scholarly journals 2135 Impact of primary care physician gatekeeping on medication prescriptions for atrial fibrillation

2018 ◽  
Vol 2 (S1) ◽  
pp. 82-83
Author(s):  
Andrew Y. Chang ◽  
Mariam Askari ◽  
Jun Fan ◽  
Paul A. Heidenreich ◽  
P. Michael Ho ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Rate Control ◽  
Primary Care Physicians ◽  
Oral Anticoagulants ◽  
Rhythm Control ◽  
Health Plans ◽  
Odds Ratios ◽  
Antiplatelet Medication ◽  
Number Of Patients

OBJECTIVES/SPECIFIC AIMS: Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice, and has widely varying treatments for stroke prevention and rhythm management. Some of these therapies are increasingly being prescribed by primary care physicians (PCPs). We therefore sought to investigate if healthcare plans with PCP gatekeeping for access to specialists are associated with different pharmacologic treatment strategies for the disease. In particular, we focused on oral anticoagulants (OACs), non-vitamin K-dependent oral anticoagulants (NOACs), rate control, and rhythm control medications. METHODS/STUDY POPULATION: We examined a commercial pharmaceutical claims database (Truven Marketscan™) to compare the prescription frequency of OAC, rate control, and rhythm control medications used to treat AF between patients with PCP-gated health plans (where the PCP is the gatekeeper to specialist referral—i.e., HMO, EPO, POS) and patients with non-PCP-gatekeeper health plans (i.e., comprehensive, PPO, CHDP, HDHP). To control for potential confounders, we also used multivariable logistic regression models to calculate adjusted odds ratios which accounted for age, sex, region, Charlson comorbidity index, CHADS2Vasc score, hypertension, diabetes, stroke/transient ischemic attack, prior myocardial infarction, peripheral artery disease, and antiplatelet medication use. We also calculated median time to therapy to determine if there was a difference in time to new prescription of these medications. RESULTS/ANTICIPATED RESULTS: We found only small differences between patients in PCP-gated and non-PCP-gated plans regarding prescription proportion of anticoagulants at 90 days following new AF diagnosis (OAC 44.2% vs. 42%, p<0.01; warfarin 39.1% vs. 37.1%, p<0.01; NOAC 5.9% vs. 6.0%, p=0.64). We observed similar trends for rate control agents (76.4% vs. 73.4%, p<0.01) and rhythm control agents (24.4% vs. 24.6%, p=0.83). We found similar odds of OAC prescription at 90 days following new AF diagnosis between patients in PCP-gated and non-PCP-gated plans (adjusted OR for PCP-gated plans relative to non-gated plans: OAC 1.006, p=0.84; warfarin 1.054, p=0.08; NOAC 0.815, p=0.001; dabigatran 0.833, p=0.004; and rivaroxaban 0.181, p=0.02). We observed similar trends for rate control agents (1.166, p<0.0001) and rhythm control agents (0.927, p=0.03). Elapsed time until receipt of medication was similar between PCP-gated and non-gated groups [OAC 4±14 days (interquartile range) vs. 5±16 days, p<0.0001; warfarin 4±14 vs. 5±14, p<0.0001; NOAC 7±26 vs. 6±23, p=0.2937; rhythm control 13±35 vs. 13±34, p=0.8661; rate control 10±25 vs. 11±30, p<0.0001]. DISCUSSION/SIGNIFICANCE OF IMPACT: We found that plans with PCP gatekeeping to specialist referrals were not associated with clinically meaningful differences in prescription rates or delays in time to prescription of oral anticoagulation, rate control, and rhythm control drug therapy. In some cases, PCP gatekeeping plans had very small but statistically significant lower odds of being prescribed NOACs. These findings suggest that PCP gatekeeping does not appear to be a major structural barrier in receipt of medications for AF, although non-PCP-gated plans may vary slightly favor facilitating the prescription of NOACs. Our findings that overall OAC prescriptions did not differ by PCP gating status may suggest completion of the rapid dissemination and uptake phase for most AF treatments. The small but statistically significant odds ratios favoring the non-PCP-gated populations in NOACs further suggests that in this newer drug group, the process is ongoing, with more specialists representing early adopters. Interestingly, the low primary care odds ratio of rivaroxaban use, relative to dabigatran, may be indicative of a gradient of uptake of later-generation NOACs, although interpretability is limited by the small number of patients in the rivaroxaban group.

