TY - JOUR
T1 - Practice-level variation in warfarin use among outpatients with atrial fibrillation (from the NCDR PINNACLE program)
AU - Chan, Paul S.
AU - Maddox, Thomas M.
AU - Tang, Fengming
AU - Spinler, Sarah
AU - Spertus, John A.
N1 - Funding Information:
The PINNACLE Registry is an initiative of the American College of Cardiology Foundation, Washington, DC, MedAxiom, and Spirit of Women. The Bristol-Myers Squibb/Sanofi, New York, New York, Pharmaceuticals Partnership is a founding sponsor of the PINNACLE Registry. Dr. Chan is supported by Career Development Grant Award K23HL102224 from the National Heart, Lung, and Blood Institute , Bethesda, Maryland. Dr. Chan, Dr. Spertus, and Ms. Tang are affiliated with the Mid America Heart Institute, Kansas City, Missouri, which is the major analytic center for the PINNACLE program and receives funding from the American College of Cardiology for this role. Dr. Maddox is supported by a Health Services Research and Development Career Development Award from the United States Department of Veterans Affairs, Austin, Texas.
Funding Information:
The efforts and cooperation of the cardiology practices currently enrolled in PINNACLE are greatly appreciated by the authors and by the NCDR PINNACLE Work Group. This research was supported by the American College of Cardiology Foundation's NCDR. Although the report underwent internal review by an NCDR research and publications committee, the views expressed in this report represent those of the authors and do not necessarily represent the official views of the NCDR or its associated professional societies (available at: http://www.ncdr.com ).
PY - 2011/10/15
Y1 - 2011/10/15
N2 - Warfarin is a complex but highly effective treatment for decreasing thromboembolic risk in atrial fibrillation (AF). We examined contemporary warfarin treatment rates in AF before the expected introduction of newer anticoagulants and extent of practice-level variation in warfarin use. Within the National Cardiovascular Data Registry Practice Innovation and Clinical Excellence program from July 2008 through December 2009, we identified 9,113 outpatients with AF from 20 sites who were at moderate to high risk for stroke (congestive heart failure, hypertension, age, diabetes, stroke score >1) and would be optimally treated with warfarin. Using hierarchical 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. Overall rate of warfarin treatment was only 55.1% (5,018 of 9,913). Untreated patients and treated patients had mean congestive heart failure, hypertension, age, diabetes, stroke scores of 2.5 (p = 0.38) and similar rates of heart failure, hypertension, diabetes mellitus, and previous 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 to 1.55, p <0.001). In conclusion, within the Practice Innovation and Clinical Excellence 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 before the introduction of newer anticoagulant agents.
AB - Warfarin is a complex but highly effective treatment for decreasing thromboembolic risk in atrial fibrillation (AF). We examined contemporary warfarin treatment rates in AF before the expected introduction of newer anticoagulants and extent of practice-level variation in warfarin use. Within the National Cardiovascular Data Registry Practice Innovation and Clinical Excellence program from July 2008 through December 2009, we identified 9,113 outpatients with AF from 20 sites who were at moderate to high risk for stroke (congestive heart failure, hypertension, age, diabetes, stroke score >1) and would be optimally treated with warfarin. Using hierarchical 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. Overall rate of warfarin treatment was only 55.1% (5,018 of 9,913). Untreated patients and treated patients had mean congestive heart failure, hypertension, age, diabetes, stroke scores of 2.5 (p = 0.38) and similar rates of heart failure, hypertension, diabetes mellitus, and previous 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 to 1.55, p <0.001). In conclusion, within the Practice Innovation and Clinical Excellence 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 before the introduction of newer anticoagulant agents.
UR - http://www.scopus.com/inward/record.url?scp=80053992926&partnerID=8YFLogxK
U2 - 10.1016/j.amjcard.2011.06.017
DO - 10.1016/j.amjcard.2011.06.017
M3 - Article
C2 - 21798501
AN - SCOPUS:80053992926
SN - 0002-9149
VL - 108
SP - 1136
EP - 1140
JO - American Journal of Cardiology
JF - American Journal of Cardiology
IS - 8
ER -