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Anticoagulation in atrial fibrillation. Is there a gap in care for ambulatory patients?

https://arctichealth.org/en/permalink/ahliterature177716
Source
Can Fam Physician. 2004 Sep;50:1244-50
Publication Type
Article
Date
Sep-2004
Author
Wayne Putnam
Kelly Nicol
David Anderson
Brenda Brownell
Meredith Chiasson
Frederick I Burge
Gordon Flowerdew
Jafna Cox
Author Affiliation
Dalhousie University, Department of Family Medicine, Dalhousie University, Halifax, NS. Wayne.Putnam@Dal.ca
Source
Can Fam Physician. 2004 Sep;50:1244-50
Date
Sep-2004
Language
English
Publication Type
Article
Keywords
Adult
Aged
Aged, 80 and over
Anticoagulants - contraindications - therapeutic use
Atrial Fibrillation - complications - drug therapy
Drug Utilization
Family Practice
Female
Health Care Surveys
Humans
Male
Middle Aged
Nova Scotia
Patient compliance
Physician's Practice Patterns
Stroke - complications - prevention & control
Warfarin - contraindications - therapeutic use
Abstract
Atrial fibrillation (AF) substantially increases risk of stroke. Evidence suggests that anticoagulation to reduce risk is underused (a "care gap"). Our objectives were to clarify measures of this gap in care by including data from family physicians and to determine why eligible patients were not receiving anticoagulation therapy.
Telephone survey of family physicians regarding specific patients in their practices.
Nova Scotia.
Ambulatory AF patients not taking warfarin who had risk factors that made anticoagulation appropriate.
Proportion of patients removed from the care gap; reasons given for not giving the remainder anticoagulants.
Half the patients thought to be in the care gap had previously unknown contraindications to anticoagulation, lacked a clear indication for anticoagulation, or were taking warfarin. Patients' refusal and anticipated problems with compliance and monitoring were among the reasons for not giving patients anticoagulants.
Adding data from primary care physicians significantly narrowed the care gap. Attention should focus on the remaining reasons for not giving eligible patients anticoagulants.
Notes
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PubMed ID
15508374 View in PubMed
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The impact of warfarin use on clinical outcomes in atrial fibrillation: a population-based study.

https://arctichealth.org/en/permalink/ahliterature163685
Source
Can J Cardiol. 2007 May 1;23(6):457-61
Publication Type
Article
Date
May-1-2007
Author
Ratika Parkash
Vinnie Wee
Martin J Gardner
Jafna L Cox
Kara Thompson
Brenda Brownell
David R Anderson
Author Affiliation
Department of Medicine, Dalhousie University and Capital Health, Halifax, Canada. ratika.parkash@cdha.nshealth.ca
Source
Can J Cardiol. 2007 May 1;23(6):457-61
Date
May-1-2007
Language
English
Publication Type
Article
Keywords
Administration, Oral
Aged
Ambulatory Care
Anticoagulants - administration & dosage - therapeutic use
Atrial Fibrillation - complications - diagnosis - drug therapy
Cohort Studies
Female
Humans
Male
Nova Scotia - epidemiology
Outcome Assessment (Health Care)
Population Surveillance
Prospective Studies
Stroke - epidemiology - etiology - prevention & control
Thromboembolism - epidemiology - etiology - prevention & control
Treatment Outcome
Warfarin - administration & dosage - therapeutic use
Abstract
Atrial fibrillation (AF) is the most common adult arrhythmia, and significantly increases the risk of ischemic stroke. Oral anticoagulation may be underused and may be less effective in community settings than clinical trial settings.
To determine the rates of thromboembolism and bleeding in an ambulatory cohort of patients with AF.
Observational study of Nova Scotian residents with AF identified by electrocardiogram in ambulatory settings between November 1999 and January 2001. Main outcome measures were rates of thromboembolism and bleeding over two years.
