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Jneid H, Chikwe J, Arnold SV, Bonow RO, Bradley SM, Chen EP, Diekemper RL, Fugar S, Johnston DR, Kumbhani DJ, Mehran R, Misra A, Patel MR, Sweis RN, Szerlip M. 2024 ACC/AHA Clinical Performance and Quality Measures for Adults With Valvular and Structural Heart Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Performance Measures. Circ Cardiovasc Qual Outcomes 2024; 17:e000129. [PMID: 38484039 DOI: 10.1161/hcq.0000000000000129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Affiliation(s)
- Hani Jneid
- ACC/AHA Joint Committee on Clinical Data Standards liaison
- Society for Cardiovascular Angiography and Interventions representative
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Frost L, Joensen AM, Dam-Schmidt U, Qvist I, Brinck M, Brandes A, Davidsen U, Pedersen OD, Damgaard D, Mølgaard I, Bedsted R, Damgaard Møller Schlünsen A, Chousa MG, Andersen J, Pedersen AR, Johnsen SP, Vinter N. The Danish Atrial Fibrillation Registry: A Multidisciplinary National Pragmatic Initiative for Monitoring and Supporting Quality of Care Based on Data Retrieved from Administrative Registries. Clin Epidemiol 2023; 15:1259-1272. [PMID: 38149081 PMCID: PMC10750776 DOI: 10.2147/clep.s443473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/09/2023] [Indexed: 12/28/2023] Open
Abstract
Aim The Danish Atrial Fibrillation (AF) Registry monitors and supports improvement of quality of care for all AF patients in Denmark. This report describes the registry's administrative and organizational structure, data sources, data flow, data analyses, annual reporting, and feedback between the registry, clinicians, and the administrative system. We also report the selection process of the quality indicators and the temporal trends in results from 2017-2021. Methods and Results The Danish AF Registry aims for complete registration and monitoring of care for all patients diagnosed with AF in Denmark. Administrative registries provide data on contacts to general practice, contacts to private cardiology practice, hospital contacts, medication prescriptions, updated vital status information, and biochemical test results. The Danish Stroke Registry provides information on stroke events. From 2017 to 2021, the proportion with a reported echocardiography among incident AF patients increased from 39.9% (95% CI: 39.3-40.6) to 82.6% (95% CI: 82.1-83.1). The initiation of oral anticoagulant therapy among patients with incident AF and a CHA2DS2-VASc score of ≥1 in men and ≥2 in women increased from 85.3% (95% CI: 84.6-85.9) to 90.4% (95% CI: 89.9-91.0). The 1-year and 2-year persistence increased from 85.2% (95% CI: 84.5-85.9) to 88.7% (95% CI: 88.0-89.3), and from 85.4% (95% CI: 84.7-86.2) to 88.2% (95% CI: 87.5-88.8), respectively. The 1-year risk of ischemic stroke among prevalent patients with AF decreased from 0.88% (95% CI: 0.83-0.93) to 0.71% (95% CI: 0.66-0.75). Variation in clinical performance between the five administrative Danish regions was reduced. Conclusion Continuous nationwide monitoring of quality indicators for AF originating from administrative registries is feasible and supportive of improvements of quality of care.
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Affiliation(s)
- Lars Frost
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Ulla Dam-Schmidt
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospitals, Copenhagen, Denmark
| | - Ina Qvist
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Margit Brinck
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Axel Brandes
- Department of Cardiology, Esbjerg Hospital – University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Ulla Davidsen
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospitals, Copenhagen, Denmark
| | - Ole Dyg Pedersen
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Inge Mølgaard
- Patient Representative, Aalborg and Roskilde, Denmark
| | | | | | - Miriam Grijota Chousa
- The Danish Clinical Quality Program – National Clinical Registries (RKKP), Aarhus, Denmark
| | - Julie Andersen
- The Danish Clinical Quality Program – National Clinical Registries (RKKP), Aarhus, Denmark
| | | | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Nicklas Vinter
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Deka P, Mathison C, Abela G, Karve M. Exercise-induced atrial fibrillation: A case report. Clin Case Rep 2023; 11:e8242. [PMID: 38028109 PMCID: PMC10661303 DOI: 10.1002/ccr3.8242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/25/2023] [Accepted: 11/08/2023] [Indexed: 12/01/2023] Open
Abstract
Key Clinical Message Middle-aged male athletes, with or without underlying coronary artery disease, exhibiting exercise induced blood pressure (BP) variability and diabetes can have an increased risk of developing atrial fibrillation (AF). Assessment in athletes should include long-term arrhythmia monitoring. In addition, it is important to exert patients beyond their calculated target heart rate (HR) during an exercise stress test to detect exercise-induced AF. We suggest this strategy be specifically used for athletes with complaints of intermittent palpitation and chest pain. Referral to an electrophysiologist for a possible ablation procedure should be considered for the management of AF in athletes in whom the use of beta-blockers may limit exercise tolerance. Bleeding risk with the use of oral anticoagulation needs to be adequately evaluated in athletes with AF who engage in high-intensity exercise or activities. Abstract The report highlights the case of a 54-year-old Caucasian male (height 5.11', BMI 29.8) who presented with complaints of chest pain, mild coronary artery disease, palpitation, dizziness, and labile BP with high-intensity biking exercise. Diagnostic tests (exercise stress test, cardiac catheterization, Holter monitor, and Bardy patch) using standard procedure were unsuccessful at detecting the problem. In a repeat exercise stress test, the patient was exerted beyond the calculated HRmax (up to 117%) when the patient's heart rhythm flipped from sinus rhythm to AF. The patient was referred to a cardiac electrophysiologist and an ablation procedure was performed to prevent exercise-induced AF with high-intensity exercise. Young adults, with or without early coronary artery disease, performing high-intensity endurance exercises may be at risk of developing exercise-induced AF. This phenomenon is prevalent and well documented in the skiing population and patients with variance in BP during exercise. Endurance athletes tend to have a lower resting HR. As such, the use of standard rate-control medications in patients with exercise-induced AF may not be appropriate. Referral to a cardiac electrophysiologist and ablation procedures should be considered in this population for management and symptom control. If tolerated, especially in young adults with complaints of palpitation and chest pain, patients should be exerted beyond their calculated HRmax during an exercise stress test to diagnose an underlying condition of exercise-induced AF.
