title: Quality of care in patients with atrial fibrillation in primary care: a cross-sectional study comparing clinical and claims data.
abstract: Objectives:Atrial fibrillation (AF) is a common cardiac arrhythmia with increased risk of thromboembolic stroke. Oral anticoagulation (OAC) reduces stroke risk by up to 68%. The aim of our study was to evaluate quality of care in patients with AF in a primary health care setting with a focus on physician guideline adherence for OAC prescription and heart rate- and rhythm management. In a second step we aimed to compare OAC rates based on primary care data with rates based on claims data.Methods:We included all GP practices in the region Vorpommern-Greifswald, Germany, which were willing to participate (N=29/182, response rate 16%). Claims data was derived from the regional association of statutory health insurance physicians. Patients with a documented AF diagnosis (ICD-10-GM-Code ICD I48.-) from 07/2011-06/2012 were identified using electronic medical records (EMR) and claims data. Stroke and bleeding risk were calculated using the CHA2DS2-VASc and HAS-BLED scores. We calculated crude treatment rates for OAC, rate and rhythm control medications and adjusted OAC treatment rates based on practice and claims data. Adjusted rates were calculated including the CHA2DS2-VASc and HAS-BLED scores and individual factors affecting guideline based treatment.Results:We identified 927 patients based on EMR and 1,247 patients based on claims data. The crude total OAC treatment rate was 69% based on EMR and 61% based on claims data. The adjusted OAC treatment rates were 90% for patients based on EMR and 63% based on claims data. 82% of the AF patients received a treatment for rate control and 12% a treatment for rhythm control. The most common reasons for non-prescription of OAC were an increased risk of falling, dementia and increased bleeding risk.Conclusion:Our results suggest that a high rate of AF patients receive a drug therapy according to guidelines. There is a large difference between crude and adjusted OAC treatment rates. This is due to individual contraindications and comorbidities which cannot be documented using ICD coding. Therefore, quality indicators based on crude EMR data or claims data would lead to a systematic underestimation of the quality of care. A possible overtreatment of low-risk patients cannot be ruled out.
authors.affiliation: Department of Family Medicine, Institute for Community Medicine, University Medicine Greifswald, Germany.
authors.forename: Rebekka
authors.initials: R
authors.lastname: Preuss
authors.affiliation: Department of Family Medicine, Institute for Community Medicine, University Medicine Greifswald, Germany.
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Chenot
authors.affiliation: Department of Family Medicine, Institute for Community Medicine, University Medicine Greifswald, Germany.
authors.forename: Aniela
authors.initials: A
authors.lastname: Angelow
mesh_terms: D000067575:Administrative Claims, Healthcare / Q000706:statistics & numerical data; 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 / Q000188:drug therapy*; D003430:Cross-Sectional Studies; D057286:Electronic Health Records / Q000706:statistics & numerical data; D005260:Female; D058006:General Practice / Q000592:standards / Q000706:statistics & numerical data; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000592:standards / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*
chemical_list: D000889:Anti-Arrhythmia Agents; D000925:Anticoagulants
keywords: atrial fibrillation; oral anticoagulation; primary health care; quality of health care; vitamin K antagonists & inhibitors