Chapman Scott A, St Hill Catherine A, Little Meg M, Swanoski Michael T, Scheiner Shellina R, Ware Kenric B, Lutfiyya M Nawal
Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA.
Department of Pharmacy Practice and Pharmaceutical Sciences, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA.
BMC Health Serv Res. 2017 Feb 11;17(1):127. doi: 10.1186/s12913-017-2025-6.
Ischemic stroke is a risk associated with atrial fibrillation (AF) and is estimated to occur five times more often in afflicted patients than in those without AF. Anti-thrombotic therapy is recommended for the prevention of ischemic stroke. Risk stratification tools, such as the CHADS, and more recently the CHADS-VASc, for predicting stroke in patients with AF have been developed to determine the level of stroke risk and assist clinicians in the selection of antithrombotic therapy. Warfarin, for stroke prevention in AF, is the most commonly prescribed anticoagulant in North America. The purpose of this study was to examine the utility of using the CHADS score levels (low and high) in contrast to the CHADS-VASc when examining the outcome of warfarin prescriptions for adult patients with AF. The CHADS-VASc tool was not widely used in 2010, when the data analyzed were collected. It has only been since 2014 that CHADS-VASc criteria has been recommended to guide anticoagulant treatment in updated AF treatment guidelines.
Bivariate and multivariate data analysis strategies were used to analyze 2010 National Ambulatory Care Survey (NAMCS) data. NAMCS is designed to collect data on the use and provision of ambulatory care services nationwide. The study population for this research was US adults with a diagnosis of AF. Warfarin prescription was the dependent variable for this study. The study population was 7,669,844 AF patients.
Bivariate analysis revealed that of those AF patients with a high CHADS score, 25.1% had received a warfarin prescription and 18.8 for those with a high CHADS-VASc score. Logistic regression analysis yielded that patients with AF had higher odds of having a warfarin prescription if they had a high CHADS score, were Caucasian, lived in a zip code where < 20% of the population had a university education, and lived in a zip code where < 10% of the population were living in households with incomes below the federal poverty level. Further, the analysis yielded that patients with AF had lesser odds of having a warfarin prescription if they were ≥ 65 years of age, female, or had health insurance.
Overall, warfarin appears to be under-prescribed for patients with AF regardless of the risk stratification system used. Based on the key findings of our study opportunities for interventions are present to improve guideline adherence in alignment with risk stratification for stroke prevention. Interprofessional health care teams can provide improved medical management of stroke prevention for patients with AF. These interprofessional health care teams should be constituted of primary care providers (physicians, physician assistants, and nurse practitioners), nurses (RN, LPN), and pharmacists (PharmD, RPh).
缺血性中风是心房颤动（AF）相关的一种风险，据估计，患病患者发生缺血性中风的几率是未患AF者的五倍。推荐采用抗血栓治疗来预防缺血性中风。已经开发出风险分层工具，如CHADS，以及最近的CHADS-VASc，用于预测AF患者的中风，以确定中风风险水平，并协助临床医生选择抗血栓治疗。在北美，用于预防AF患者中风的华法林是最常用的抗凝剂。本研究的目的是在检查成年AF患者华法林处方的结果时，对比CHADS评分水平（低和高）与CHADS-VASc的效用。在收集所分析数据的2010年，CHADS-VASc工具并未广泛使用。直到2014年，CHADS-VASc标准才在更新的AF治疗指南中被推荐用于指导抗凝治疗。
采用双变量和多变量数据分析策略来分析2010年国家门诊医疗调查（NAMCS）数据。NAMCS旨在收集全国范围内门诊医疗服务的使用和提供情况的数据。本研究的研究人群为诊断为AF的美国成年人。华法林处方是本研究的因变量。研究人群为7669844名AF患者。
双变量分析显示，CHADS评分高的AF患者中，25.1%接受了华法林处方，CHADS-VASc评分高的患者中这一比例为18.8%。逻辑回归分析得出，如果AF患者CHADS评分高、为白种人、居住在大学学历人口比例<20%的邮政编码地区，以及居住在家庭收入低于联邦贫困水平的人口比例<10%的邮政编码地区，则他们开具华法林处方的几率更高。此外，分析得出，如果AF患者年龄≥65岁、为女性或有医疗保险，则他们开具华法林处方的几率较低。
总体而言，无论使用何种风险分层系统，AF患者的华法林处方似乎都开具不足。基于我们研究的关键发现，存在干预机会以改善与中风预防风险分层相一致的指南依从性。跨专业医疗团队可为AF患者提供更好的中风预防医疗管理。这些跨专业医疗团队应由初级保健提供者（医生、医师助理和执业护士）、护士（注册护士、执业护士）和药剂师（药学博士、注册药剂师）组成。
