Download PDF
Thromb Haemost 2011; 105(06): 1010-1023
DOI: 10.1160/TH11-02-0070
Blood Coagulation, Fibrinolysis and Cellular Haemostasis
Schattauer GmbH

Impact of the type of centre on management of AF patients: Surprising evidence for differences in antithrombotic therapy decisions

Paulus Kirchhof   *
1   Department of Cardiology and Angiology, University Hospital Münster, Münster, Germany
,
Michael Nabauer   *
2   Medizinische Klinik und Poliklinik I, Campus Grosshadern, Ludwig-Maximilians-University, Munich, Germany
,
Andrea Gerth
2   Medizinische Klinik und Poliklinik I, Campus Grosshadern, Ludwig-Maximilians-University, Munich, Germany
,
Tobias Limbourg
3   Institute for Research in Myocardial Infarction Ludwigshafen of the University of Heidelberg, Heidelberg, Germany
,
Thorsten Lewalter
4   University of Bonn, Bonn, Germany
,
Andreas Goette
5   St Vincenz-Hospital Hospital Paderborn, Germany and Department of Clinical Pharmacology, University of Magdeburg Hospital, Magdeburg, Germany
,
Karl Wegscheider
6   Department of Medical Biometry and Epidemiology, University Hospital, Hamburg-Eppendorf, Germany
,
Andras Treszl
6   Department of Medical Biometry and Epidemiology, University Hospital, Hamburg-Eppendorf, Germany
,
Thomas Meinertz
7   Department of Cardiology, University Heart Center Hamburg, Hamburg, Germany
,
Michael Oeff
8   Department of Medicine I, Brandenburg Municipal Hospital, Brandenburg, Germany
,
Ursula Ravens
9   Department of Pharmacology and Toxicology, Medical Faculty, Dresden University of Technology, Dresden, Germany
,
Günter Breithardt
1   Department of Cardiology and Angiology, University Hospital Münster, Münster, Germany
,
Gerhard Steinbeck
2   Medizinische Klinik und Poliklinik I, Campus Grosshadern, Ludwig-Maximilians-University, Munich, Germany
,
the AFNET › Author Affiliations
Further Information

Publication History

Received: 04 February 2011

Accepted after minor revision: 09 March 2011

Publication Date:
28 November 2017 (online)

    Permissions and Reprints

Summary

Atrial fibrillation (AF) patients may receive treatment from specialists or from general medicine physicians representing different levels of care within a structured health care system. This “choice” is influenced by patient flow within a health care system, patient preference, and individual access to health care resources. We analysed how the postgraduate training and work environment of treating physicians affects management decisions in AF patients. Patient characteristics and treatment decisions were analysed at the time of enrolment into the registry of the German Atrial Fibrillation NETwork (AFNET). A total of 9,577 patients were enrolled from 2004 to 2006 in 191 German centres that belonged to the following four levels of care: 13 tertiary care centres (TCC) enrolled 3,795 patients (39.6%), 58 district hospitals (DH) enrolled 2,339 patients (24.4%), 62 office-based cardiologists (OC) enrolled 2,640 patients (27.6%), and 58 general practitioners or internists (GP) enrolled 803 patients (8.4%). Patients with new-onset AF were often treated in DH. TCC treated younger patients who more often presented with paroxysmal AF. Older patients and patients in permanent AF more often received outpatient care. Consistent with recommendations, younger patients and patients with non-permanent AF received rhythm control therapy more often. In addition, the type of centre affected the decision for rhythm control. Stroke risk was similar between centre types (mean CHADS2 scores 1.6 –1.9). TCC (68.8%) and OC (73.6%) administered adequate antithrombotic therapy more often than DH (55.1%) or GP (52.0%, p<0.001 between groups). Upon multivariate analysis, enrolment by TCC or OC was associated with a 1.60 (1.20–2.12, p=0.001) fold chance for adequate antithrombotic treatment. This difference between centre types was consistent irrespective of the type of stroke risk estimation (ESC 2001 guidelines, CHADS2 score), and also consistent when the recently suggested CHA2DS2-VASc score was used to estimate stroke risk. In conclusion, management decisions in AF are influenced by the education and clinical background of treating physicians in Germany. Inpatients receive more rhythm control therapy. Adequate antithrombotic therapy is more often administered in specialist (cardiologist) centres.

Keywords

Atrial fibrillation - access to health care - antithrombotic therapy - rhythm control therapy - level of care - registry

* These authors contributed equally.


