Warfarin for stroke prevention still underused in atrial fibrillation: patterns of omission.
ABSTRACT The value of warfarin in preventing stroke in patients with chronic atrial fibrillation is well established. However, the prevalence of such treatment generally lags behind actual requirements. The aim of this study was to evaluate doctor- and/or patient-related demographic, clinical, and echocardiographic factors that influence decision for warfarin treatment.
Between 1990 and 1998, 1027 patients were discharged with chronic or persistent atrial fibrillation. This population was composed of (1) patients with cardiac prosthetic valves (n=48), (2) those with increased bleeding risks (n=152), (3) physically or mentally handicapped patients (n=317), and (4) the remaining 510 patients, the main study group who were subjected to thorough statistical analysis for determining factors influencing warfarin use.
The respective rates of warfarin use on discharge in the 4 groups were 93.7%, 30.9%, 17.03%, and 59.4% (P=0.001); of the latter, an additional 28.7% were discharged on aspirin. In the main study group, warfarin treatment rates increased with each consecutive triennial period (29.7%, 53.6%, and 77.1%, respectively; P=0.001). Age >80 years, poor command of Hebrew, and being hospitalized in a given medical department emerged as independent variables negatively influencing warfarin use: P=0.0001, OR 0.30 (95% CI 0.17 to 0.55); P=0.02, OR 0.59 (95% CI 0.36 to 0.94); and P=0.0002, OR 0.26 (95% CI 0.12 to 0.52), respectively. In contrast, past history of stroke and availability of echocardiographic information, regardless of the findings, each increased warfarin use (P=0.03, OR 1.95 [95% CI 1.04 to 3.68], and P=0.0001, OR 3.52 [95% CI 2.16 to 5.72], respectively).
Old age, language difficulties, insufficient doctor alertness to warfarin benefit, and patient disability produced reluctance to treat. Warfarin use still lags behind requirements.
- SourceAvailable from: Stephan Spat[show abstract] [hide abstract]
ABSTRACT: BACKGROUND - RATIONALE FOR STUDY: In elderly patients, long-term self-management of oral anticoagulation has been shown to reduce the number of major thromboembolic and bleeding complications and improve the quality of oral anticoagulation (OAC) control compared to routine care for a mean follow-up period of three years. This article presents the results of the predefined secondary endpoint treatment-related quality of life (QoL). METHODS AND RESULTS: The effect of self-management on five aspects of QoL was evaluated in comparison with routine care. A validated questionnaire specifically designed for patients receiving OAC was used. The evaluation was possible for 141 patients, comprising 90% of surviving patients on OAC. At baseline, all patients had high scores for the following QoL-aspects: general treatment satisfaction, self-efficacy, daily hassles and strained social network. A high proportion of patients in both groups explicitly reported high distress, indicating that general psychological distress seems to be of particular concern in this population. After about 3 years of follow-up, patients performing self-management showed a significantly greater improvement in general treatment satisfaction than controls (median score increase [25th percentile, 75th percentile]: 0.9 [0.0, 1.6] vs. 0.0 [-0.2, 0.6], p=0.002; scale 1-6). Changes in general psychological distress, self-efficacy, daily hassles and strained social network were not significant. CONCLUSION: Treatment related quality of life in elderly patients performing self-management of OAC was similar as for patients in routine care setting, with a tendency of higher general treatment satisfaction, after three years of follow up.Thrombosis Research 06/2012; 130(3):e60-6. · 3.13 Impact Factor
Dataset: CEM stroke 37
- [show abstract] [hide abstract]
ABSTRACT: Despite warfarin's marked efficacy, not all eligible patients receive it for stroke prevention in AF. The aim of this meta-analysis was to evaluate the association between prescriber and/or patient characteristics and subsequent prescription of warfarin for stroke prevention in patients with atrial fibrillation (AF). Observational studies conducted in the US using multivariate analysis to determine the relationship between characteristics and the odds of receiving warfarin for stroke prevention were identified in MEDLINE, EMBASE and a manual review of references. Effect estimates of prescriber and/or patient characteristics from individual studies were pooled to calculate odds ratios (ORs) with 95% confidence intervals. Twenty-eight studies reporting results of 33 unique multivariate analyses were identified. Warfarin use across studies ranged from 9.1%-79.8% (median=49.1%). There was a moderately-strong correlation between warfarin use and year of study (r=0.60, p=0.002). Upon meta-analysis, characteristics associated with a statistically significant increase in the odds of warfarin use included history of cerebrovascular accident (OR=1.59), heart failure (OR=1.36), and male gender (OR=1.12). Those associated with a significant reduction in the odds of warfarin use included alcohol/drug abuse (OR=0.62), perceived barriers to compliance (OR=0.87), contraindication(s) to warfarin (OR=0.81), dementia (OR=0.32), falls (OR=0.60), gastrointestinal hemorrhage (OR=0.47), intracranial hemorrhage (OR=0.39), hepatic (OR=0.59), and renal impairment (OR=0.69). While age per 10-year increase (OR=0.78) and advancing age as a dichotomized variable (cut-off varied by study) (OR=0.57) were associated with significant reductions in warfarin use; qualitative review of results of studies evaluating age as a categorical variable did not confirm this relationship. Warfarin use has increased somewhat over time. The decision to prescribe warfarin for stroke prevention in atrial fibrillation is based upon multiple prescriber and patient characteristics. These findings can be used by family practice prescribers and other healthcare decision-makers to target interventions or methods to improve utilization of warfarin when it is indicated for stroke prevention.BMC Family Practice 01/2012; 13:5. · 1.61 Impact Factor