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Affiliation(s)
- Pallav Deka
- College of NursingMichigan State UniversityEast LansingMichiganUSA
- Capital Cardiology PCLansingMichiganUSA
| | | | - George Abela
- College of Human MedicineMichigan State UniversityEast LansingMichiganUSA
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Zheng J, Heidenreich PA, Kohsaka S, Fearon WF, Sandhu AT. Long-Term Outcomes of Early Coronary Artery Disease Testing After New-Onset Heart Failure. Circ Heart Fail 2023; 16:e010426. [PMID: 37212148 PMCID: PMC10523905 DOI: 10.1161/circheartfailure.122.010426] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 04/07/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) testing remains underutilized in patients with newly diagnosed heart failure (HF). The longitudinal clinical impact of early CAD testing has not been well-characterized. We investigated changes in clinical management and long-term outcomes after early CAD evaluation in patients with incident HF. METHODS We identified Medicare patients with incident HF from 2006 to 2018. The exposure variable was early CAD testing within 1 month of initial HF diagnosis. Covariate-adjusted rates of cardiovascular interventions after testing, including CAD-related management, were modeled using mixed-effects regression with clinician as a random intercept. We assessed mortality and hospitalization outcomes using landmark analyses with inverse probability-weighted Cox proportional hazards models. Falsification end points and mediation analysis were employed for bias assessment. RESULTS Among 309 559 patients with new-onset HF without prior CAD, 15.7% underwent early CAD testing. Patients who underwent prompt CAD evaluation had higher adjusted rates of subsequent antiplatelet/statin prescriptions and revascularization, guideline-directed therapy for HF, and stroke prophylaxis for atrial fibrillation/flutter than controls. In weighted Cox models, 1-month CAD testing was associated with significantly reduced all-cause mortality (hazard ratio, 0.93 [95% CI, 0.91-0.96]). Mediation analyses indicated that ≈70% of this association was explained by CAD management, largely from new statin prescriptions. Falsification end points (outpatient diagnoses of urinary tract infection and hospitalizations for hip/vertebral fracture) were nonsignificant. CONCLUSIONS Early CAD testing after incident HF was associated with a modest mortality benefit, driven mostly by subsequent statin therapy. Further investigation on clinician barriers to testing and treating high-risk patients may improve adherence to guideline-recommended cardiovascular interventions.
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Affiliation(s)
- Jimmy Zheng
- Stanford University School of Medicine, Stanford, CA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
- Department of Medicine, Palo Alto VA Veteran’s Affairs Hospitals, Palo Alto, CA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - William F Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
- Department of Medicine, Palo Alto VA Veteran’s Affairs Hospitals, Palo Alto, CA
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
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Souza-Silva MVR, Domingues MLDP, Chagas VS, Pereira DN, de Sá LC, Almeida MSS, Sales TLS, Raposo MC, Guimarães NS, Oliveira JADQ, Ribeiro ALP, Cardoso CS, Martins MAP, Enes TB, Soares TBDC, Baldoni AO, Marcolino MS. Implementation of a text messaging intervention to patients on warfarin therapy in Brazilian primary care units: a quasi-experimental study. BMC PRIMARY CARE 2022; 23:54. [PMID: 35321654 PMCID: PMC8942053 DOI: 10.1186/s12875-022-01647-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/23/2022] [Indexed: 11/10/2022]
Abstract
Background Warfarin remains the most affordable oral anticoagulant in many countries. However, it may have serious side effects, and the success of the therapy depends on the patient’s understanding of the medication and their adherence to treatment. The use of short messages services (SMS) is a strategy that can be used to educate patients, but there are no studies evaluating this intervention in patients taking warfarin. Therefore, we aimed to develop, implement, and assess the feasibility of an intervention using SMS to primary care patients taking warfarin in a medium-sized Brazilian city. Methods A bank of 79 SMS was drafted and validated by an expert panel. During 6 months, three times a week, patients received messages about anticoagulation with warfarin. At baseline and after 3 months, we assessed their knowledge and adherence with validated instruments. At the end of the follow-up, participants answered a satisfaction questionnaire. Subsequently, a scale-up phase was conducted, with another round of the intervention including 82 participants (29 from the first phase and 53 newly recruited). Seven months after the end of the scale-up, we asked the patients for their insights about the long-term effects of this program. All patients signed informed consent. The study was approved by the Research and Ethics committee of the Universidade Federal de Minas Gerais. Results In the pilot, 33 (89.2%) patients completed the follow-up. Among the participants who answered the satisfaction questionnaire (n = 29), 86.2% considered that the intervention motivated a healthy lifestyle and improved their understanding of warfarin therapy. All patients were willing to continue receiving the messages. Adherence measured by the Measure of Adherence to Treatment (MAT) test was high in the pre-intervention assessment and remained high (96.7% vs. 93.3%; p = 1.0000). The proportion of patients who achieved > 75% correct answers on the Oral Anticoagulation Knowledge (OAK) test increased from 6.5% to 25.6, p = 0.0703. In the scale-up, 23 patients answered the long-term assessment questionnaire. The main long-term knowledge reported was dietary information. Nine patients received the messages but did not remember their content. Conclusion The intervention was well-accepted and had a positive impact on patient’s knowledge about oral anticoagulation therapy. The scale-up assessment reinforced the need to constantly monitor digital interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01647-5.
