Gehi Anil K, Doros Gheorghe, Glorioso Thomas J, Grunwald Gary K, Hsu Jonathan, Song Yang, Turakhia Mintu P, Turchin Alexander, Virani Salim S, Maddox Thomas M
Section of Cardiac Electrophysiology, Division of Cardiology, University of North Carolina, Chapel Hill, NC.
Harvard Clinical Research Institute, Boston, MA; Department of Biostatistics, Boston University, Boston, MA.
Am Heart J. 2017 May;187:88-97. doi: 10.1016/j.ahj.2017.02.006. Epub 2017 Feb 16.
Decisions to use rhythm control in atrial fibrillation (AF) should generally be dictated by patient factors, such as quality of life, heart failure, and other comorbidities. Whether or not other factors affect decisions about the use of rhythm control, and catheter ablation in particular, is unknown.
A cohort of all patients diagnosed with nonvalvular AF were identified from the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence (PINNACLE) AF registry of US outpatient cardiology practices during the study period from May 1, 2008, to December 31, 2014. Overall and practice-specific rates of rhythm control (cardioversion, antiarrhythmic drug therapy, or catheter ablation) were assessed. We assessed patient and practice factors associated with rhythm control and determined the relative contribution of patient, practice, and unmeasured practice factors with its use.
Among 511,958 PINNACLE AF patients, 22.3% were treated with rhythm control and 2.9% underwent catheter ablation. Significant practice variation in rhythm control was present (median rate of rhythm control across practices 22.8%, range 0.2%-62.9%). Significant patient factors associated with rhythm control therapy included white (vs nonwhite) race (odds ratio [OR] 2.43, P<.001), private (vs nonprivate) insurance (OR 1.04, P<.001), and whether a patient was seen by an electrophysiologist (OR 1.77, P<.001). In an analysis of the relative contribution of patient, practice, and unmeasured practice factors with rhythm control, the contribution of unmeasured practice factors (95% range OR 0.29-3.44) exceeded that of either patient (95% range OR 0.46-2.30) or practice (95% range OR 0.15-2.77) factors.
One in 5 AF patients in the PINNACLE registry received rhythm control, and 1 in 50 received catheter ablation, suggesting that rhythm control may be underused. A variety of measured and unmeasured practice factors unrelated to patient characteristics play a disproportionate role in the use of rhythm control treatment decisions. Understanding the drivers of these decisions may identify inappropriate treatment variation and better inform optimal use of these therapies.
心房颤动（AF）患者是否采用节律控制策略通常应由患者因素决定，如生活质量、心力衰竭及其他合并症。其他因素是否会影响节律控制决策，尤其是导管消融决策，目前尚不清楚。
在2008年5月1日至2014年12月31日的研究期间，从美国门诊心脏病学实践的国家心血管数据注册中心的实践创新与临床卓越（PINNACLE）房颤注册库中识别出所有诊断为非瓣膜性房颤的患者队列。评估节律控制（复律、抗心律失常药物治疗或导管消融）的总体及特定实践发生率。我们评估了与节律控制相关的患者和实践因素，并确定了患者、实践及未测量的实践因素在其使用中的相对贡献。
在511,958例PINNACLE房颤患者中，22.3%接受了节律控制治疗，2.9%接受了导管消融。节律控制存在显著的实践差异（各实践中节律控制的中位发生率为22.8%，范围为0.2%-62.9%）。与节律控制治疗相关的显著患者因素包括白人（与非白人相比）种族（优势比[OR] 2.43，P<0.001）、私人（与非私人相比）保险（OR 1.04，P<0.001）以及患者是否由电生理学家诊治（OR 1.77，P<0.001）。在分析患者、实践及未测量的实践因素对节律控制的相对贡献时，未测量的实践因素（95%范围OR 0.29-3.44）的贡献超过了患者（95%范围OR 0.46-2.30）或实践（95%范围OR 0.15-2.77）因素。
PINNACLE注册库中五分之一的房颤患者接受了节律控制，五十分之一接受了导管消融，这表明节律控制可能未得到充分应用。多种与患者特征无关的已测量和未测量的实践因素在节律控制治疗决策的使用中发挥了不成比例的作用。了解这些决策的驱动因素可能有助于识别不适当的治疗差异，并为这些治疗的最佳使用提供更好的信息。