scholarly journals Screening and management of atrial fibrillation in primary care

BMJ ◽  
2021 ◽  
pp. n379
Author(s):  
Shiva P Ponamgi ◽  
Konstantinos C Siontis ◽  
David R Rushlow ◽  
Jonathan Graff-Radford ◽  
Victor Montori ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Primary Care Physicians ◽  
Stroke Risk ◽  
Diagnostic Testing ◽  
Therapeutic Agents ◽  
Rhythm Control ◽  
Medical Illness ◽  
Hospital Services ◽  
Common Chronic Disease

AbstractAtrial fibrillation is a common chronic disease seen in primary care offices, emergency departments, inpatient hospital services, and many subspecialty practices. Atrial fibrillation care is complicated and multifaceted, and, at various points, clinicians may see it as a consequence and cause of multi-morbidity, as a silent driver of stroke risk, as a bellwether of an acute medical illness, or as a primary rhythm disturbance that requires targeted treatment. Primary care physicians in particular must navigate these priorities, perspectives, and resources to meet the needs of individual patients. This includes judicious use of diagnostic testing, thoughtful use of novel therapeutic agents and procedures, and providing access to subspecialty expertise. This review explores the epidemiology, screening, and risk assessment of atrial fibrillation, as well as management of its symptoms (rate and various rhythm control options) and stroke risk (anticoagulation and other treatments), and offers a model for the integration of the components of atrial fibrillation care.

Optimizing Heart Rate and Controlling Symptoms in Atrial Fibrillation

2016 ◽  
Vol 10 (1) ◽  
pp. 26
Author(s):  
Pragnesh Parikh ◽  
◽  
KL Venkatachalam ◽  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Rate Control ◽  
Stroke Risk ◽  
Symptom Control ◽  
Review Article ◽  
Rhythm Control ◽  
Ventricular Rate ◽  
Control Methods ◽  
Novel Approaches

Atrial fibrillation (AF) is the most common arrhythmia noted in clinical practice and its incidence and prevalence are on the rise. The single most important intervention is the evaluation and treatment of stroke risk. Once the risk for stroke has been minimized, controlling the ventricular rate and treating symptoms become relevant. In this review article, we emphasize the importance of confirming and treating the appropriate arrhythmia and correlating symptoms with rhythm changes. Furthermore, we evaluate some of the risk factors for AF that independently result in symptoms, underlining the need to treat these risk factors as part of symptom control. We then discuss existing and novel approaches to rate control in AF and briefly cover rhythm control methods.

Electronic cigarettes: How confident and effective are allergists, pulmonologists, and primary care physicians in their practice behavior?

2020 ◽  
Vol 41 (3) ◽  
pp. 192-197
Author(s):  
Sherry S. Zhou ◽  
Alan P. Baptist
Keyword(s):  
Primary Care ◽  
Primary Care Physicians ◽  
Electronic Cigarettes ◽  
The United States ◽  
Fisher Exact Test ◽  
Exact Test ◽  
Knowledge And Beliefs ◽  
Tobacco Cigarette ◽  
Number Of Patients ◽  
Personal Use

Background: There has been a striking increase in electronic cigarette (EC) use in the United States. The beliefs and practices toward ECs among physicians are unknown. Objective: The purpose of this study was to investigate EC practice patterns among allergists, pulmonologists, and primary care physicians. Methods: An anonymous survey was sent to physicians. The survey contained 32 questions and addressed issues related to demographics, cessation counseling behaviors, personal use, and knowledge and beliefs about ECs. Statistical analysis was performed by using analysis of variance, the Pearson χ2 test, Fisher exact test, and logistic regression. Results: A total of 291 physicians completed the survey (222 primary care physicians, 33 pulmonologists, and 36 allergists) for a response rate of 46%. The allergists asked about tobacco cigarette use as frequently as did the pulmonologists and more than the primary care physicians (p < 0.001), but they rarely asked about EC use. The pulmonologists scored highest on self-reported knowledge on ECs, although all the groups answered <40% of the questions correctly. The allergists did not feel as comfortable about providing EC cessation counseling as did the pulmonologists and primary care physicians (p < 0.001). All three groups were equally unlikely to recommend ECs as a cessation tool for tobacco cigarette users. Conclusion: Allergists lacked knowledge and confidence in providing education and cessation counseling for EC users. As the number of patients who use these products continues to increase, there is an urgent need for all physicians to be comfortable and knowledgeable with counseling about ECs.

