title: Evaluation of practice patterns in the treatment of atrial fibrillation among the commercially insured.
abstract: OBJECTIVE
  The management of atrial fibrillation (AF) involves two choices: (1) rate control versus rhythm control, and (2) anticoagulation treatment based upon risk of stroke. The objective of the study was to describe practice patterns in both of these treatment areas in patients with newly diagnosed AF among a commercially insured population.
  
  
  METHODS
  This retrospective administrative claims analysis included patients with ≥2 AF claims between 1 January 2008 and 30 September 2010. Patients with AF claims within a year prior to the index date (i.e., the first AF diagnosis date) were excluded. The primary outcome was the proportion of patients treated with rate control (i.e., beta blockers, calcium channel blockers, digoxin) versus rhythm control (i.e., electrical cardioversion, left atrial catheter ablation [LACA], and/or surgical ablation) and the use of anticoagulants stratified by risk of stroke based on CHADS2 score.
  
  
  RESULTS
  Of 48,814 patients with a diagnosis of AF, 38,502 (78.9%) received treatment. Of those treated, the majority received only pharmacologic treatment (73.4%), of which beta blockers were predominantly used in the initial regimen (66.7%). Antiarrhythmic drugs were used in 23.9% of patients, but within the initial regimen in only 11.7% of patients. Direct current cardioversion occurred in 18.2% of patients, with the majority being either first-line (8.5%) or second-line (9.1%) therapy. LACA was used in only 5.2% of patients and was typically reserved for use after pharmacologic treatment or direct current cardioversion. Of 1924 patients who received LACA, 14.6% received a repeat procedure and 53.4% of the repeat procedures occurred within 6 months of the initial one. A little more than half of all patients (57.0%) received anticoagulant therapy (predominantly warfarin); of those at high risk for stroke, 63.8% with a CHADS2 score ≥2 received anticoagulants.
  
  
  CONCLUSIONS
  It is a retrospective analysis using administrative claims data from a commercially insured population only. Identification of the first episode of AF may be inaccurate, and we cannot differentiate between paroxysmal and persistent AF.
  
  
  CONCLUSIONS
  Debate continues regarding whether the preferred management of most patients with AF is through rate control or restoration of normal sinus rhythm. Our retrospective study found that treatments to restore normal heart rhythm, including LACA, which could be considered aggressive initial treatment, were typically reserved as second- or third-line alternatives. Initial standard of care for the majority patients was beta blockers. Though use of anticoagulation may be higher than other observational studies, opportunities exist to increase treatment in high risk patients.
authors.affiliation: HealthCore Inc. , Wilmington, DE , USA.
authors.forename: Jinan
authors.initials: J
authors.lastname: Liu
authors.forename: Gosia
authors.initials: G
authors.lastname: Sylwestrzak
authors.forename: John
authors.initials: J
authors.lastname: Barron
authors.forename: Alan
authors.initials: A
authors.lastname: Rosenberg
authors.forename: Jeffrey
authors.initials: J
authors.lastname: White
authors.forename: John
authors.initials: J
authors.lastname: Whitney
authors.forename: Rita
authors.initials: R
authors.lastname: Redberg
authors.forename: David
authors.initials: D
authors.lastname: Malenka
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use*; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000628:therapy*; D017115:Catheter Ablation / Q000706:statistics & numerical data*; D016208:Databases, Factual; D004554:Electric Countershock / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007348:Insurance, Health; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D014481:United States; D055815:Young Adult
chemical_list: D000889:Anti-Arrhythmia Agents; D000925:Anticoagulants
keywords: Antiarrhythmics; Anticoagulants; Atrial fibrillation; Rate control; Rhythm control