Mid America Heart Institute, Kansas City, Missouri, USA.
Am J Cardiol. 2011 Oct 15;108(8):1136-40. doi: 10.1016/j.amjcard.2011.06.017. Epub 2011 Jul 26.
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.
华法林是一种复杂但高效的治疗心房颤动（AF）血栓栓塞风险的方法。我们在新型抗凝剂预期引入之前，检查了 AF 中当代华法林治疗率以及华法林使用中的实践水平变化程度。在 2008 年 7 月至 2009 年 12 月期间，国家心血管数据登记处的实践创新和临床卓越计划中，我们从 20 个地点确定了 9113 名患有中度至高度中风风险（充血性心力衰竭、高血压、年龄、糖尿病、中风评分>1）的 AF 门诊患者，这些患者最适合使用华法林治疗。使用层次模型，通过中位数率比来量化站点水平变化的程度，这可以解释为 2 个随机实践在治疗“相同”患者的华法林时，差异的可能性。华法林治疗的总体比率仅为 55.1%（9913 例中的 5018 例）。未治疗的患者和治疗的患者的充血性心力衰竭、高血压、年龄、糖尿病、中风评分分别为 2.5（p = 0.38），心力衰竭、高血压、糖尿病和先前中风的发生率相似，表明治疗几乎呈“随机”模式。然而，在实践层面上，治疗方面存在很大差异，从 25%到 80%不等（实践的四分位距为 50 到 65），中位数率比为 1.31（1.22 到 1.55，p<0.001）。总之，在实践创新和临床卓越登记处，我们发现 AF 中的华法林治疗并不理想，实践之间存在很大的治疗差异。我们的发现表明，在新型抗凝剂引入之前，为 AF 门诊患者预防中风提供了重要的实践水平改进机会，并确定了基准治疗率。
