-guided dosing were compared with dabigatran, rivaroxaban, apixaban and edoxaban. The analysis was performed from the Slovenian healthcare payer perspective using 2014 costs. RESULTS In the base case, the incremental cost-effectiveness ratio for apixaban, dabigatran and edoxaban was below the threshold of €25,000 per quality-adjusted life-years compared with adjusted-dose warfarin with a TTR of 60%. The probability that warfarin was a cost-effective option was around 1%. This percentage rises as the quality of anticoagulation control improves. At a TTR of 70%, warfarin was the preferred treatment in half the iterations. CONCLUSION The cost effectiveness of NOACs for stroke prevention in patients with nonvalvular atrial fibrillation who are at increased risk for stroke is highly sensitive to warfarin anticoagulation control. NOACs are more likely to be cost-effective options in settings with poor warfarin management than in settings with better anticoagulation control, where they may not represent good value for money.
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Affiliation(s)
- Andrej Janzic
- Faculty of Pharmacy, University of Ljubljana, Aškerčeva cesta 7, 1000, Ljubljana, Slovenia
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45
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The Cauldron: Desert Island ICU: (Organised by the Trainee Committee). J Intensive Care Soc 2015; 16:8-15. [PMID: 28979362 PMCID: PMC5606493 DOI: 10.1177/1751143715577562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2023] Open
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46
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Gallagher R, Roach K, Sadler L, Belshaw J, Kirkness A, Zhang L, Proctor R, Neubeck L. Who gets stroke prevention? Stroke prevention in atrial fibrillation patients in the inpatient setting. Heart Lung Circ 2015; 24:488-94. [PMID: 25613238 DOI: 10.1016/j.hlc.2014.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Current guidelines strongly recommend antithrombotic therapy, particularly warfarin, for stroke prevention in atrial fibrillation (AF) patients at high risk of stroke. Despite this, use of these medications is far from optimal. The aim of this study was to describe the use of stroke prevention medication in inpatients and identify factors associated with prescription in one local health district in Sydney, Australia. METHODS A prospective audit of medical records for patients admitted with an AF diagnosis to five hospitals in the health district and excluding cardiac surgery patients was undertaken. Patients were classified as high or low for stroke risk as well as for risk of bleeding and predictors were identified by logistic regression. RESULTS A total of 204 patients were enrolled from July 2012 to April 2013, with a mean age of 75 years (SD 13) and half (50%) were male. Valve disease was present in 17% and 15% received a procedure for their AF (cardioversion/ablation/pulmonary vein isolation). Patients were least likely to be prescribed warfarin/novel oral anticoagulant (NOAC) if they were non-valvular and did not undergo cardioversion/ablation (p=.03), and least likely to be prescribed aspirin if they had no AF procedure (p=.01). In non-valvular patients who did not have cardioversion/ablation the odds of being prescribed warfarin/NOAC were increased by being classified at high risk of stroke (OR 3.1, 95% CI 1.0 -9.5) and decreased if there was a prescription for aspirin (OR .3. 95% CI .1 -.6). CONCLUSIONS Overall use of stroke prevention medication indicates that gaps remain in translation of evidence into clinical practice.
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Affiliation(s)
- Robyn Gallagher
- Sydney Nursing School, Charles Perkins Centre, University of Sydney, Camperdown, NSW 2006.
| | - Kellie Roach
- Ryde Hospital, Northern Sydney Local Health District, NSW
| | - Leonie Sadler
- Manly and Mona Vale Hospitals, Northern Sydney Local Health District, NSW
| | - Julie Belshaw
- Hornsby Ku-ring-gai Health Service, Northern Sydney Local Health District, NSW
| | - Ann Kirkness
- Royal North Shore Hospital, Northern Sydney Local Health District, NSW
| | - Ling Zhang
- Sydney Nursing School, Charles Perkins Centre, University of Sydney, Camperdown, NSW 2006
| | - Ross Proctor
- Royal North Shore Hospital, Northern Sydney Local Health District, NSW
| | - Lis Neubeck
- Sydney Nursing School, Charles Perkins Centre, University of Sydney, Camperdown, NSW 2006; The George Institute for Global Health, Camperdown, NSW 2050
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Abstract
Despite the availability of predictive tools and treatment guidelines, anticoagulant therapies are underprescribed and many patients are undertreated for conditions that predispose to thromboembolic complications, including stroke. This review explores reasons for which physicians fear that the risks of anticoagulation may be greater than the potential benefit. The results of numerous clinical trials confirm that patients benefit from judiciously managed anticoagulation and that physicians can take various approaches to minimize risk. Use of stratification scores for patient selection and accurate estimation of stroke risk may improve outcomes; bleeding risk is less important than stroke risk. Adoption of newer anticoagulants with simpler regimens may help physicians allay their fears of anticoagulant use in patients with atrial fibrillation. These fears, although not groundless, should not overtake caution and hinder the delivery of appropriate evidence-based care.
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48
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Treasure T, Macbeth F. An exception that proves the rule: recurrence free survival five years after extrapleural pneumonectomy for malignant pleural mesothelioma. J Cardiothorac Surg 2014; 9:181. [PMID: 25403951 PMCID: PMC4237761 DOI: 10.1186/s13019-014-0181-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 11/10/2014] [Indexed: 11/10/2022] Open
Abstract
Are case reports at all relevant and useful? A case report of an unusual case of mesothelioma prompts a discussion and concludes that they do have a role but that their observations and conclusions need to be treated with care.
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Affiliation(s)
- Tom Treasure
- Clinical Operational Research Unit, University College London, London, WC1H 0BT, UK.
| | - Fergus Macbeth
- Wales Cancer Trials Unit, Cardiff University, Cardiff, CF14 7XL, UK.
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49
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Could some geriatric characteristics hinder the prescription of anticoagulants in atrial fibrillation in the elderly? J Aging Res 2014; 2014:693740. [PMID: 25295192 PMCID: PMC4175391 DOI: 10.1155/2014/693740] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 08/06/2014] [Accepted: 08/19/2014] [Indexed: 11/17/2022] Open
Abstract
Several studies have reported underprescription of anticoagulants in atrial fibrillation (AF). We conducted an observational study on 142 out of a total of 995 consecutive ≥75 years old patients presenting AF (14%) when admitted in an emergency unit of a general hospital, in search of geriatric characteristics that might be associated with the underprescription of anticoagulation therapy (mostly antivitamin K at the time of the study). The following data was collected from patients presenting AF: medical history including treatment and comorbidities, CHADS2 score, ISAR scale (frailty), Lawton's scale (ADL), GDS scale (mood status), MUST (nutrition), and blood analysis (INR, kidney function, and albumin). Among those patients for who anticoagulation treatment was recommended (73%), only 61% were treated with it. In the group with anticoagulation therapy, the following characteristics were observed more often than in the group without such therapy: a recent (≤6 months) hospitalization and medical treatment including digoxin or based on >3 different drugs. Neither the value of the CHADS2 score, nor the geriatric characteristics could be correlated with the presence or the absence of an anticoagulation therapy. More research is thus required to identify and clarify the relative importance of patient-, physician-, and health care system-related hurdles for the prescription of oral anticoagulation therapy in older patients with AF.
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50
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Reach G. Clinical inertia, uncertainty and individualized guidelines. DIABETES & METABOLISM 2014; 40:241-5. [DOI: 10.1016/j.diabet.2013.12.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 12/16/2013] [Accepted: 12/16/2013] [Indexed: 11/27/2022]
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