** All authors are members of the German Atrial Fibrillation competence NETwork (AFNET).


 

  • References

  • 1 Fuster V. et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electro-physiology. Eur Heart J 2001; 22: 1852-1923.
    CrossrefPubMedGoogle Scholar
  • 2 Fuster V. et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation-executive summary: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Eur Heart J 2006; 27: 1979-2030.
    CrossrefPubMedGoogle Scholar
  • 3 Calkins H. et al. HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures and Follow-Up: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation Developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and Approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society. Europace 2007; 9: 335-379.
    CrossrefPubMedGoogle Scholar
  • 4 Kirchhof P. et al. Outcome parameters for trials in atrial fibrillation: executive summary: Recommendations from a consensus conference organized by the German Atrial Fibrillation Competence NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eur Heart J 2007; 28: 2803-2817.
    CrossrefPubMedGoogle Scholar
  • 5 Kirchhof P. et al. Early and comprehensive management of atrial fibrillation: executive summary of the proceedings from the 2nd AFNET-EHRA consensus conference ‘research perspectives in AF‘. Eur Heart J 2009; 30: 2969-2977c.
    CrossrefPubMedGoogle Scholar
  • 6 Hart RG. et al. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med 1999; 131: 492-501.
    PubMedGoogle Scholar
  • 7 Hylek EM. et al. Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation. N Engl J Med 2003; 349: 1019-1026.
    CrossrefPubMedGoogle Scholar
  • 8 Mant J. et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007; 370: 493-503.
    CrossrefPubMedGoogle Scholar
  • 9 Nattel S, Opie LH. Controversies in atrial fibrillation. Lancet 2006; 367: 262-272.
    CrossrefPubMedGoogle Scholar
  • 10 Roy D. et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med 2008; 358: 2667-2677.
    CrossrefPubMedGoogle Scholar
  • 11 Calkins H. et al. HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2007; 4: 816-861.
    CrossrefPubMedGoogle Scholar
  • 12 Healey JS. et al. Prevention of atrial fibrillation with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: a meta-analysis. J Am Coll Cardiol 2005; 45: 1832-1839.
    CrossrefPubMedGoogle Scholar
  • 13 Camm AJ. et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31: 2369-2429.
    CrossrefPubMedGoogle Scholar
  • 14 Singer DE. et al. Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (Suppl. 03) 429S-456S.
    CrossrefPubMedGoogle Scholar
  • 15 Snow V. et al. Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med 2003; 139: 1009-1017.
    CrossrefPubMedGoogle Scholar
  • 16 AFFIRM I. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002; 347: 1825-1833.
    CrossrefPubMedGoogle Scholar
  • 17 Van Gelder I. et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002; 347: 1834-1840.
    CrossrefPubMedGoogle Scholar
  • 18 Nieuwlaat R. et al. Atrial fibrillation management: a prospective survey in ESC member countries: the Euro Heart Survey on Atrial Fibrillation. Eur Heart J 2005; 26: 2422-2434.
    CrossrefPubMedGoogle Scholar
  • 19 Kerr CR. et al. The Canadian Registry of Atrial Fibrillation: a noninterventional follow-up of patients after the first diagnosis of atrial fibrillation. Am J Cardiol 1998; 82: 82N-85N.
    CrossrefPubMedGoogle Scholar
  • 20 Levy S. et al. Characterization of different subsets of atrial fibrillation in general practice in France: the ALFA study. The College of French Cardiologists. Circulation 1999; 99: 3028-3035.
    CrossrefPubMedGoogle Scholar
  • 21 Reiffel JA. et al. Practice patterns among United States cardiologists for managing adults with atrial fibrillation (from the AFFECTS Registry). Am J Cardiol 2010; 105: 1122-1129.
    CrossrefPubMedGoogle Scholar
  • 22 Heuzey JY. et al. The RecordAF study: design, baseline data, and profile of patients according to chosen treatment strategy for atrial fibrillation. Am J Cardiol 2010; 105: 687-693.
    CrossrefPubMedGoogle Scholar
  • 23 Nabauer M. et al. The Registry of the German Competence NETwork on Atrial Fibrillation: Patient characteristics and initial management. Europace 2009; 11: 423-434.