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Ullal AJ, Holmes DN, Lytle BL, Matsouaka RA, Sheng S, Desai NR, Curtis AB, Fang MC, McCabe PJ, Fonarow GC, Russo AM, Lewis WR, Heidenreich PA, Piccini JP, Turakhia MP, Perino AC, On Behalf Of The Gwtg-Afib Working Group. Achievement and quality measure attainment in patients hospitalized with atrial fibrillation: Results from The Get With The Guidelines - Atrial Fibrillation (GWTG-AFIB) registry. Am Heart J 2022; 245:90-99. [PMID: 34932998 DOI: 10.1016/j.ahj.2021.12.002] [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] [Received: 03/08/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The Get With The Guidelines - Atrial Fibrillation (GWTG-AFIB) Registry uses achievement and quality measures to improve the care of patients with atrial fibrillation (AF). We sought to evaluate overall and site-level variation in attainment of these measures among sites participating in the GWTG-AFIB Registry. METHODS From the GWTG-AFIB registry, we included patients with AF admitted between 1/3/2013 and 6/30/2019. We described patient-level attainment and variation in attainment across sites of 6 achievement measures with 1) defect-free scores (percent of patients with all eligible measures attained), and 2) composite opportunity scores (percent of all eligible patient measures attained). We also described attainment of 11 quality measures at the patient-level. RESULTS Among 80,951 patients hospitalized for AF (age 70±13 years, 47.0% female; CHA2DS2-VASc 3.6±1.8) at 132 sites. Site-level defect-free scores ranged from 4.7% to 85.8% (25th, 50th, 75th percentile: 32.7%, 52.1%, 64.4%). Composite opportunity scores ranged from 39.4% to 97.5% (25th, 50th, 75th: 68.1%, 80.3%, 87.1%). Attainment was notably low for the following quality measures: 1) aldosterone antagonist prescription when ejection fraction ≤35% (29% of those eligible); and 2) avoidance of antiplatelet therapy with OAC in patients without coronary/peripheral artery disease (81% of those eligible). CONCLUSIONS Despite high overall attainment of care measures across GWTG-AFIB registry sites, large site variation was present with meaningful opportunities to improve AF care beyond OAC prescription, including but not limited to prescription of aldosterone antagonists in those with AF and systolic dysfunction and avoidance of non-indicated adjunctive antiplatelet therapy.
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Key Words
- ACC, American College of Cardiology
- AF, atrial fibrillation
- AFL, atrial flutter
- AHA, American Heart Association
- CI, confidence interval, eGFR, estimate glomerular filtration rate
- CKD, chronic kidney disease
- GWTG-AFIB, Get With The Guidelines® – Atrial Fibrillation
- HRS, Heart Rhythm Society
- OAC, oral anticoagulation
- OR, odds ratio
- QI, quality improvement
- atrial fibrillation
- performance
- quality
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7
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Essien UR, Kim N, Hausmann LRM, Mor MK, Good CB, Magnani JW, Litam TMA, Gellad WF, Fine MJ. Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System. JAMA Netw Open 2021; 4:e2114234. [PMID: 34319358 PMCID: PMC8319757 DOI: 10.1001/jamanetworkopen.2021.14234] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups. Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients. OBJECTIVE To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included 111 666 patients within the VA system with incident atrial fibrillation between January 1, 2014, and December 31, 2018. Data were analyzed between December 1, 2019, and March 31, 2020. EXPOSURES Any anticoagulation was defined as receipt of warfarin or direct-acting oral anticoagulants, apixaban, dabigatran, edoxaban, or rivaroxaban. MAIN OUTCOMES AND MEASURES Initiation of any anticoagulation (or direct-acting oral anticoagulant therapy in those who initiated any anticoagulation) was examined within 90 days of an index atrial fibrillation diagnosis. RESULTS Our final cohort comprised 111 666 patients (109 386 men [98.0%] and 95 493 White patients [85.5%]; mean [SD] age, 72.9 [10.4] years). A total of 69 590 patients (62.3%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity (P < .001); initiation was lowest in Asian (52.2% [n = 676]) and Black (60.3% [n = 6177]) patients and highest in White patients (62.7% [n = 59 881]). Among anticoagulant initiators, 45 381 (65.2%) used direct-acting oral anticoagulants, varying 7.2 percentage points by race/ethnicity (P < .001); initiation was lowest in Hispanic (58.3% [n = 1470]), American Indian/Alaska Native (59.8% [n = 201]), and Black (60.9% [n = 3763]) patients and highest in White patients (66.0% [n = 39 502). Compared with White patients, the odds of initiating any anticoagulant therapy were significantly lower for Asian (adjusted odds ratio [aOR], 0.82; 95% CI, 0.72-0.94) and Black (aOR, 0.90; 95% CI 0.85-0.95) patients. Among initiators, the adjusted odds of direct-acting oral anticoagulant initiation were significantly lower for Hispanic (aOR, 0.79; 95% CI, 0.70-0.89), American Indian/Alaska Native (aOR, 0.75; 95% CI, 0.57-0.99), and Black (aOR, 0.74; 95% CI 0.69-0.80) patients. CONCLUSIONS AND RELEVANCE This cohort study found that in patients with incident atrial fibrillation managed in the VA system, race/ethnicity was independently associated with initiating any anticoagulant therapy and direct-acting oral anticoagulant use among anticoagulant initiators. Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients treated in the VA system.
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Affiliation(s)
- Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, Pennsylvania
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Terrence M A Litam
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Liu H, Collins R, Miller RJH, Southern DA, Arena R, Aggarwal S, Sajobi T, James MT, Wilton SB. Use of a Clinical Electrocardiographic Database to Enhance Atrial Fibrillation/Atrial Flutter Identification Algorithms Based on Administrative Data. J Am Heart Assoc 2021; 10:e018511. [PMID: 33719522 PMCID: PMC8174383 DOI: 10.1161/jaha.120.018511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Administrative data have limited sensitivity for case finding of atrial fibrillation/atrial flutter (AF/AFL). Linkage with clinical repositories of interpreted ECGs may enhance diagnostic yield of AF/AFL. Methods and Results We retrieved 369 ECGs from the institutional Marquette Universal System for Electrocardiography (MUSE) repository as validation samples, with rhythm coded as AF (n=49), AFL (n=50), or other competing rhythm diagnoses (n=270). With blinded, duplicate review of ECGs as the reference comparison, we compared multiple MUSE coding definitions for identifying AF/AFL. We tested the agreement between MUSE diagnosis and reference comparison, and calculated the sensitivity and specificity. Using a data set linking clinical registries, administrative data, and the MUSE repository (n=11 662), we assessed the incremental diagnostic yield of AF/AFL by incorporating ECG data to administrative data‐based algorithms. The agreement between MUSE diagnosis and reference comparison depended on the coding definitions applied, with the Cohen κ ranging from 0.57 to 0.75. Sensitivity ranged from 60.6% to 79.1%, and specificity ranged from 93.2% to 98.0%. A coding definition with AF/AFL appearing in the first 3 ECG statements had the highest sensitivity (79.1%), with little loss of specificity (94.5%). Compared with the algorithms with only administrative data, incorporating ECG data increased the diagnostic yield of preexisting AF/AFL by 14.5% and incident AF/AFL by 7.5% to 16.1%. Conclusions Routine ECG interpretation using MUSE coding is highly specific and moderately sensitive for AF/AFL detection. Inclusion of MUSE ECG data in AF/AFL case identification algorithms can identify cases missed using administrative data‐based algorithms alone.
