title: The health care setting rather than medical speciality impacts on physicians adherence to guideline-conform anticoagulation in outpatients with non-valvular atrial fibrillation: a cross sectional survey.
abstract: BACKGROUND
  In patients with non-valvular atrial fibrillation (NVAF) at high risk for stroke guidelines consistently recommend long-term oral anticoagulation (OAC) with a vitamin K antagonist. However recommendations remain ambiguous in respect to the precise OAC initiation regimens. Based on the clinical observation, that the initiation of OAC for NVAF varies considerably in daily practice, we aimed to assess the current practice in Switzerland.
  
  
  METHODS
  Cross-sectional survey of randomly selected general practitioners, internists and cardiologists from different health care settings in an urban Swiss region that covers 1.4 million inhabitants. The main outcome measures were the preferred antithrombotic initiation regimen and long-term treatment in patients with newly diagnosed NVAF at high risk for stroke.
  
  
  RESULTS
  We received 226 out of 388 (58.2%) surveys. Compared to physicians working in a hospital setting (33.6% of respondents) physicians in ambulatory care reported more years of experience and claimed lower-use (never or seldom) of guidelines in general (47.6 vs. 12.2%). Regarding long-term thromboembolic prophylaxis 93.7% of all responders followed current recommendation by choosing an OAC. When focussing on guideline-consistent correct OAC initiation (either low-dose initial OAC or a combination of LMWH and OAC) adherence dropped to 60.6% with hospital physicians demonstrating a significantly higher use of guideline-conform OAC regimens (79.7 vs. 51.0%). Medical speciality in non-hospital physicians was not related to correct guideline-use. Hospital setting remained independently associated with a guideline-conform OAC initiation regimen (OR 2.8, p = 0.023) when controlled for medical speciality, physicians' characteristics and clinical experience. Problems when starting an anticoagulation treatment were seldom reported (never or seldom accounting for 94.1% of all responses).
  
  
  CONCLUSIONS
  The guideline adherence with respect to OAC initiation regimens in NVAF was significantly lower when compared to long-term treatment and health care setting rather than medical speciality explained guideline-conform OAC initiation. The majority of the physicians did not consider the initiation of anticoagulation to be a major obstacle in outpatient care.
authors.affiliation: Clinic of Haematology, University Hospital Zurich, Raemistrasse 100, 8091 Zuerich, Switzerland. bernhard.gerber@usz.ch
authors.forename: Bernhard
authors.initials: B
authors.lastname: Gerber
authors.forename: Georg
authors.initials: G
authors.lastname: Stussi
authors.forename: Thomas
authors.initials: T
authors.lastname: Rosemann
authors.forename: Oliver
authors.initials: O
authors.lastname: Senn
mesh_terms: D000553:Ambulatory Care; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care; D004501:Education, Medical; D019983:Guideline Adherence; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use; D006801:Humans; D008511:Medicine; D010820:Physicians; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D020521:Stroke / Q000517:prevention & control* / Q000628:therapy; D013557:Switzerland; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D014859:Warfarin