Amanda Marie Somer Christesen1,2, Nicklas Vinter1,2, Leif Spange Mortensen3, Morten Fenger-Grøn4, Søren Paaske Johnsen2,5,6, Lars Frost1,2. 1. Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 3, Silkeborg, Denmark. 2. Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus N, Denmark. 3. Spange Statistics, Elleparken 10, Lystrup, Denmark. 4. Research Unit for General Practice and Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, Aarhus, Denmark. 5. Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, Aarhus N, Denmark. 6. Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Mølleparkvej 10, Aalborg, Denmark.
Abstract
Aim: To explore the potential of small-area variation analysis as a tool for identifying unwarranted variation in oral anticoagulation (OAC) use and clinical outcomes in patients with atrial fibrillation (AF) and thereby identify locations with opportunity for improvement in AF care. Methods and results: Based on Danish health care registries, we conducted a nationwide historical cohort study including first-time AF patients with a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75, diabetes, thromboembolism, vascular disease, age 65-74, and sex category) score ≥ 2 between 2007 and 2014 (n = 94 482). For each administrative region and municipality, we assessed OAC initiation and persistence as well as the risk of ischaemic stroke, haemorrhagic stroke, and other major bleeding, respectively. In addition, potential temporal changes were examined for all outcomes. Initiation of OAC varied among regions from 49.5% to 62.4%. In patients initiating OAC, the proportion of patients still receiving OAC after 1 year varied from 73.9% to 79.3%. Oral anticoagulation use increased in all regions during the study period, particularly after 2010, but regional variation in OAC initiation persisted. Generally, the regions and municipalities with the highest initiation of OAC also had the highest OAC persistence. The risk of ischaemic stroke and other major bleeding was lower in these regions and municipalities. We found no significant difference between regions in risk of haemorrhagic stroke. Conclusion: Substantial geographical variation in OAC use and clinical outcomes occurs in Denmark demonstrating the potential of small-area variation analysis as a tool for identifying unwarranted variation in AF care and clinical outcomes. Our findings demonstrate the need for additional initiatives to ensure uniform high-quality care for AF patients.
Aim: To explore the potential of small-area variation analysis as a tool for identifying unwarranted variation in oral anticoagulation (OAC) use and clinical outcomes in patients with atrial fibrillation (AF) and thereby identify locations with opportunity for improvement in AF care. Methods and results: Based on Danish health care registries, we conducted a nationwide historical cohort study including first-time AFpatients with a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75, diabetes, thromboembolism, vascular disease, age 65-74, and sex category) score ≥ 2 between 2007 and 2014 (n = 94 482). For each administrative region and municipality, we assessed OAC initiation and persistence as well as the risk of ischaemic stroke, haemorrhagic stroke, and other major bleeding, respectively. In addition, potential temporal changes were examined for all outcomes. Initiation of OAC varied among regions from 49.5% to 62.4%. In patients initiating OAC, the proportion of patients still receiving OAC after 1 year varied from 73.9% to 79.3%. Oral anticoagulation use increased in all regions during the study period, particularly after 2010, but regional variation in OAC initiation persisted. Generally, the regions and municipalities with the highest initiation of OAC also had the highest OAC persistence. The risk of ischaemic stroke and other major bleeding was lower in these regions and municipalities. We found no significant difference between regions in risk of haemorrhagic stroke. Conclusion: Substantial geographical variation in OAC use and clinical outcomes occurs in Denmark demonstrating the potential of small-area variation analysis as a tool for identifying unwarranted variation in AF care and clinical outcomes. Our findings demonstrate the need for additional initiatives to ensure uniform high-quality care for AFpatients.
Authors: Jordan K Schaefer; Mengbing Li; Zhenke Wu; Tanima Basu; Geoffrey D Barnes; Marc Carrier; Jennifer J Griggs; Suman L Sood Journal: J Thromb Thrombolysis Date: 2021-02-05 Impact factor: 2.300
Authors: Derek S Chew; Flora Au; Yuan Xu; Braden J Manns; Marcello Tonelli; Stephen B Wilton; Brenda Hemmelgarn; Shiying Kong; Derek V Exner; Amity E Quinn Journal: CMAJ Open Date: 2022-08-02