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Variation in practice patterns among specialties in the acute management of atrial fibrillation.

Funk AM, Kocher KE, Rohde JM, West BT, Crawford TC, Froehlich JB, Saberi S - BMC Cardiovasc Disord (2015)

Bottom Line: Australasian physicians were more aggressive with rhythm control for paroxysmal AF with low CHADS2 score compared to US physicians.Significant variation exists among specialties in the management of acute AF, likely reflecting a lack of high quality research to direct the provider.Future studies may help to standardize practice leading to decreased rates of hospitalization and overall cost.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan School of Medicine, Ann Arbor, USA. amaire@med.umich.edu.

ABSTRACT

Background: Atrial fibrillation (AF) is commonly managed by a variety of specialists. Current guidelines differ in their recommendations leading to uncertainty regarding important clinical decisions. We sought to document practice pattern variation among cardiologists, emergency physicians (EP) and hospitalists at a single academic, tertiary-care center.

Methods: A survey was created containing seven clinical scenarios of patients presenting with AF. We analyzed respondent choices regarding rate vs rhythm control, thromboembolic treatment and hospitalization strategies. Finally, we contrasted our findings with a comparable Australasian survey to provide an international reference.

Results: There was a 78% response rate (124 of 158), 37% hospitalists, 31.5% cardiologists, and 31.5% EP. Most respondents chose rate over rhythm control (92.2%; 95% CI, 89.1% - 94.5%) and thromboembolic treatment (67.8%; 95% CI, 63.8% - 71.7%). Compared to both hospitalists and EPs, cardiologists were more likely to choose thromboembolic treatment for new and paroxysmal AF (adjusted OR 2.38; 95% CI, 1.05 - 5.41). They were less likely to favor hospital admission across all types of AF (adjusted OR 0.36; 95% CI, 0.17 - 0.79) but thought cardiology consultation was more important (adjusted OR 1.88, 95% CI, 0.97 - 3.64). Australasian physicians were more aggressive with rhythm control for paroxysmal AF with low CHADS2 score compared to US physicians.

Conclusions: Significant variation exists among specialties in the management of acute AF, likely reflecting a lack of high quality research to direct the provider. Future studies may help to standardize practice leading to decreased rates of hospitalization and overall cost.

No MeSH data available.


Related in: MedlinePlus

1st choice management options selected by >1%respondents. Stacked bar graph depicting the percentage of each specialty that selected Diltiazem, Esmolol, DCCV, or Metoprolol as 1st line management across all scenarios. NOTE: Other choices in the survey not represented in the graph included: Digoxin, Verapamil, Amiodarone, Ibutilide, Procainamide, Propafenone, and Other. There was a significant difference between specialties regarding 1st choice management across all scenarios, p = 0.032. Abbreviation: DCCV, direct current cardioversion.
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Fig1: 1st choice management options selected by >1%respondents. Stacked bar graph depicting the percentage of each specialty that selected Diltiazem, Esmolol, DCCV, or Metoprolol as 1st line management across all scenarios. NOTE: Other choices in the survey not represented in the graph included: Digoxin, Verapamil, Amiodarone, Ibutilide, Procainamide, Propafenone, and Other. There was a significant difference between specialties regarding 1st choice management across all scenarios, p = 0.032. Abbreviation: DCCV, direct current cardioversion.

Mentions: As illustrated in Figure 1, the majority of respondents among all specialties selected rate over rhythm control as their 1st line treatment across all scenarios (92.2%; 95% CI, 89.1% to 94.5%) with diltiazem being the most preferred agent (78%) followed by metoprolol (14%). When a rhythm control strategy was selected, DCCV was most common overall with 21 respondents selecting it as 1st line therapy (5%). Interestingly, DCCV was the only rhythm control strategy employed by EPs and hospitalists, while cardiologists on occasion selected other agents such as amiodarone, ibutilide, or propafenone (all chosen by < 1% of respondents). In multivariable modeling, the adjusted odds of choosing rate control were higher with AF ≥ 48 hours compared to < 48 hours (OR 6.27, 95% CI 2.35 to 16.74) and higher with chronic AF compared with new diagnosis AF (OR 3.09, 95% CI 1.04 to 9.15). Specialty, CHADS2 score, experience with AF, years in practice, and use of current guidelines were not independent predictors of choosing rate control.Figure 1


Variation in practice patterns among specialties in the acute management of atrial fibrillation.