Initiation of anticoagulation in atrial fibrillation by primary care physicians: Results of a telephone survey

2021 ◽  
Author(s):  
Stephanie Carlin ◽  
Alison Bond ◽  
Peter Gross ◽  
Alan Bell ◽  
James Douketis ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Primary Care Physicians ◽  
Telephone Survey

scholarly journals Diagnosis and Management of Atrial Fibrillation by Primary Care Physicians in Italy

2012 ◽  
Vol 32 (11) ◽  
pp. 771-777 ◽  
Author(s):  
Gaetano Piccinocchi ◽  
Matteo Laringe ◽  
Bruno Guillaro ◽  
Giovanni Arpino ◽  
Roberto Piccinocchi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Primary Care Physicians ◽  
Diagnosis And Management

scholarly journals Rhythm and rate control of atrial fibrillation in the emergency department – A large community-based observational study

CJEM ◽  
2017 ◽  
Vol 20 (6) ◽  
pp. 834-840 ◽  
Author(s):  
Cameron J. Gilbert ◽  
Paul Angaran ◽  
Zana Mariano ◽  
Theresa Aves ◽  
Paul Dorian
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Rate Control ◽  
Primary Diagnosis ◽  
Left Ventricular ◽  
Rhythm Control ◽  
Chads2 Score ◽  
Control Factors ◽  
Wide Range ◽  
Canadian City

AbstractObjectiveAtrial fibrillation (AF) is the most common arrhythmia presentation to the emergency department (ED) and frequently results in admission to the hospital. Although rarely life-threatening and not usually an emergent condition, AF places a large burden on our health-care system. The objective of this study was to describe the practices of ED physicians in the management of AF in a large urban Canadian city.MethodsFrom January 1, 2010 to December 31, 2010, patients with a primary diagnosis of AF were identified across 10 EDs in Toronto, Canada (N=2,609). Fifty patients were selected at random from each hospital for a detailed chart review (n=500).ResultsTwo hundred thirty-two patients (46%) received rate control, and 129 (26%) received rhythm control with the remainder (28%) receiving neither therapy. Sixty-seven percent of patients were discharged home. Most patients (79%) were symptomatic on arrival; however, only a minority of these (31%) received rhythm control. Factors that were associated with rhythm control included younger age, duration of palpitations ≤ 48 hours, a lower CHADS2 score, and the absence of left ventricular dysfunction.ConclusionOur data suggest a wide range of practice amongst ED physicians treating patients presenting to the ED with a primary diagnosis of AF. A randomized trial is needed to better understand the optimal management strategy in this patient population and setting.

scholarly journals Rate-control vs rhythm-control of atrial fibrillation in elderly patients. From new, age-oriented outcomes to a more complex management strategy

2018 ◽  
Vol 88 (2) ◽  
Author(s):  
Stefano Fumagalli ◽  
Serena Boni ◽  
Simone Pupo ◽  
Marta Migliorini ◽  
Irene Marozzi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Control Strategy ◽  
Rate Control ◽  
The Elderly ◽  
Epidemiological Studies ◽  
Rhythm Control ◽  
Aged Patients ◽  
Aged People ◽  
Arrhythmia Management

Atrial fibrillation (AF) is the most frequent arrhythmia in elderly people. Findings derived from clinical trials seem to demonstrate that a rate-control strategy of AF in aged patients improves prognosis if compared to a rhythm-control one. However, epidemiological studies concordantly show that the arrhythmia is associated to increased hospitalization and mortality rates. In last years, the proportion of patients admitted to hospital for AF has progressively increased; this trend is observed in subjects >75 and >85 years, while no change was found in younger cohorts. Importantly, in aged individuals, probably because of the loss of atrial activity, the increase of heart rate and the irregularity of RR intervals, AF begins a vicious cycle, leading from heart failure, through the compromise of functional and neurocognitive status, to overt disability, dementia and increased mortality. Evidence specifically aimed at clarifying the effects of arrhythmia management on outcomes characteristic of aged people is completely lacking. In the elderly, the question regarding the effects of a rate- or a rhythm-control strategy of AF should be considered as an aspect of a more complex strategy, addressed to reduce disability and hospitalizations, and to improve quality of life and survival.

