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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

Australasian versus US comparison in thromboembolic treatment decisions. a: Australasian versus US Comparison in Thromboembolic Treatment Decisions for Scenarios of Paroxysmal AF < 48 hours with Low CHADS2 Score. US cardiologists more often chose no thromboembolic treatment, fewer used aspirin, and more selected heparin or other strategies compared to their Australasian counterparts. The category “Other” included Australasian survey responses of clopidogrel, US responses of dabigatran and rivaroxaban, as well as, write-in responses in both surveys. Abbreviations: AF, atrial fibrillation; EP, emergency medicine physicians; US, United States. b: Australasian versus US Comparison in Thromboembolic Treatment Decisions for Scenarios of New Onset AF ≥ 48 hours with Low CHADS2 Score. There were significant differences among both physician groups. US cardiologists chose no thromboembolic treatment and heparin more often, and used aspirin and warfarin alone less often than their Australasian colleagues. US EPs more often selected not to use thromboembolic treatment compared to their Australasian counterparts, and selected aspirin and heparin less frequently. Abbreviations: AF, atrial fibrillation; EP, emergency medicine physicians; US, United States.
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Fig5: Australasian versus US comparison in thromboembolic treatment decisions. a: Australasian versus US Comparison in Thromboembolic Treatment Decisions for Scenarios of Paroxysmal AF < 48 hours with Low CHADS2 Score. US cardiologists more often chose no thromboembolic treatment, fewer used aspirin, and more selected heparin or other strategies compared to their Australasian counterparts. The category “Other” included Australasian survey responses of clopidogrel, US responses of dabigatran and rivaroxaban, as well as, write-in responses in both surveys. Abbreviations: AF, atrial fibrillation; EP, emergency medicine physicians; US, United States. b: Australasian versus US Comparison in Thromboembolic Treatment Decisions for Scenarios of New Onset AF ≥ 48 hours with Low CHADS2 Score. There were significant differences among both physician groups. US cardiologists chose no thromboembolic treatment and heparin more often, and used aspirin and warfarin alone less often than their Australasian colleagues. US EPs more often selected not to use thromboembolic treatment compared to their Australasian counterparts, and selected aspirin and heparin less frequently. Abbreviations: AF, atrial fibrillation; EP, emergency medicine physicians; US, United States.

Mentions: The most significant differences in the international comparison were noted in a scenario of paroxysmal AF with symptoms < 48 hours and a low CHADS2 score. Australasian physicians were more aggressive with rhythm control strategies as a 1st line treatment option compared with our physicians (Figure 4) and use of thromboembolic treatment also differed significantly (Figure 5a). Qualitatively, 34% of Australasians chose aspirin while none of their US counterparts did.Figure 4


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)

Australasian versus US comparison in thromboembolic treatment decisions. a: Australasian versus US Comparison in Thromboembolic Treatment Decisions for Scenarios of Paroxysmal AF < 48 hours with Low CHADS2 Score. US cardiologists more often chose no thromboembolic treatment, fewer used aspirin, and more selected heparin or other strategies compared to their Australasian counterparts. The category “Other” included Australasian survey responses of clopidogrel, US responses of dabigatran and rivaroxaban, as well as, write-in responses in both surveys. Abbreviations: AF, atrial fibrillation; EP, emergency medicine physicians; US, United States. b: Australasian versus US Comparison in Thromboembolic Treatment Decisions for Scenarios of New Onset AF ≥ 48 hours with Low CHADS2 Score. There were significant differences among both physician groups. US cardiologists chose no thromboembolic treatment and heparin more often, and used aspirin and warfarin alone less often than their Australasian colleagues. US EPs more often selected not to use thromboembolic treatment compared to their Australasian counterparts, and selected aspirin and heparin less frequently. Abbreviations: AF, atrial fibrillation; EP, emergency medicine physicians; US, United States.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Fig5: Australasian versus US comparison in thromboembolic treatment decisions. a: Australasian versus US Comparison in Thromboembolic Treatment Decisions for Scenarios of Paroxysmal AF < 48 hours with Low CHADS2 Score. US cardiologists more often chose no thromboembolic treatment, fewer used aspirin, and more selected heparin or other strategies compared to their Australasian counterparts. The category “Other” included Australasian survey responses of clopidogrel, US responses of dabigatran and rivaroxaban, as well as, write-in responses in both surveys. Abbreviations: AF, atrial fibrillation; EP, emergency medicine physicians; US, United States. b: Australasian versus US Comparison in Thromboembolic Treatment Decisions for Scenarios of New Onset AF ≥ 48 hours with Low CHADS2 Score. There were significant differences among both physician groups. US cardiologists chose no thromboembolic treatment and heparin more often, and used aspirin and warfarin alone less often than their Australasian colleagues. US EPs more often selected not to use thromboembolic treatment compared to their Australasian counterparts, and selected aspirin and heparin less frequently. Abbreviations: AF, atrial fibrillation; EP, emergency medicine physicians; US, United States.
Mentions: The most significant differences in the international comparison were noted in a scenario of paroxysmal AF with symptoms < 48 hours and a low CHADS2 score. Australasian physicians were more aggressive with rhythm control strategies as a 1st line treatment option compared with our physicians (Figure 4) and use of thromboembolic treatment also differed significantly (Figure 5a). Qualitatively, 34% of Australasians chose aspirin while none of their US counterparts did.Figure 4

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