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Affiliation(s)
- Hongwei Liu
- Libin Cardiovascular InstituteCumming School of MedicineUniversity of Calgary Calgary AB Canada.,Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary AB Canada
| | - Reid Collins
- Libin Cardiovascular InstituteCumming School of MedicineUniversity of Calgary Calgary AB Canada
| | - Robert J H Miller
- Libin Cardiovascular InstituteCumming School of MedicineUniversity of Calgary Calgary AB Canada
| | - Danielle A Southern
- Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary AB Canada.,O'Brien Institute for Public HealthCumming School of MedicineUniversity of Calgary Calgary AB Canada
| | - Ross Arena
- TotalCardiology Research Network Calgary AB Canada.,Department of Physical Therapy College of Applied Health Sciences University of Illinois at Chicago Chicago IL
| | - Sandeep Aggarwal
- Libin Cardiovascular InstituteCumming School of MedicineUniversity of Calgary Calgary AB Canada.,TotalCardiology Research Network Calgary AB Canada.,TotalCardiology Rehabilitation Calgary AB Canada
| | - Tolulope Sajobi
- Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary AB Canada.,O'Brien Institute for Public HealthCumming School of MedicineUniversity of Calgary Calgary AB Canada
| | - Matthew T James
- Libin Cardiovascular InstituteCumming School of MedicineUniversity of Calgary Calgary AB Canada.,Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary AB Canada.,O'Brien Institute for Public HealthCumming School of MedicineUniversity of Calgary Calgary AB Canada
| | - Stephen B Wilton
- Libin Cardiovascular InstituteCumming School of MedicineUniversity of Calgary Calgary AB Canada.,Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary AB Canada.,TotalCardiology Research Network Calgary AB Canada
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Ritchie LA, Lip GYH, Lane DA. Optimization of atrial fibrillation care: management strategies and quality measures. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:121-133. [PMID: 32761177 DOI: 10.1093/ehjqcco/qcaa063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/22/2020] [Accepted: 07/29/2020] [Indexed: 12/14/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and a leading cause of mortality and morbidity. Optimal management of AF is paramount to improve quality of life and reduce the impact on health and social care services. Owing to its strong associations with other cardiovascular and non-cardiovascular comorbidities, a holistic management approach to AF care is advocated but this is yet to be clearly defined by international clinical guidelines. This ambiguity has prompted us to review the available clinical evidence on different management strategies to optimize AF care in the context of performance and quality measures, which can be used to objectively assess standards of care.
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Affiliation(s)
- Leona A Ritchie
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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10
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Wilton SB, Kaul P, Islam S, Atzema CL, Cruz J, MacFarlane K, McKelvie R, Poon S, Lambert L, Rush K, Deyell M, Wyse DG, Cox JL, Skanes A, Sandhu RK. Surveillance for Outcomes Selected as Atrial Fibrillation Quality Indicators in Canada: 10-Year Trends in Stroke, Major Bleeding, and Heart Failure. CJC Open 2021; 3:609-618. [PMID: 34036258 PMCID: PMC8134946 DOI: 10.1016/j.cjco.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/04/2021] [Indexed: 11/29/2022] Open
Abstract
Background Whether advances in identification and management of atrial fibrillation and atrial flutter (collectively, AF) have led to improved outcomes is unclear. We sought to study trends in clinical outcomes selected as quality indicators for nonvalvular AF in Canada. Methods We identified hospitalized patients with a first diagnosis of nonvalvular AF between April 2006 and March 2015, in all of Canada except Quebec. We assessed trends in 1-year incidence of stroke/systemic embolism (SSE), major bleeding, and initial heart failure (HF) hospitalization. Results The cohort included 466,476 patients. The median age was 77 years (interquartile range, 68-84 years), 46% were female, and 68% had a Congestive Heart Failure, Hypertension, Age (≥75 years), Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age (65-74 years), Sex (Female) (CHA2DS2-VASc) score > 3. Within 1 year of discharge, 3.5% were hospitalized for stroke or SSE, 1.6% for major bleeding, and 8.6% for new HF. Over the study period, the crude rate of SSE declined from 3.6% to 3.3% (P = 0.002), whereas the rates of hospitalization for new HF and for major bleeding did not significantly change. After adjustment for CHA2DS2-VASc score, the yearly rates of incident SSE (risk ratio, 0.99; 95% confidence interval [CI], 0.98-0.99; P = 0.002) and HF (risk ratio, 0.99; 95% CI, 0.99-1.00; P = 0.001) declined ≤ 1% absolute, whereas major bleeding remained unchanged (risk ratio, 1.00; 95% CI, 0.99-1.00; P = 0.28). Conclusions Among hospitalized patients with nonvalvular AF in Canada, the rate of SSE and new HF decreased modestly over a 10-year period, with no significant change in major bleeding. Efforts to study process-based quality indicators, with increased focus on HF prevention, are needed.