    PubMedGoogle Scholar
  • 24 Blanc JJ. et al. Consensus document on antithrombotic therapy in the setting of electrophysiological procedures. Europace 2008; 10: 513-527.
    CrossrefPubMedGoogle Scholar
  • 25 Nieuwlaat R. et al. Guideline-adherent antithrombotic treatment is associated with improved outcomes compared with undertreatment in high-risk patients with atrial fibrillation. The Euro Heart Survey on Atrial Fibrillation. Am Heart J 2007; 153: 1006-1012.
    CrossrefPubMedGoogle Scholar
  • 26 Gage BF. et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. J Am Med Assoc 2001; 285: 2864-2870.
    CrossrefPubMedGoogle Scholar
  • 27 Lip GY. et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010; 137: 263-272.
    CrossrefPubMedGoogle Scholar
  • 28 Wachtell K. et al. Angiotensin II receptor blockade reduces new-onset atrial fibrillation and subsequent stroke compared to atenolol: the Losartan Intervention For End Point Reduction in Hypertension (LIFE) study. J Am Coll Cardiol 2005; 45: 712-719.
    CrossrefPubMedGoogle Scholar
  • 29 Nieuwlaat R. et al. Should we abandon the common practice of withholding oral anticoagulation in paroxysmal atrial fibrillation?. Eur Heart J 2008; 29: 915-922.
    CrossrefPubMedGoogle Scholar
  • 30 Meiltz A. et al. Atrial fibrillation management by practice cardiologists: a prospective survey on the adherence to guidelines in the real world. Europace 2008; 10: 674-680.
    CrossrefPubMedGoogle Scholar
  • 31 Lip GY. et al. Physician variation in the management of patients with atrial fibrillation. Heart 1996; 75: 200-205.
    CrossrefPubMedGoogle Scholar
  • 32 Lane DA, Lip GY. Barriers to anticoagulation in patients with atrial fibrillation: changing physician-related factors. Stroke 2008; 39: 7-9.
    CrossrefPubMedGoogle Scholar
  • 33 Cohen N. et al. Warfarin for stroke prevention still underused in atrial fibrillation: patterns of omission. Stroke 2000; 31: 1217-1222.
    CrossrefPubMedGoogle Scholar
  • 34 Lip GY. et al. Ethnic differences in patient perceptions of atrial fibrillation and anticoagulation therapy: the West Birmingham Atrial Fibrillation Project. Stroke 2002; 33: 238-242.
    CrossrefPubMedGoogle Scholar
  • 35 Camm AJ. et al. Guidelines for the management of atrial fibrillation. Eur Heart J 2010; 31: 2369-2429.
    CrossrefPubMedGoogle Scholar
  • 36 van Staa T. et al. A comparison of risk stratification schemes for stroke in 79 884 atrial fibrillation patients in general practice. J Thromb Haemost 2011; 9: 39-48.
    CrossrefPubMedGoogle Scholar
  • 37 Lip GY, Lim HS. Atrial fibrillation and stroke prevention. Lancet Neurol 2007; 6: 981-993.
    CrossrefPubMedGoogle Scholar
  • 38 Andersen KK, Olsen TS. Reduced poststroke mortality in patients with stroke and atrial fibrillation treated with anticoagulants: results from a Danish quality-control registry of 22,179 patients with ischemic stroke. Stroke 2007; 38: 259-263.
    CrossrefPubMedGoogle Scholar
  • 39 O’Donnell M. et al. Preadmission antithrombotic treatment and stroke severity in patients with atrial fibrillation and acute ischaemic stroke: an observational study. Lancet Neurol 2006; 5: 749-754.
    CrossrefPubMedGoogle Scholar
  • 40 Gorin L. et al. Antithrombotic treatment and the risk of death and stroke in patients with atrial fibrillation and a CHADS2 score=1. Thromb Haemost 2010; 103: 833-840.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 41 Karthikeyan G, Eikelboom JW. The CHADS2 score for stroke risk stratification in atrial fibrillation--friend or foe?. Thromb Haemost 2010; 104: 45-48.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 42 Ahrens I. et al. New oral anticoagulant drugs in cardiovascular disease. Thromb Haemost 2010; 104: 49-60.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Holbrook A. et al. Influence of decision aids on patient preferences for anticoagulant therapy: a randomized trial. CMAJ 2007; 176: 1583-1587.
    CrossrefPubMedGoogle Scholar
  • 44 Metra M. et al. Postdischarge assessment after a heart failure hospitalization: the next step forward. Circulation 2010; 122: 1782-1785.
    CrossrefPubMedGoogle Scholar
  • 45 Lee DS. et al. Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department. Circulation 2010; 122: 1806-1814.
    CrossrefPubMedGoogle Scholar