Impact of the type of centre on management of AF patients: Surprising evidence for differences in antithrombotic therapy decisions

Paulus Kirchhof; Michael Nabauer; Andrea Gerth; Tobias Limbourg; Thorsten Lewalter; Andreas Goette; Karl Wegscheider; Andras Treszl; Thomas Meinertz; Michael Oeff; Ursula Ravens; Günter Breithardt; Gerhard Steinbeck; the AFNET; on behalf of

doi:10.1160/TH11-02-0070

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2011; 105(06): 1010-1023
DOI: 10.1160/TH11-02-0070

Blood Coagulation, Fibrinolysis and Cellular Haemostasis

Schattauer GmbH

Impact of the type of centre on management of AF patients: Surprising evidence for differences in antithrombotic therapy decisions

Paulus Kirchhof^*

¹Department of Cardiology and Angiology, University Hospital Münster, Münster, Germany

,

Michael Nabauer^*

²Medizinische Klinik und Poliklinik I, Campus Grosshadern, Ludwig-Maximilians-University, Munich, Germany

,

Andrea Gerth

²Medizinische Klinik und Poliklinik I, Campus Grosshadern, Ludwig-Maximilians-University, Munich, Germany

,

Tobias Limbourg

³Institute for Research in Myocardial Infarction Ludwigshafen of the University of Heidelberg, Heidelberg, Germany

,

Thorsten Lewalter

⁴University of Bonn, Bonn, Germany

,

Andreas Goette

⁵St Vincenz-Hospital Hospital Paderborn, Germany and Department of Clinical Pharmacology, University of Magdeburg Hospital, Magdeburg, Germany

,

Karl Wegscheider

⁶Department of Medical Biometry and Epidemiology, University Hospital, Hamburg-Eppendorf, Germany

,

Andras Treszl

⁶Department of Medical Biometry and Epidemiology, University Hospital, Hamburg-Eppendorf, Germany

,

Thomas Meinertz

⁷Department of Cardiology, University Heart Center Hamburg, Hamburg, Germany

,

Michael Oeff

⁸Department of Medicine I, Brandenburg Municipal Hospital, Brandenburg, Germany

,

Ursula Ravens

⁹Department of Pharmacology and Toxicology, Medical Faculty, Dresden University of Technology, Dresden, Germany

,

Günter Breithardt

¹Department of Cardiology and Angiology, University Hospital Münster, Münster, Germany

,

Gerhard Steinbeck

²Medizinische Klinik und Poliklinik I, Campus Grosshadern, Ludwig-Maximilians-University, Munich, Germany

,

the AFNET

› Author Affiliations

Abstract

Summary

Atrial fibrillation (AF) patients may receive treatment from specialists or from general medicine physicians representing different levels of care within a structured health care system. This “choice” is influenced by patient flow within a health care system, patient preference, and individual access to health care resources. We analysed how the postgraduate training and work environment of treating physicians affects management decisions in AF patients. Patient characteristics and treatment decisions were analysed at the time of enrolment into the registry of the German Atrial Fibrillation NETwork (AFNET). A total of 9,577 patients were enrolled from 2004 to 2006 in 191 German centres that belonged to the following four levels of care: 13 tertiary care centres (TCC) enrolled 3,795 patients (39.6%), 58 district hospitals (DH) enrolled 2,339 patients (24.4%), 62 office-based cardiologists (OC) enrolled 2,640 patients (27.6%), and 58 general practitioners or internists (GP) enrolled 803 patients (8.4%). Patients with new-onset AF were often treated in DH. TCC treated younger patients who more often presented with paroxysmal AF. Older patients and patients in permanent AF more often received outpatient care. Consistent with recommendations, younger patients and patients with non-permanent AF received rhythm control therapy more often. In addition, the type of centre affected the decision for rhythm control. Stroke risk was similar between centre types (mean CHADS2 scores 1.6 –1.9). TCC (68.8%) and OC (73.6%) administered adequate antithrombotic therapy more often than DH (55.1%) or GP (52.0%, p<0.001 between groups). Upon multivariate analysis, enrolment by TCC or OC was associated with a 1.60 (1.20–2.12, p=0.001) fold chance for adequate antithrombotic treatment. This difference between centre types was consistent irrespective of the type of stroke risk estimation (ESC 2001 guidelines, CHADS2 score), and also consistent when the recently suggested CHA₂DS₂-VASc score was used to estimate stroke risk. In conclusion, management decisions in AF are influenced by the education and clinical background of treating physicians in Germany. Inpatients receive more rhythm control therapy. Adequate antithrombotic therapy is more often administered in specialist (cardiologist) centres.

Keywords

Atrial fibrillation - access to health care - antithrombotic therapy - rhythm control therapy - level of care - registry