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Affiliation(s)
- Stephen B Wilton
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Padma Kaul
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Sunjidatul Islam
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Clare L Atzema
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jennifer Cruz
- Cardiac Arrhythmia Service, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Robert McKelvie
- Division of Cardiology, Western University, London, Ontario, Canada
| | - Stephanie Poon
- Division of Cardiology, Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Laurie Lambert
- Institut national d'excellence en santé et en services sociaux, Montreal, Quebec, Canada
| | - Kathy Rush
- Faculty of Health and Social Development, School of Nursing, University of British Columbia, Kelowna, British Columbia, Canada.,Departments of Medicine and of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Marc Deyell
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - D George Wyse
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jafna L Cox
- Departments of Medicine and of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Allan Skanes
- Department of Medicine, London Heart Institute, University of Western Ontario, London, Ontario, Canada
| | - Roopinder K Sandhu
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
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11
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Field ME, Holmes DN, Page RL, Fonarow GC, Matsouaka RA, Turakhia MP, Lewis WR, Piccini JP. Guideline-Concordant Antiarrhythmic Drug Use in the Get With The Guidelines-Atrial Fibrillation Registry. Circ Arrhythm Electrophysiol 2021; 14:e008961. [PMID: 33419385 DOI: 10.1161/circep.120.008961] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antiarrhythmic drug (AAD) therapy for atrial fibrillation (AF) can be associated with both proarrhythmic and noncardiovascular toxicities. Practice guidelines recommend tailored AAD therapy for AF based on patient-specific characteristics, such as coronary artery disease and heart failure, to minimize adverse events. However, current prescription patterns for specific AADs and the degree to which these guidelines are followed in practice are unknown. METHODS Patients enrolled in the Get With The Guidelines-Atrial Fibrillation registry with a primary diagnosis of AF discharged on an AAD between January 2014 and November 2018 were included. We analyzed rates of prescription of each AAD in several subgroups including those without structural heart disease. We classified AAD use as guideline concordant or nonguideline concordant based on 6 criteria derived from the American Heart Association/American College of Cardiology/Heart Rhythm Society AF guidelines. Guideline concordance for amiodarone was not considered applicable, since its use is not specifically contraindicated in the guidelines for reasons such as structural heart disease or renal function. We analyzed guideline-concordant AAD use by specific patient and hospital characteristics, and regional and temporal trends. RESULTS Among 21 921 patients from 123 sites, the median age was 69 years, 46% female and 51% had paroxysmal AF. The most commonly prescribed AAD was amiodarone (38%). Sotalol (23.2%) and dofetilide (19.2%) were each more commonly prescribed than either flecainide (9.8%) or propafenone (4.8%). Overall guideline-concordant AAD prescription at discharge was 84%. Guideline-concordant AAD use by drug was as follows: dofetilide 93%, sotalol 66%, flecainide 68%, propafenone 48%, and dronedarone 80%. There was variability in rate of guideline-concordant AAD use by hospital and geographic region. CONCLUSIONS Amiodarone remains the most commonly prescribed AAD for AF followed by sotalol and dofetilide. Rates of guideline-concordant AAD use were high, and there was significant variability by specific drugs, hospitals, and regions, highlighting opportunities for additional quality improvement.
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Affiliation(s)
- Michael E Field
- Medical University of South Carolina, Charleston, SC (M.E.F.)
| | | | - Richard L Page
- Larner College of Medicine, University of Vermont, Burlington (R.L.P.)
| | - Gregg C Fonarow
- Ronald Reagan-UCLA Medical Center, University of California, Los Angeles (G.C.F.)
| | - Roland A Matsouaka
- Duke Clinical Research Institute (D.N.H., R.A.M., J.P.P.), Durham, NC.,Duke University Medical Center (R.A.M., J.P.P.), Durham, NC
| | - Mintu P Turakhia
- VA Palo Alto Health Care System and Stanford University School of Medicine, CA (M.P.T.)
| | - William R Lewis
- MetroHealth System Campus, Case Western Reserve University, Cleveland, OH (W.R.L.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute (D.N.H., R.A.M., J.P.P.), Durham, NC.,Duke University Medical Center (R.A.M., J.P.P.), Durham, NC
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12
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Racial disparities among Asian Americans with atrial fibrillation: An analysis from the NCDR® PINNACLE Registry. Int J Cardiol 2021; 329:209-216. [PMID: 33412180 DOI: 10.1016/j.ijcard.2020.12.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/02/2020] [Accepted: 12/18/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is paucity of data on Atrial Fibrillation (AF) management and associated clinical outcomes among Asian Americans. This study sought to investigate baseline risk factor profiles, racial disparities in clinical management and adverse clinical outcomes among White and Asian Americans. METHODS We used National Cardiovascular Data Registry (NCDR®) Practice Innovation and Clinical Excellence (PINNACLE) registry and linked Centers of Medicare and Medicaid Services data to identify Asian and White patients with AF between January 1, 2013-June 30, 2018. We compared rates of baseline risk factors, management strategies (rate versus rhythm control), anticoagulation use and rates of adverse events between racial groups. The two race groups were compared using hierarchical multivariable adjusted regression models to account for site and confounders. RESULTS In total, 1,359,827 patients (18,793 Asians and 1,341,034 Whites) were included in our analysis. Compared to White Americans, Asian Americans were more likely to use a rate control strategy (Odds Ratio [OR]: 1.20, 95% Confidence Interval [CI]: 1.15-1.25) and lower odds of rhythm control strategy (atrial ablations, cardioversions, or use of antiarrhythmic drugs) (OR: 0.83, 95% CI: 0.80-0.87) in adjusted analysis. Use of oral anticoagulants and direct oral anticoagulants were similar. There were no significant race-based differences in likelihood of all-cause mortality, stroke, and bleeding requiring hospitalization. Analyses performed using propensity score matching were consistent with the main results. CONCLUSIONS Asian Americans with AF have a lower likelihood of being managed with rhythm control strategies. Overall use of OAC and AF related adverse events remain similar between the two racial groups.
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13
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Heidenreich PA, Estes NAM, Fonarow GC, Jurgens CY, Kittleson MM, Marine JE, McManus DD, McNamara RL. 2020 Update to the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ Cardiovasc Qual Outcomes 2020; 14:e000100. [PMID: 33284642 DOI: 10.1161/hcq.0000000000000100] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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14
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Lee MT, Park KY, Kim MS, You SH, Kang YJ, Jung SY. Concomitant Use of NSAIDs or SSRIs with NOACs Requires Monitoring for Bleeding. Yonsei Med J 2020; 61:741-749. [PMID: 32882758 PMCID: PMC7471076 DOI: 10.3349/ymj.2020.61.9.741] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Non-vitamin K antagonist oral anticoagulants (NOACs) are widely used in patients with atrial fibrillation (AF) because of their effectiveness in preventing stroke and their better safety, compared with warfarin. However, there are concerns for an increased risk of bleeding associated with concomitant use of non-steroidal anti-inflammatory drugs (NSAIDs) or selective serotonin reuptake inhibitors (SSRIs) with NOACs. In this study, we aimed to evaluate the risk of bleeding events in individuals taking concomitant NSAIDs or SSRIs with NOACs after being diagnosed with AF. MATERIALS AND METHODS A nested case-control analysis to assess the safety of NSAIDs and SSRIs among NOAC users with AF was performed using data from Korean National Health Insurance Service from January 2012 to December 2017. Among patients who were newly prescribed NOACs, 1233 cases hospitalized for bleeding events were selected, and 24660 controls were determined. RESULTS The risk of bleeding events was higher in patients receiving concomitant NSAIDs [adjusted odds ratio (aOR) 1.41; 95% confidence interval (CI) 1.24-1.61] or SSRIs (aOR 1.92; 95% CI 1.52-2.42) with NOACs, compared to no use of either drug, respectively. The risk of upper gastrointestinal bleeding was higher in patients receiving concomitant NSAIDs or SSRIs without proton pump inhibitors (PPIs) (NSAIDs: aOR 2.47; 95% CI 1.26-4.83, SSRI: aOR 10.8; 95% CI 2.41-2.48) compared to no use. CONCLUSION When NSAIDs or SSRIs are required for NOAC users with AF, physicians need to monitor bleeding events and consider the use of PPIs, especially for combined use of both drugs or when initiating NOACs treatment.