FDA-Catalyst—Using FDA’s Sentinel Initiative for large-scale pragmatic randomized trials: Approach and lessons learned during the planning phase of the first trial

2018 ◽  
Vol 16 (1) ◽  
pp. 90-97 ◽  
Author(s):  
Noelle M Cocoros ◽  
Sean D Pokorney ◽  
Kevin Haynes ◽  
Crystal Garcia ◽  
Hussein R Al-Khalidi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Transient Ischemic Attack ◽  
Oral Anticoagulant ◽  
Oral Anticoagulants ◽  
Pragmatic Trial ◽  
Lessons Learned ◽  
Health Plans ◽  
Planning Phase ◽  
Ischemic Attack ◽  
Sentinel Initiative

Background: The US Food and Drug Administration’s Sentinel Initiative is well positioned to support pragmatic clinical trials. FDA-Catalyst combines direct contact with health plan members and/or providers with data in the Sentinel infrastructure. Here, we describe the rationale, feasibility analyses, and lessons learned from the planning phase of the first large pragmatic trial conducted using the Sentinel Initiative’s delivery system capabilities—IMplementation of a randomized controlled trial to imProve treatment with oral AntiCoagulanTs in patients with Atrial Fibrillation (the IMPACT-AFib trial). Methods: During the planning phase, we convened representatives from five commercial health plans, FDA, study coordinating centers, and a patient representative for protocol development, institutional review board preparation, and other activities. Administrative claims data from the plans were included in a retrospective cohort analysis to assess sample size for the trial. Members ≥30 years old with ≥365 days of medical/pharmacy coverage, ≥2 diagnosis codes for atrial fibrillation, a guideline-based indication for oral anticoagulant use for stroke prevention, and no evidence of oral anticoagulant use in the 365 days prior to the index atrial fibrillation diagnosis in 2013 were included. Exclusions for the analysis included other conditions requiring anticoagulation, history of intracranial hemorrhage, and gastrointestinal bleed. We calculated rates of oral anticoagulant use, transient ischemic attack or stroke, and bleeding in the 365 days following the index atrial fibrillation diagnosis. Results: A total of 44,786 members with atrial fibrillation with no evidence of recent oral anticoagulant use were identified. In total, 87% (n = 38,759) were classified as having a guideline-based indication for oral anticoagulants. Of those, 33% (n = 12,867) had a new oral anticoagulant dispensed during the following year, 15% (n = 5917) were hospitalized for stroke or transient ischemic attack, and 9% (n = 3469) for bleeding events. This information was used to develop the trial protocol including sample size, power calculations, and level of randomization. Conclusion: Sentinel infrastructure generated preliminary data that supported planning and implementation of a large pragmatic trial embedded in health plans. This planning identified unanticipated challenges that must be addressed in similar trials.

scholarly journals Rhythm-control vs rate-control in the elderly: When to do it and which drug to prefer?

2018 ◽  
Vol 88 (2) ◽  
Author(s):  
Giovanni Luca Botto ◽  
Carlo Piemontese ◽  
Giovanni Russo
Keyword(s):  
Atrial Fibrillation ◽  
Elderly Patient ◽  
Rate Control ◽  
Ischemic Cardiomyopathy ◽  
Elderly Population ◽  
Antiarrhythmic Drugs ◽  
Treatment Options ◽  
The Elderly ◽  
Rhythm Control ◽  
Abnormal Rate

Atrial fibrillation (AF) is a relevant cardiovascular condition that is more prevalent in the elderly patients aged over 65 years. AF, with abnormal rate and rhythm can cause symptoms directly or indirectly by exacerbating other frequently coexisting cardiac conditions such as valvular heart disease, hypertension, ischemic cardiomyopathy, dilated cardiomyopathy, and hypertrophic cardiomyopathy. Evidence suggests that aging-related cardiovascular changes predispose to the elderly to AF. Current therapeutic options such as antiarrhythmic drugs have not been extensively evaluated in the elderly population. Emerging pharmacological and non-pharmacological treatment options for the management of AF, such as dronedarone or catheter ablation, are of particular interest in the elderly. The present paper reviews the pathophysiology, diagnosis, and the management of AF in the elderly patient.

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