Four hundred twenty-five patients were included in the study. The mean (+/-SD) age was 70.6+/-11.1 years, and 40% were women. Warfarin therapy was used by 68% of patients. Sixty-two per cent of patients had hypertension, 21% had a previous stroke or transient ischemic attack, 44% had congestive heart failure and 20% were diabetic. The overall rate of thromboembolic events was 2.7% in warfarin users and 8.5% in nonwarfarin users over two years, with an RR reduction of 68% (OR 0.31, 95% CI 0.09 to 0.91; P=0.047). The annual rate of ischemic stroke was 1.2% and 3.1% in warfarin and nonwarfarin users, respectively, with an RR reduction of 62% (OR 0.29, 95% CI 0.08 to 1.04; P=0.057). The overall rate of major bleeding was 2.6% in warfarin users and 1.4% in nonwarfarin users (P=0.667). The annual mortality rate was 7.79% in warfarin users and 9.93% in nonwarfarin users (P=0.192).
Warfarin use was found to significantly reduce the rate of thromboembolic events without a concomitant increase in hemorrhagic events. The present study confirms the effectiveness of warfarin therapy in a population-based cohort.
Notes
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PubMed ID
17487290 View in PubMed
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A multi-region assessment of population rates of cardiac catheterization and yield of high-risk coronary artery disease.

https://arctichealth.org/en/permalink/ahliterature129376
Source
BMC Health Serv Res. 2011;11:323
Publication Type
Article
Date
2011
Author
Fiona M Clement
Braden J Manns
Brenda Brownell
Peter D Faris
Michelle M Graham
Karin Humphries
Michael Love
Merril L Knudtson
William A Ghali
Author Affiliation
Department of Medicine, Faculty of Medicine, University of Calgary, Foothills Medical Centre-North Tower, 9th Floor, 1403 29th Street NW, Calgary, AB T2N 2T9, Canada.
Source
BMC Health Serv Res. 2011;11:323
Date
2011
Language
English
Publication Type
Article
Keywords
Adult
Age Factors
Aged
Alberta - epidemiology
Cardiac Catheterization - statistics & numerical data - trends
Cardiology Service, Hospital - utilization
Coronary Artery Disease - complications - epidemiology - therapy
Databases, Factual
Female
Humans
Male
Middle Aged
Models, Statistical
Outcome Assessment (Health Care) - methods
Population Surveillance
Quality-Adjusted Life Years
Regional Medical Programs - standards
Risk factors
Sex Distribution
Time and Motion Studies
Utilization Review
Abstract
There is variation in cardiac catheterization utilization across jurisdictions. Previous work from Alberta, Canada, showed no evidence of a plateau in the yield of high-risk disease at cardiac catheterization rates as high as 600 per 100,000 population suggesting that the optimal rate is higher. This work aims 1) To determine if a previously demonstrated linear relationship between the yield of high-risk coronary disease and cardiac catheterization rates persists with contemporary data and 2) to explore whether the linear relationship exists in other jurisdictions.
Detailed clinical information on all patients undergoing cardiac catheterization in 3 Canadian provinces was available through the Alberta Provincial Project for Outcomes Assessment in Coronary Heart (APPROACH) disease and partner initiatives in British Columbia and Nova Scotia. Population rates of catheterization and high-risk coronary disease detection for each health region in these three provinces, and age-adjusted rates produced using direct standardization. A mixed effects regression analysis was performed to assess the relationship between catheterization rate and high-risk coronary disease detection.
In the contemporary Alberta data, we found a linear relationship between the population catheterization rate and the high-risk yield. Although the yield was slightly less in time period 2 (2002-2006) than in time period 1(1995-2001), there was no statistical evidence of a plateau. The linear relationship between catheterization rate and high-risk yield was similarly demonstrated in British Columbia and Nova Scotia and appears to extend, without a plateau in yield, to rates over 800 procedures per 100,000 population.
Our study demonstrates a consistent finding, over time and across jurisdictions, of linearly increasing detection of high-risk CAD as population rates of cardiac catheterization increase. This internationally-relevant finding can inform country-level planning of invasive cardiac care services.
Notes
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PubMed ID
22115358 View in PubMed
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Population-based evaluation of the management of antithrombotic therapy for atrial fibrillation.