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Affiliation(s)
- Min Taek Lee
- College of Pharmacy, Chung-Ang University, Seoul, Korea
| | - Kwang Yeol Park
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Myo Song Kim
- College of Pharmacy, Chung-Ang University, Seoul, Korea
| | - Seung Hun You
- College of Pharmacy, Chung-Ang University, Seoul, Korea
| | - Ye Jin Kang
- College of Pharmacy, Chung-Ang University, Seoul, Korea
| | - Sun Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Korea.
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15
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Fu R, Feng S, Wu Y, He F, Lin Z, Jiang Y, Hu Z. Association between compliance with quality indicators and hospitalisation expenses in patients with heart failure: a retrospective study using quantile regression model in China. BMJ Open 2020; 10:e033926. [PMID: 32709638 PMCID: PMC7380880 DOI: 10.1136/bmjopen-2019-033926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To explore the association between compliance with quality indicators and hospitalisation expenses in patients with heart failure. DESIGN Generalised linear model and quantile regression model were used to examine the association between compliance with five quality indicators and hospitalisation expenses. SETTING Grade A hospital in Fujian Province, China. PARTICIPANTS Data on 2568 heart failure admissions between 2010 and 2015 were analysed. RESULTS The median (IQR) of hospitalisation expenses of 2568 patients was ¥10.9 (¥6.9-¥31.6) thousand. The rates of compliance with five quality indicators were 90.3% for evaluation of left ventricular function, 43.8% for diuretics, 62.0% for ACE inhibitors (ACEI) or angiotensin receptor blockers (ARB), 67.4% for beta-blockers, and 58.9% for aldosterone receptor antagonists. After adjustment for gender, age, residence, method of payment, number of diseases before admission, number of diseases at admission, number of emergency treatments during hospital stay and length of stay, patients who received evaluation for left ventricular function, diuretics, or ACEI or ARB had lower hospitalisation expenses, and patients who received beta-blockers had higher hospitalisation expenses, compared with their counterparts in generalised linear models. Differences in hospitalisation expenses between compliance and non-compliance with quality indicators became larger across quantile levels of hospitalisation expenses, and were found to be statistically significant when quantile level exceeded 0.80 (¥39.7 thousand) in quantile regression models. CONCLUSIONS The quality of care for patients with heart failure was below the target level. There was a negative relationship between compliance with quality indicators and hospitalisation expenses at the extreme quantile of expenses. More attention should be given to patients who may experience extreme expenses, and effective measures should be taken to improve the quality of care they receive.
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Affiliation(s)
- Rong Fu
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian, China
| | - Shaodan Feng
- Emergency Department, Fujian Medical University Affiliated Fuzhou First Hospital, Fuzhou, Fujian, China
| | - Yilong Wu
- Emergency Department, Fujian Medical University Affiliated Fuzhou First Hospital, Fuzhou, Fujian, China
| | - Fei He
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian, China
| | - Zheng Lin
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian, China
| | - Yixian Jiang
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian, China
| | - Zhijian Hu
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian, China
- Fujian Digital Institute for Tumor Big Data, Fujian Medical University, Fuzhou, Fujian, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian, China
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16
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Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019; 139:e56-e528. [PMID: 30700139 DOI: 10.1161/cir.0000000000000659] [Citation(s) in RCA: 5292] [Impact Index Per Article: 1058.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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17
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Seidman J, Masi D, Gomez-Rexrode AE. Personalizing Value in Cancer Care: The Case for Incorporating Patient Preferences Into Routine Clinical Decision Making. J Particip Med 2019; 11:e13800. [PMID: 33055068 PMCID: PMC7434102 DOI: 10.2196/13800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/03/2019] [Accepted: 05/25/2019] [Indexed: 12/01/2022] Open
Abstract
Despite growing research demonstrating the potential for shared decision making (SDM) to improve health outcomes, patient preferences—including financial trade-offs—are still not routinely incorporated into health care decision making. As the US health care delivery system transitions to rewarding value-based care, the question of “value to whom?” assumes greater importance. To achieve the goals of value-based care, the patient voice must be incorporated into clinical decision making by embedding SDM as a routine part of clinical practice. Identified as a priority by the Centers for Medicare & Medicaid Services (CMS), SDM-related measures and initiatives have already been integrated into CMS’ Center for Medicare and Medicaid Innovation (Innovation Center) demonstration projects (eg, the Oncology Care Model and Transforming Clinical Practice Initiative) and value-based payment programs (eg, the Merit-based Incentive Payment System, Medicare Shared Savings Program) to incentivize more proactive SDM engagement between patients and their providers. Furthermore, CMS has also integrated formal shared decision-making encounters into coverage and reimbursement policies (eg, for implantable cardioverter defibrillators), demonstrating a growing interest in SDM and its potential for eliciting and promoting the integration of patient preferences into the clinical decision-making process. In addition to increasing policy efforts to promote SDM, we need more research investments aimed at understanding how to optimize the science and practice of meaningful SDM. The current landscape and proposed road map for next steps in research, outlined in this review article, will help ensure the transition of pilots and research projects regarding the implementation of SDM into sustainable solutions.
