Quality of Care for Atrial Fibrillation Among Patients Hospitalized for Heart Failure

Duke Clinical Research Institute, Durham, North Carolina 27715, USA.
Journal of the American College of Cardiology (Impact Factor: 16.5). 09/2009; 54(14):1280-9. DOI: 10.1016/j.jacc.2009.04.091
Source: PubMed

ABSTRACT This study sought to examine quality of care and warfarin use at discharge in patients with atrial fibrillation (AF) and heart failure (HF).
Atrial fibrillation is common in HF, and national guidelines recommend discharge on warfarin for stroke prophylaxis. However, the frequency and factors associated with the guideline adherence are poorly described.
We analyzed 72,534 HF admissions from January 2005 through March 2008 at 255 hospitals participating in the American Heart Association's Get With The Guidelines HF program. Multivariable logistic regression was used to identify independent factors associated with warfarin use at discharge.
In this HF population, 20.5% (n=14,901) had AF on admission, whereas another 13.7% (n=9,918) had a prior history of AF but were in a regular rhythm at admission. Contraindications to warfarin therapy were documented in 9.2%. Among eligible HF patients without contraindications, the median prevalence of warfarin therapy at discharge was 64.9% (interquartile range 55.5 to 73.4) and did not improve during the 3.5 years of study. After adjustment, major factors associated with no warfarin use at discharge included increasing age, nonwhite race, anemia, and treatment in the south. Warfarin use also varied inversely with CHADS2 (congestive heart failure, hypertension, age>75, diabetes, and prior stroke or transient ischemic attack) risk (70.9% to 59.5% for CHADS2 score 1 to 6, p<0.0001).
Guideline-recommended warfarin use in patients with AF and HF is less than optimal, has not improved over time, and varies significantly according to age, race, risk profile, region, and hospital site.

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Available from: Manesh R Patel, Dec 16, 2013
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    • "Once the need for oral anticoagulation is identified, several additional factors must be considered. Despite the evidence demonstrating the benefits of anticoagulation therapy in AF and HF, adherence to these recommendations is far from optimal.10,29,30 The hesitation to anticoagulate patients is often based upon fear of adverse effects and poor adherence with monitoring, and this is most pronounced in the elderly.12 "
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    ABSTRACT: Atrial fibrillation is a common arrhythmia in heart failure and a risk factor for stroke. Risk assessment tools can assist clinicians with decision making in the allocation of thromboprophylaxis. This review provides an overview of current validated risk assessment tools for atrial fibrillation and emphasizes the importance of tailoring individual risk and the importance of weighing the benefits of treatment. Further, this review provides details of innovative and patient-centered methods for ensuring optimal adherence to prescribed therapy. Prior to initiating oral anticoagulant therapy, a comprehensive risk assessment should include evaluation of associated cardiogeriatric conditions, potential for adherence to prescribed therapy, frailty, and functional and cognitive ability.
    Vascular Health and Risk Management 01/2013; 2013(9):3-11. DOI:10.2147/VHRM.S39571
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    • "Malignant or benign brain neoplasms, bleeding disorders, alcoholism, Alzheimers and other dementias, seizure disorders, chronic renal disease, cerebal hemorrhage, liver disease, peptic ulcer disease, gastritis, or duodenitis Prescription or continuation of warfarin during office visit (52.2%) 2001- 2006 Piccini, 2009 15,748 R, O (nested in the prospective GWTG database) "
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    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 02/2012; 13(1):5. DOI:10.1186/1471-2296-13-5 · 1.67 Impact Factor
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    Journal of the American College of Cardiology 09/2009; 54(14):1290-2. DOI:10.1016/j.jacc.2009.04.090 · 16.50 Impact Factor
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