https://arctichealth.org/en/permalink/ahliterature175674
Source
Can J Cardiol. 2005 Mar;21(3):257-66
Publication Type
Article
Date
Mar-2005
Author
David R Anderson
Martin J Gardner
Wayne Putnam
Davinder Jassal
Brenda Brownell
Gordon Flowerdew
Seema Nagpal
Kara Thompson
Jafna L Cox
Author Affiliation
Queen Elizabeth II Health Science Centre, Halifax, Canada. david.anderson@dal.ca
Source
Can J Cardiol. 2005 Mar;21(3):257-66
Date
Mar-2005
Language
English
Publication Type
Article
Keywords
Administration, Oral
Adult
Aged
Anticoagulants - therapeutic use
Atrial Fibrillation - complications - diagnosis - drug therapy - epidemiology
Community Health Planning
Cross-Sectional Studies
Drug Prescriptions - standards - statistics & numerical data
Drug Utilization - standards - statistics & numerical data
Education, Medical
Educational Status
Electrocardiography
Family Practice - education - standards - statistics & numerical data
Female
Fibrinolytic Agents - therapeutic use
Guideline Adherence - standards - statistics & numerical data
Health Care Surveys
Health Knowledge, Attitudes, Practice
Humans
Male
Medicine - standards - statistics & numerical data
Middle Aged
Nova Scotia - epidemiology
Physician's Practice Patterns - standards - statistics & numerical data
Practice Guidelines as Topic
Questionnaires
Risk factors
Specialization
Thrombosis - etiology - prevention & control
Abstract
Oral anticoagulation is an effective therapy for the prevention of cardioembolic complications in patients with atrial fibrillation. However, previous practice reviews have indicated that oral anticoagulants are often underused in this setting. Most of those reports have focused on reviews of hospitalized and institutionalized patients, or small geographical areas.
To determine the use of antithrombotic therapy for the treatment of atrial fibrillation in Nova Scotia and to survey the knowledge of antithrombotic therapy for atrial fibrillation among a concurrent cohort of primary care and specialist physicians involved in the management of patients with atrial fibrillation.
Patients with atrial fibrillation were identified through outpatient electrocardiography clinics held throughout Nova Scotia. Following consent of the primary care physicians, patients were contacted and completed a survey about their current management. Family physicians and specialists in Nova Scotia were also surveyed about the management of atrial fibrillation with antithrombotic therapy through the receipt of one of four case scenarios.
Four hundred twenty-five patients participated in the cross-sectional survey. The mean patient age was 70.6 years, 255 (60%) were male and 398 (93.6%) had at least one risk factor for stroke in addition to atrial fibrillation. Two hundred ninety-four patients (69.2%) were receiving oral anticoagulants either alone (61.9%) or in combination with acetylsalicylic acid (ASA) (7.3%). An additional 85 patients (20%) received ASA alone. There was no difference in the rates of prescription of oral anticoagulants between elderly patients (75 years of age and older) and those younger than 75 years (71.7% versus 67.3%, 95% CI -13.1% to 4.5%; P=0.34). Overall, 72.0% of patients were receiving antithrombotic therapy in accordance with the 2001 guidelines of the American College of Chest Physicians, with no difference in the rates between individuals younger than 75 years (72.2%) and those over 75 years of age (71.7%) (absolute difference -0.5%, 95% CI -9.2% to 8.1%). Physician responses to case scenarios indicated that knowledge was high among both general practitioners and specialists regarding the appropriate use of oral anticoagulants for the prevention of thrombotic complications associated with atrial fibrillation.
The appropriate use of oral antithrombotic therapy for the prevention of thrombotic complications of atrial fibrillation occurs in approximately 72% of patients studied in Nova Scotia, and physician knowledge about this indication is high. There was no bias against prescribing oral anticoagulants to elderly patients. The findings suggest that with time, education and evidence have positively impacted the use of antithrombotic therapy in these patients.
PubMed ID
15776115 View in PubMed
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Trends in five-year survival of patients discharged after acute myocardial infarction.

https://arctichealth.org/en/permalink/ahliterature169589
Source
Can J Cardiol. 2006 Apr;22(5):399-404
Publication Type
Article
Date
Apr-2006
Author
Iqbal R Bata
Ronald D Gregor
Hermann K Wolf
Brenda Brownell
Author Affiliation
Department of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada.
Source
Can J Cardiol. 2006 Apr;22(5):399-404
Date
Apr-2006
Language
English
Publication Type
Article
Keywords
Adult
Age Distribution
Aged
Cause of Death
Comorbidity
Coronary Artery Bypass - statistics & numerical data
Diabetes Mellitus - epidemiology
Electrocardiography
Female
Hospital Mortality
Humans
Hypertension - epidemiology
Length of Stay - statistics & numerical data
Logistic Models
Male
Middle Aged
Myocardial Infarction - classification - diagnosis - mortality - therapy
Nova Scotia - epidemiology
Patient Discharge - statistics & numerical data
Prevalence
Prognosis
Severity of Illness Index
Sex Distribution
Shock - epidemiology
Smoking - epidemiology
Survival Analysis
Abstract
It has previously been shown that the increased use of therapeutic intervention may not reduce patient fatality if there is a simultaneous increase in case severity. The present study was designed to extend the relationship between case severity and therapeutic interventions to long-term survival in the same study population.