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Affiliation(s)
- Joshua Seidman
- Avalere Health, Center for Healthcare Transformation, Washington, DC, United States
| | - Domitilla Masi
- Avalere Health, Center for Healthcare Transformation, Washington, DC, United States
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18
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Wang SV, Rogers JR, Jin Y, DeiCicchi D, Dejene S, Connors JM, Bates DW, Glynn RJ, Fischer MA. Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation. BMJ Qual Saf 2019; 28:835-842. [PMID: 31243156 DOI: 10.1136/bmjqs-2019-009367] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/30/2019] [Accepted: 06/04/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Clinical guidelines recommend anticoagulation for patients with atrial fibrillation (AF) at high risk of stroke; however, studies report 40% of this population is not anticoagulated. OBJECTIVE To evaluate a population health intervention to increase anticoagulation use in high-risk patients with AF. METHODS We used machine learning algorithms to identify patients with AF from electronic health records at high risk of stroke (CHA2DS2-VASc risk score ≥2), and no anticoagulant prescriptions within 12 months. A clinical pharmacist in the anticoagulation service reviewed charts for algorithm-identified patients to assess appropriateness of initiating an anticoagulant. The pharmacist then contacted primary care providers of potentially undertreated patients and offered assistance with anticoagulation management. We used a stepped-wedge design, evaluating the proportion of potentially undertreated patients with AF started on anticoagulant therapy within 28 days for clinics randomised to intervention versus usual care. RESULTS Of 1727 algorithm-identified high-risk patients with AF in clinics at the time of randomisation to intervention, 432 (25%) lacked evidence of anticoagulant prescriptions in the prior year. After pharmacist review, only 17% (75 of 432) of algorithm-identified patients were considered potentially undertreated at the time their clinic was randomised to intervention. Over a third (155 of 432) were excluded because they had a single prior AF episode (transient or provoked by serious illness); 36 (8%) had documented refusal of anticoagulation, the remainder had other reasons for exclusion. The intervention did not increase new anticoagulant prescriptions (intervention: 4.1% vs usual care: 4.0%, p=0.86). CONCLUSIONS Algorithms to identify underuse of anticoagulation among patients with AF in healthcare databases may not capture clinical subtleties or patient preferences and may overestimate the extent of undertreatment. Changing clinician behaviour remains challenging.
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Affiliation(s)
- Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James R Rogers
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yinzhu Jin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David DeiCicchi
- Anticoagulation Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Sara Dejene
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M Connors
- Anticoagulation Services, Brigham and Women's Hospital, Boston, MA, USA
| | - David W Bates
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael A Fischer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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19
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Whitsett M, Wilcox J, Yang A, Zhao L, Rinella M, VanWagner LB. Atrial fibrillation is highly prevalent yet undertreated in patients with biopsy-proven nonalcoholic steatohepatitis. Liver Int 2019; 39:933-940. [PMID: 30536602 PMCID: PMC6483865 DOI: 10.1111/liv.14018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/21/2018] [Accepted: 11/29/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Nonalcoholic steatohepatitis (NASH) is associated with increased cardiovascular disease. Atrial fibrillation is a prominent risk marker for underlying cardiovascular disease with a prevalence of 2% in patients <65 years old. Atrial fibrillation prevalence in NASH is unknown. We sought to assess the prevalence and impact of atrial fibrillation on healthcare utilization in NASH. METHODS Patients were identified from a tertiary care centre Electronic Database from 2002 to 2015. International Classification of Diseases 9 (ICD9) codes identified comorbidities and atrial fibrillation. Descriptive statistics were used to compare characteristics between patients with NASH with and without atrial fibrillation. RESULTS Of 9108 patients with ICD9 diagnosis of NASH, 215 (2.3%, mean age 57 years, 32% male) had biopsy-proven NASH. Atrial fibrillation prevalence was 4.6%. Patients with NASH and atrial fibrillation had a higher prevalence of heart failure (54.5% vs 8.8%, P < 0.001) and cerebrovascular (27.3% vs 2.0%, P < 0.001) or vascular disease (54.5% vs 13.2%, P = 0.002), compared to NASH without atrial fibrillation. All patients with NASH and atrial fibrillation had a CHA2DS2VASc score ≥2 indicating high stroke risk and need for anticoagulation. Eight of 10 patients were eligible for anticoagulation and 5 of 8 (62.5%) received appropriate therapy. CONCLUSION Atrial fibrillation prevalence is two-fold higher in patients with NASH compared to the general population. Patients with NASH have a high risk of stroke; however, many do not receive appropriate guideline-directed therapy. Future studies are needed to identify whether guideline-based management of atrial fibrillation in NASH reduces cardiovascular morbidity and mortality.
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Affiliation(s)
| | - Jane Wilcox
- Divison of Cardiology, Northwestern University Feinberg School of Medicine
| | - Amy Yang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
| | - Lihui Zhao
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
| | - Mary Rinella
- Divison of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine
| | - Lisa B. VanWagner
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine,Divison of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine
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20
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Zeballos-Palacios CL, Hargraves IG, Noseworthy PA, Branda ME, Kunneman M, Burnett B, Gionfriddo MR, McLeod CJ, Gorr H, Brito JP, Montori VM. Developing a Conversation Aid to Support Shared Decision Making: Reflections on Designing Anticoagulation Choice. Mayo Clin Proc 2019; 94:686-696. [PMID: 30642640 PMCID: PMC6450705 DOI: 10.1016/j.mayocp.2018.08.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/02/2018] [Accepted: 08/29/2018] [Indexed: 12/31/2022]
Abstract
Patient-centered care requires that treatments respond to the problematic situation of each patient in a manner that makes intellectual, emotional, and practical sense, an achievement that requires shared decision making (SDM). To implement SDM in practice, tools-sometimes called conversation aids or decision aids-are prepared by collating, curating, and presenting high-quality, comprehensive, and up-to-date evidence. Yet, the literature offers limited guidance for how to make evidence support SDM. Herein, we describe our approach and the challenges encountered during the development of Anticoagulation Choice, a conversation aid to help patients with atrial fibrillation and their clinicians jointly consider the risk of thromboembolic stroke and decide whether and how to respond to this risk with anticoagulation.
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Affiliation(s)
| | - Ian G. Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Peter A. Noseworthy
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Megan E. Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Louis Park, MN, USA
| | | | - Christopher J. McLeod
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Haeshik Gorr
- Department of Medicine, Hennepin Healthcare System, Minneapolis, MN, USA
| | - Juan Pablo Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
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21
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Piccini JP, Xu H, Cox M, Matsouaka RA, Fonarow GC, Butler J, Curtis AB, Desai N, Fang M, McCabe PJ, Page II RL, Turakhia M, Russo AM, Knight BP, Sidhu M, Hurwitz JL, Ellenbogen KA, Lewis WR. Adherence to Guideline-Directed Stroke Prevention Therapy for Atrial Fibrillation Is Achievable. Circulation 2019; 139:1497-1506. [DOI: 10.1161/circulationaha.118.035909] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jonathan P. Piccini
- Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (J.P.P., H.X., M.C., R.A.M.)
| | - Haolin Xu
- Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (J.P.P., H.X., M.C., R.A.M.)
| | - Margueritte Cox
- Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (J.P.P., H.X., M.C., R.A.M.)
| | - Roland A. Matsouaka
- Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (J.P.P., H.X., M.C., R.A.M.)
| | - Gregg C. Fonarow
- Ronald Reagan-UCLA Medical Center, University of California, Los Angeles (G.C.F.)
| | - Javed Butler
- Stony Brook University School of Medicine, NY (J.B.)
| | | | | | | | | | | | - Mintu Turakhia
- VA Palo Alto Health Care System and Stanford University School of Medicine, CA (M.T.)
| | | | - Bradley P. Knight
- Feinberg School of Medicine, Northwestern University, Chicago, IL (B.P.K.)
| | | | | | | | - William R. Lewis
- MetroHealth System Campus, Case Western Reserve University, Cleveland, OH (W.R.L.)
