Practice-level variation in warfarin use among outpatients with atrial fibrillation (from the NCDR PINNACLE program).
Practice-level variation in warfarin use among outpatients with atrial fibrillation (from the NCDR PINNACLE program).
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DOI：
10.1016/j.amjcard.2011.06.017
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发表时间：
2011-10-15
影响因子：
2.8
通讯作者：
Spertus, John A.
中科院分区：
文献类型：
--
作者：
Chan, Paul S.;Maddox, Thomas M.;Tang, Fengming;Spinler, Sarah;Spertus, John A.
华法林是一种复杂但高效的治疗方法，可降低房颤（AF）的血栓栓塞风险。我们研究了在预期引入新的抗凝剂之前，房颤患者的华法林治疗率以及华法林使用的实践水平变化程度。在2008年7月至2009年12月的国家心血管数据登记PINNACLE项目中，我们从20个研究中心确定了9113例门诊房颤患者，这些患者具有中至高卒中风险（CHADS 2评分>1），并将接受华法林最佳治疗。使用分层回归模型，用中位率比量化研究中心水平变异的程度，中位率比可以解释为2种随机实践在华法林治疗“相同”患者方面存在差异的可能性。华法林治疗的总体比率仅为55.1%（5018/9913）。未治疗患者和治疗患者的平均CHADS 2评分均为2.5（P=0.38），心力衰竭、高血压、糖尿病和既往卒中的发生率相似，表明治疗模式几乎是“随机”的。然而，在实践水平上，治疗有很大的差异，范围从25%到80%（实践的四分位数范围：50%到65%），中位率比为1.31（1.22，1.55），P<0.001。总之，在PINNACLE登记研究中，我们发现华法林治疗AF的效果欠佳，在不同实践中观察到的治疗差异很大。我们的研究结果表明，重要的机会，提高实践水平的中风预防门诊房颤患者，并确定一个基准的治疗率之前，引入新的抗凝剂。
Warfarin is a complex but highly effective treatment for reducing thromboembolic risk in atrial fibrillation (AF). We examined contemporary warfarin treatment rates in AF prior to the expected introduction of newer anticoagulants and the extent of practice-level variation in warfarin use. Within the National Cardiovascular Data Registry PINNACLE program between July 2008 and December 2009, we identified 9113 outpatients with AF from 20 sites who were at moderate to high risk for stroke (CHADS2 score >1) and would be optimally treated with warfarin. Using hierarchical regression models, the extent of site-level variation was quantified with the median rate ratio, which can be interpreted as the likelihood that 2 random practices would differ in treating ‘identical’ patients with warfarin. The overall rate of warfarin treatment was only 55.1% (5018/9913). Both untreated patients and treated patients had mean CHADS2 scores of 2.5 (P=0.38) and similar rates of heart failure, hypertension, diabetes mellitus, and prior stroke, suggesting an almost ‘random’ pattern of treatment. At the practice level, however, there was substantial variation in treatment, ranging from 25% to 80% (interquartile range for practices: 50% to 65%), with a median rate ratio of 1.31 (1.22, 1.55), P<0.001. In conclusion, within the PINNACLE registry, we found that warfarin treatment in AF was suboptimal, with large variations in treatment observed across practices. Our findings suggest important opportunities for practice-level improvement in stroke prevention for outpatients with AF and define a benchmark treatment rate prior to the introduction of newer anticoagulant agents.
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影响因子：
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Howitt, A;Armstrong, D
通讯作者：
Armstrong, D
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通讯作者：
Spertus, John A.