To compare five-year survival of patients discharged after acute myocardial infarction from 1984 to 1988 and from 1989 to 1993, and to evaluate possible reasons for survival differences.
The present study was population-based. Survival time was determined by record linkage into the Canadian Mortality Database. Association of five-year survival with patient characteristics, in-hospital treatment and discharge medications was assessed by logistical regression analysis. Case severity was calculated as the probability of death within five years, given the patient profile and excluding any interventions.
Between the two study periods, most patient characteristics and treatment intensity changed, but case severity for the study population remained constant. Five-year survival improved from 74.8% to 79.2% (P(chi2)=0.001). The improvement was adequately described by the combination of changes in patient profile and treatment without residual period effect (P(goodness-of-fit)=0.752). The treatments significantly associated with five-year survival were coronary artery bypass graft surgery (OR 2.74; 95% CI 1.86 to 4.05), percutaneous coronary intervention (OR 2.63; 95% CI 1.67 to 4.14) and thrombolysis (OR 1.98; 95% CI 1.50 to 2.62) during admission, as well as acetylsalicylic acid (OR 1.39; 95% CI 1.15 to 1.68) or beta-blocker (OR 1.60; 95% CI 1.34 to 1.92) prescription at discharge.
Changes in patient profile did not affect long-term prognosis; instead, treatment modalities accounted for the observed improvement in five-year survival.
Notes
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PubMed ID
16639475 View in PubMed
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Use of primary prevention implantable cardioverter-defibrillators in a population-based cohort is associated with a significant survival benefit.

https://arctichealth.org/en/permalink/ahliterature123590
Source
Circ Arrhythm Electrophysiol. 2012 Aug 1;5(4):706-13
Publication Type
Article
Date
Aug-1-2012
Author
Ratika Parkash
John L Sapp
Magdy Basta
Steve Doucette
Kara Thompson
Martin Gardner
Chris Gray
Brenda Brownell
Hena Kidwai
Jafna Cox
Author Affiliation
Department of Medicine, Queen Elizabeth II Health Sciences Center and the Department of Community Health and Epidemiology, Research Methods Unit, Dalhousie University, Halifax, Nova Scotia, Canada. parkashr@cdha.nshealth.ca
Source
Circ Arrhythm Electrophysiol. 2012 Aug 1;5(4):706-13
Date
Aug-1-2012
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Chi-Square Distribution
Death, Sudden, Cardiac - etiology - prevention & control
Defibrillators, Implantable
Electric Countershock - adverse effects - instrumentation - mortality
Female
Humans
Kaplan-Meier Estimate
Logistic Models
Male
Middle Aged
Multivariate Analysis
Nova Scotia
Patient Selection
Primary prevention - methods
Propensity Score
Referral and Consultation
Registries
Retrospective Studies
Risk assessment
Risk factors
Time Factors
Treatment Outcome
Abstract
Underuse of implantable defibrillators has been previously noted in patients at risk for sudden cardiac death, as well as for survivors of sudden cardiac death. We sought to determine the utilization rates in a primary prevention implantable cardioverter-defibrillator (ICD)-eligible population and mortality in this group compared with a group that had undergone implantation of this therapy.
A retrospective cohort of patients from April 1, 2006, to December 31, 2009, was used to define a primary prevention ICD-eligible population. Two groups were compared on the basis of ICD implantation (no-ICD versus ICD). The primary outcome measure was mortality. Of the 717 patients found to be potentially eligible for a primary prevention ICD, 116 (16%) were referred. The remaining cohort of 601 patients were compared with an existing cohort of primary prevention ICD patients (n=290). A significant survival benefit was associated with primary prevention ICD implantation (hazard ratio, 0.46; 95% CI [0.33-0.64]; P
Notes
Comment In: Circ Arrhythm Electrophysiol. 2012 Aug 1;5(4):624-522895600
PubMed ID
22685111 View in PubMed
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