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22
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Padrini R. Clinical Pharmacokinetics and Pharmacodynamics of Direct Oral Anticoagulants in Patients with Renal Failure. Eur J Drug Metab Pharmacokinet 2018; 44:1-12. [DOI: 10.1007/s13318-018-0501-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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23
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Feldberg J, Patel P, Farrell A, Sivarajahkumar S, Cameron K, Ma J, Battistella M. A systematic review of direct oral anticoagulant use in chronic kidney disease and dialysis patients with atrial fibrillation. Nephrol Dial Transplant 2018; 34:265-277. [DOI: 10.1093/ndt/gfy031] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/24/2018] [Indexed: 12/15/2022] Open
Affiliation(s)
- Jordanne Feldberg
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Param Patel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Ashley Farrell
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | | | - Karen Cameron
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
| | - Jennifer Ma
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
| | - Marisa Battistella
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
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24
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Goldfarb M, Bibas L, Newby LK, Henry TD, Katz J, van Diepen S, Cercek B. Systematic review and directors survey of quality indicators for the cardiovascular intensive care unit. Int J Cardiol 2018. [PMID: 29514748 DOI: 10.1016/j.ijcard.2018.02.113] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Quality indicators (QIs) are increasingly used in cardiovascular care as measures of performance but there is currently no consensus on indicators for the cardiovascular intensive care unit (CICU). METHODS We searched Medline, CINAHL, EMBASE, and COCHRANE databases from inception until October 2016 and websites for organizations involved in quality measurement for QIs relevant to cardiovascular disease in an intensive or critical care setting. We surveyed 14 expert cardiac intensivist-administrators (7 European; 7 North American) on the importance and relevance of each indicator as a measure of CICU care quality using a scale of 1 (=lowest) to 10 (=highest). Indicators with a mean score ≥8/10 for both importance and relevance were included in the final set. RESULTS Overall, 108 QIs (70 process, 18 structural, 18 outcome, 1 patient engagement, and 1 covering multiple domains) were identified in 30 articles representing 23 agencies, organizations, and societies. Disease-specific QIs included myocardial infarction (n = 37), heart failure (n = 31), atrial fibrillation (n = 11), and cardiac rehabilitation (n = 1); general QIs represented about one-quarter (n = 28) of all measures. Fifteen QIs were selected for the final QI set: 7 process, 2 structural, and 6 outcome measures, including 6 general and 9 disease-specific measures. Outcome measures chosen to evaluate general CICU performance included overall CICU mortality, length of stay, and readmission rate. CONCLUSIONS Numerous QIs relevant to the CICU have been recommended by a variety of organizations. The indicators chosen by the cardiac intensivist-administrators could serve as a basis for future efforts to develop a standardized set of quality measures for the CICU.
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Affiliation(s)
- Michael Goldfarb
- Division of Pulmonary and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Lior Bibas
- Division of Cardiology, McGill University, Montreal, Quebec, Canada
| | - L Kristin Newby
- Division of Cardiology, Duke University, Durham, NC, United States
| | - Timothy D Henry
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Jason Katz
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Bojan Cercek
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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25
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Yong CM, Liu Y, Apruzzese P, Doros G, Cannon CP, Maddox TM, Gehi A, Hsu JC, Lubitz SA, Virani S, Turakhia MP. Association of insurance type with receipt of oral anticoagulation in insured patients with atrial fibrillation: A report from the American College of Cardiology NCDR PINNACLE registry. Am Heart J 2018; 195:50-59. [PMID: 29224646 DOI: 10.1016/j.ahj.2017.08.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 08/16/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND It is poorly understood whether insurance type may be a major contributor to the underuse of oral anticoagulation (OAC) among patients with atrial fibrillation (AF), particularly for novel oral anticoagulants (NOACs). METHODS We performed a retrospective cohort registry study of patients with insurance, AF, CHA2DS2-VASc ≥2, and at least one outpatient encounter recorded in the ACC NCDR's PINNACLE Registry between January 1, 2011 and December 31, 2014. We used hierarchical regression, adjusting for patient characteristics and clustering by physician, to evaluate the association of insurance type (Private, Military, Medicare, Medicaid, Other) with receipt of OAC (any OAC, warfarin, or NOAC). RESULTS In 363,309 patients (age 75±10; 48% female), we found a significant difference in proportions of OAC and NOAC prescription across insurance types (OAC: Military 53%, Private 53%, Medicare 52%, Other 41%, Medicaid 41%, P<.001; NOAC: Military 24%, Private 19%, Medicare 17%, Other 17%, Medicaid 8%, P<.001). After adjustment for patient characteristics and facility, private, Medicaid, and other insurance were independently associated with a lower odds of OAC prescription relative to Medicare, but military insured patients were not significantly different. After adjustment, military and private insurance were independently associated with a higher odds of NOAC prescription relative to Medicare, while Medicaid and other insurance were associated with a lower odds of NOAC prescription. CONCLUSIONS In a contemporary US AF population, there was significant variation of OAC prescription across insurance plans, with the highest among private and Medicare insured patients. These differences may indicate that insurance plan, and its associated pharmacy benefits, affect the pace of diffusion of new therapies.
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26
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Dewland TA, Stecker EC. Riskier Business. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.117.003801. [DOI: 10.1161/circoutcomes.117.003801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas A. Dewland
- From the Knight Cardiovascular Institute, Oregon Health & Science University, Portland
| | - Eric C. Stecker
- From the Knight Cardiovascular Institute, Oregon Health & Science University, Portland
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