Quality of care for atrial fibrillation among patients hospitalized for heart failure.
OBJECTIVE
This study sought to examine quality of care and warfarin use at discharge in patients with atrial fibrillation (AF) and heart failure (HF).


BACKGROUND
Atrial fibrillation is common in HF, and national guidelines recommend discharge on warfarin for stroke prophylaxis. However, the frequency and factors associated with the guideline adherence are poorly described.


METHODS
We analyzed 72,534 HF admissions from January 2005 through March 2008 at 255 hospitals participating in the American Heart Association's Get With The Guidelines HF program. Multivariable logistic regression was used to identify independent factors associated with warfarin use at discharge.


RESULTS
In this HF population, 20.5% (n=14,901) had AF on admission, whereas another 13.7% (n=9,918) had a prior history of AF but were in a regular rhythm at admission. Contraindications to warfarin therapy were documented in 9.2%. Among eligible HF patients without contraindications, the median prevalence of warfarin therapy at discharge was 64.9% (interquartile range 55.5 to 73.4) and did not improve during the 3.5 years of study. After adjustment, major factors associated with no warfarin use at discharge included increasing age, nonwhite race, anemia, and treatment in the south. Warfarin use also varied inversely with CHADS2 (congestive heart failure, hypertension, age>75, diabetes, and prior stroke or transient ischemic attack) risk (70.9% to 59.5% for CHADS2 score 1 to 6, p<0.0001).


CONCLUSIONS
Guideline-recommended warfarin use in patients with AF and HF is less than optimal, has not improved over time, and varies significantly according to age, race, risk profile, region, and hospital site.
Duke Clinical Research Institute, Durham, North Carolina 27715, USA.
Jonathan P
JP
Piccini
Adrian F
AF
Hernandez
Xin
X
Zhao
Manesh R
MR
Patel
William R
WR
Lewis
Eric D
ED
Peterson
Gregg C
GC
Fonarow
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000453:epidemiology; D004359:Drug Therapy, Combination; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence; D006333:Heart Failure / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010351:Patient Discharge; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D011787:Quality of Health Care; D044469:Racial Groups; D012042:Registries; D012111:Residence Characteristics; D018570:Risk Assessment; D020521:Stroke / Q000517:prevention & control; D014481:United States / Q000453:epidemiology; D014859:Warfarin / Q000627:therapeutic use*
D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D014859:Warfarin