Full Text

References

References
1 Fuster V. et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electro-physiology. Eur Heart J 2001; 22: 1852-1923.
2 Fuster V. et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation-executive summary: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Eur Heart J 2006; 27: 1979-2030.
3 Calkins H. et al. HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures and Follow-Up: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation Developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and Approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society. Europace 2007; 9: 335-379.
4 Kirchhof P. et al. Outcome parameters for trials in atrial fibrillation: executive summary: Recommendations from a consensus conference organized by the German Atrial Fibrillation Competence NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eur Heart J 2007; 28: 2803-2817.
5 Kirchhof P. et al. Early and comprehensive management of atrial fibrillation: executive summary of the proceedings from the 2nd AFNET-EHRA consensus conference ‘research perspectives in AF‘. Eur Heart J 2009; 30: 2969-2977c.
6 Hart RG. et al. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med 1999; 131: 492-501.
7 Hylek EM. et al. Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation. N Engl J Med 2003; 349: 1019-1026.
8 Mant J. et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007; 370: 493-503.
9 Nattel S, Opie LH. Controversies in atrial fibrillation. Lancet 2006; 367: 262-272.
10 Roy D. et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med 2008; 358: 2667-2677.
11 Calkins H. et al. HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2007; 4: 816-861.
12 Healey JS. et al. Prevention of atrial fibrillation with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: a meta-analysis. J Am Coll Cardiol 2005; 45: 1832-1839.
13 Camm AJ. et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31: 2369-2429.
14 Singer DE. et al. Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (Suppl. 03) 429S-456S.
15 Snow V. et al. Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med 2003; 139: 1009-1017.
16 AFFIRM I. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002; 347: 1825-1833.
17 Van Gelder I. et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002; 347: 1834-1840.
18 Nieuwlaat R. et al. Atrial fibrillation management: a prospective survey in ESC member countries: the Euro Heart Survey on Atrial Fibrillation. Eur Heart J 2005; 26: 2422-2434.
19 Kerr CR. et al. The Canadian Registry of Atrial Fibrillation: a noninterventional follow-up of patients after the first diagnosis of atrial fibrillation. Am J Cardiol 1998; 82: 82N-85N.
20 Levy S. et al. Characterization of different subsets of atrial fibrillation in general practice in France: the ALFA study. The College of French Cardiologists. Circulation 1999; 99: 3028-3035.
21 Reiffel JA. et al. Practice patterns among United States cardiologists for managing adults with atrial fibrillation (from the AFFECTS Registry). Am J Cardiol 2010; 105: 1122-1129.
22 Heuzey JY. et al. The RecordAF study: design, baseline data, and profile of patients according to chosen treatment strategy for atrial fibrillation. Am J Cardiol 2010; 105: 687-693.
23 Nabauer M. et al. The Registry of the German Competence NETwork on Atrial Fibrillation: Patient characteristics and initial management. Europace 2009; 11: 423-434.
24 Blanc JJ. et al. Consensus document on antithrombotic therapy in the setting of electrophysiological procedures. Europace 2008; 10: 513-527.
25 Nieuwlaat R. et al. Guideline-adherent antithrombotic treatment is associated with improved outcomes compared with undertreatment in high-risk patients with atrial fibrillation. The Euro Heart Survey on Atrial Fibrillation. Am Heart J 2007; 153: 1006-1012.
26 Gage BF. et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. J Am Med Assoc 2001; 285: 2864-2870.
27 Lip GY. et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010; 137: 263-272.
28 Wachtell K. et al. Angiotensin II receptor blockade reduces new-onset atrial fibrillation and subsequent stroke compared to atenolol: the Losartan Intervention For End Point Reduction in Hypertension (LIFE) study. J Am Coll Cardiol 2005; 45: 712-719.
29 Nieuwlaat R. et al. Should we abandon the common practice of withholding oral anticoagulation in paroxysmal atrial fibrillation?. Eur Heart J 2008; 29: 915-922.
30 Meiltz A. et al. Atrial fibrillation management by practice cardiologists: a prospective survey on the adherence to guidelines in the real world. Europace 2008; 10: 674-680.
31 Lip GY. et al. Physician variation in the management of patients with atrial fibrillation. Heart 1996; 75: 200-205.
32 Lane DA, Lip GY. Barriers to anticoagulation in patients with atrial fibrillation: changing physician-related factors. Stroke 2008; 39: 7-9.
33 Cohen N. et al. Warfarin for stroke prevention still underused in atrial fibrillation: patterns of omission. Stroke 2000; 31: 1217-1222.
34 Lip GY. et al. Ethnic differences in patient perceptions of atrial fibrillation and anticoagulation therapy: the West Birmingham Atrial Fibrillation Project. Stroke 2002; 33: 238-242.
35 Camm AJ. et al. Guidelines for the management of atrial fibrillation. Eur Heart J 2010; 31: 2369-2429.
36 van Staa T. et al. A comparison of risk stratification schemes for stroke in 79 884 atrial fibrillation patients in general practice. J Thromb Haemost 2011; 9: 39-48.
37 Lip GY, Lim HS. Atrial fibrillation and stroke prevention. Lancet Neurol 2007; 6: 981-993.
38 Andersen KK, Olsen TS. Reduced poststroke mortality in patients with stroke and atrial fibrillation treated with anticoagulants: results from a Danish quality-control registry of 22,179 patients with ischemic stroke. Stroke 2007; 38: 259-263.
39 O’Donnell M. et al. Preadmission antithrombotic treatment and stroke severity in patients with atrial fibrillation and acute ischaemic stroke: an observational study. Lancet Neurol 2006; 5: 749-754.
40 Gorin L. et al. Antithrombotic treatment and the risk of death and stroke in patients with atrial fibrillation and a CHADS2 score=1. Thromb Haemost 2010; 103: 833-840.
41 Karthikeyan G, Eikelboom JW. The CHADS2 score for stroke risk stratification in atrial fibrillation--friend or foe?. Thromb Haemost 2010; 104: 45-48.
42 Ahrens I. et al. New oral anticoagulant drugs in cardiovascular disease. Thromb Haemost 2010; 104: 49-60.
43 Holbrook A. et al. Influence of decision aids on patient preferences for anticoagulant therapy: a randomized trial. CMAJ 2007; 176: 1583-1587.
44 Metra M. et al. Postdischarge assessment after a heart failure hospitalization: the next step forward. Circulation 2010; 122: 1782-1785.
45 Lee DS. et al. Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department. Circulation 2010; 122: 1806-1814.