Funk AM, Kocher KE, Rohde JM, West BT, Crawford TC, Froehlich JB, Saberi S - BMC Cardiovasc Disord (2015)

1st choice management options selected by >1%respondents. Stacked bar graph depicting the percentage of each specialty that selected Diltiazem, Esmolol, DCCV, or Metoprolol as 1st line management across all scenarios. NOTE: Other choices in the survey not represented in the graph included: Digoxin, Verapamil, Amiodarone, Ibutilide, Procainamide, Propafenone, and Other. There was a significant difference between specialties regarding 1st choice management across all scenarios, p = 0.032. Abbreviation: DCCV, direct current cardioversion.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4359491&req=5

Fig1: 1st choice management options selected by >1%respondents. Stacked bar graph depicting the percentage of each specialty that selected Diltiazem, Esmolol, DCCV, or Metoprolol as 1st line management across all scenarios. NOTE: Other choices in the survey not represented in the graph included: Digoxin, Verapamil, Amiodarone, Ibutilide, Procainamide, Propafenone, and Other. There was a significant difference between specialties regarding 1st choice management across all scenarios, p = 0.032. Abbreviation: DCCV, direct current cardioversion.
Mentions: As illustrated in Figure 1, the majority of respondents among all specialties selected rate over rhythm control as their 1st line treatment across all scenarios (92.2%; 95% CI, 89.1% to 94.5%) with diltiazem being the most preferred agent (78%) followed by metoprolol (14%). When a rhythm control strategy was selected, DCCV was most common overall with 21 respondents selecting it as 1st line therapy (5%). Interestingly, DCCV was the only rhythm control strategy employed by EPs and hospitalists, while cardiologists on occasion selected other agents such as amiodarone, ibutilide, or propafenone (all chosen by < 1% of respondents). In multivariable modeling, the adjusted odds of choosing rate control were higher with AF ≥ 48 hours compared to < 48 hours (OR 6.27, 95% CI 2.35 to 16.74) and higher with chronic AF compared with new diagnosis AF (OR 3.09, 95% CI 1.04 to 9.15). Specialty, CHADS2 score, experience with AF, years in practice, and use of current guidelines were not independent predictors of choosing rate control.Figure 1

Bottom Line: Australasian physicians were more aggressive with rhythm control for paroxysmal AF with low CHADS2 score compared to US physicians.Significant variation exists among specialties in the management of acute AF, likely reflecting a lack of high quality research to direct the provider.Future studies may help to standardize practice leading to decreased rates of hospitalization and overall cost.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan School of Medicine, Ann Arbor, USA. amaire@med.umich.edu.

ABSTRACT

Background: Atrial fibrillation (AF) is commonly managed by a variety of specialists. Current guidelines differ in their recommendations leading to uncertainty regarding important clinical decisions. We sought to document practice pattern variation among cardiologists, emergency physicians (EP) and hospitalists at a single academic, tertiary-care center.

Methods: A survey was created containing seven clinical scenarios of patients presenting with AF. We analyzed respondent choices regarding rate vs rhythm control, thromboembolic treatment and hospitalization strategies. Finally, we contrasted our findings with a comparable Australasian survey to provide an international reference.

Results: There was a 78% response rate (124 of 158), 37% hospitalists, 31.5% cardiologists, and 31.5% EP. Most respondents chose rate over rhythm control (92.2%; 95% CI, 89.1% - 94.5%) and thromboembolic treatment (67.8%; 95% CI, 63.8% - 71.7%). Compared to both hospitalists and EPs, cardiologists were more likely to choose thromboembolic treatment for new and paroxysmal AF (adjusted OR 2.38; 95% CI, 1.05 - 5.41). They were less likely to favor hospital admission across all types of AF (adjusted OR 0.36; 95% CI, 0.17 - 0.79) but thought cardiology consultation was more important (adjusted OR 1.88, 95% CI, 0.97 - 3.64). Australasian physicians were more aggressive with rhythm control for paroxysmal AF with low CHADS2 score compared to US physicians.

Conclusions: Significant variation exists among specialties in the management of acute AF, likely reflecting a lack of high quality research to direct the provider. Future studies may help to standardize practice leading to decreased rates of hospitalization and overall cost.

No MeSH data available.


Related in: MedlinePlus