Implementing hospital guidelines improves warfarin use in non-valvular atrial fibrillation: a before-after study.
BACKGROUND
The use of oral anticoagulant therapy (OAT) to prevent non-valvular atrial fibrillation (NVAF) related-strokes is often sub-optimal. We aimed to evaluate whether implementing guidelines on antithrombotic therapy (AT) by a multifaceted strategy may improve appropriateness of its prescription in NVAF-patients discharged from a large tertiary-care hospital.


METHODS
A survey was conducted on all consecutive NVAF patients discharged before (1st January-30th June 2000, n = 313) and after (1st January-30th June 2004, n = 388) guideline development and implementation.


RESULTS
When strongly recommended, OAT use increased from 56.6% (60/106 in 2000) to 81.9% (86/105 in 2004), with an absolute difference of +25.3% (95%CI: 15% 35%). In patients for whom the choice OAT/acetylsalicylic acid should be individualised, those discharged without any AT were 33.7% (34/101) in 2000 and 16.9% (21/124) in 2004 (-16.7%;95%CI: -26.2% -7.2%). In a logistic regression model, OAT prescription in 2004 was increased by 2.11 times (95%CI: 1.47 3.04), after accounting for stroke risk, presence of contraindications (OR = 0.18; 0.13 0.27), older age (OR = 0.30; 0.21 0.45), prophylaxis at admission (OR = 3.03; 2.08 4.43). OAT was positively associated with the stroke risk in the 2004 sample only.


CONCLUSIONS
The guideline implementation has substantially improved the appropriateness of OAT at discharge, through a better evaluation at patient's individual level of the benefit-to-risk ratio.
Bo
Simona
S
Department of Internal Medicine, University of Torino, Italy. sbo@molinette.piemonte.it
Valpreda
Susanna
S
Scaglione
Luca
L
Boscolo
Daniela
D
Piobbici
Marina
M
Bo
Mario
M
Ciccone
Giovannino
G
D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D018890:Chemoprevention; D000075202:Contraindications; D017723:Drug Utilization Review; D005260:Female; D015577:Geriatric Assessment; D006784:Hospitals, Teaching / Q000592:standards*; D006801:Humans; D007558:Italy; D016015:Logistic Models; D008297:Male; D010351:Patient Discharge; D017410:Practice Guidelines as Topic; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000150:complications / Q000517:prevention & control*; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D014859:Warfarin / Q000008:administration & dosage / Q000627:therapeutic use*
D000925:Anticoagulants; D014859:Warfarin
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