Abstract Background Oral anticoagulation (OAC) with warfarin is underused for atrial fibrillation (AF). The availability of direct oral anticoagulants (DOACs) may improve overall OAC rates in AF ...patients, but a large-scale evaluation of their effects has not been conducted. Objectives This study assessed the effect of DOAC availability on overall OAC rates for nonvalvular AF. Methods Between April 1, 2008 and September 30, 2014, we identified 655,000 patients with nonvalvular AF and a CHA2 DS2 -VASc score of >1 in the National Cardiovascular Data Registry PINNACLE registry. Temporal trends in overall OAC and individual warfarin and DOAC use were analyzed. Multivariable hierarchical logistic regression identified patient factors associated with OAC and DOAC use. Practice variation of OAC and DOAC use was also assessed. Results Overall OAC rates increased from 52.4% to 60.7% among eligible AF patients (p for trend <0.01). Warfarin use decreased from 52.4% to 34.8% (p for trend <0.01), and DOAC use increased from 0% to 25.8% (p for trend <0.01). An increasing CHA2 DS2 -VASc score was associated with higher OAC use (odds ratio OR: 1.06; 95% confidence interval CI: 1.05 to 1.07), but with lower DOAC use (OR: 0.97; 95% CI: 0.96 to 0.98). Significant practice variation was present in OAC use (median odds ratio MOR: 1.52; 95% CI: 1.45 to 1.57) and in DOAC use (MOR: 3.58; 95% CI: 3.05 to 4.13). Conclusions Introduction of DOACs in routine practice was associated with improved rates of overall OAC use for AF, but significant gaps remain. In addition, there is significant practice-level variation in OAC and DOAC use.
Background Practices in vascular access management with intensive hemodialysis may differ from those used in conventional hemodialysis. Study Design We conducted a systematic review to inform ...clinical practice guidelines for the provision of intensive hemodialysis. Setting & Population Adult patients receiving maintenance (>3 months) intensive hemodialysis (frequent ≥5 hemodialysis treatments per week and/or long >5.5 hours per hemodialysis treatment). Selection Criteria for Studies We searched EMBASE and MEDLINE (1990-2011) for randomized and observational studies. We also searched conference proceedings (2007-2011). Interventions (1) Central venous catheter (CVC) versus arteriovenous (AV) access, (2) buttonhole versus rope-ladder cannulation, (3) topical antimicrobial cream versus none in buttonhole cannulation, and (4) closed connector devices among CVC users. Outcomes Access-related infection, survival, hospitalization, patency, access survival, intervention rates, and quality of life. Results We included 23, 7, and 5 reports describing effectiveness by access type, buttonhole cannulation, and closed connector device, respectively. No study directly compared CVC with AV access. On average, bacteremia and local infection rates were higher with CVC compared with AV access. Access intervention rates were higher with more frequent hemodialysis, but access survival did not differ. Buttonhole cannulation was associated with bacteremia rates similar to those seen with CVCs in some series. Topical mupirocin seemed to attenuate this effect. No direct comparisons of closed connector devices versus standard luer-locking devices were found. Low rates of actual or averted (near misses) air embolism and bleeding were reported with closed connector devices. Limitations Overall, evidence quality was very low. Limited direct comparisons addressing main review questions, small sample sizes, selective outcome reporting, publication bias, and residual confounding were major factors. Conclusions This review highlights several differences in the management of vascular access in conventional and intensive hemodialysis populations. We identify a need for standardization of vascular access outcome reporting and a number of priorities for future research.
Background Hospital-acquired anemia (HAA) is common during acute myocardial infarction (AMI) and associated with higher long-term mortality. The relationship between HAA and adverse in-hospital ...outcomes may be particularly relevant to hospitals' efforts to implement prevention programs, but the association between HAA and in-hospital mortality is unclear. Methods We studied 17,676 patients with AMI with normal admission hemoglobin level who did not undergo bypass surgery. Hospital-acquired anemia was defined as development of new anemia during hospitalization (based on nadir hemoglobin) using age-, gender-, and race-specific criteria. In-hospital mortality of patients with mild (hemoglobin level less than HAA threshold but >11 g/dL), moderate (hemoglobin level 9-11 g/dL), and severe HAA (hemoglobin level, < 9 g/dL) was compared with those without HAA using hierarchical logistic regression, adjusting for site and potential confounders. Results Hospital-acquired anemia developed in 10,166 patients (57.5%); 6,615 (37.4%) had mild; 2,740 (15.5%), moderate; and 811 (4.6%), severe HAA. In-hospital mortality was higher in patients with HAA and increased with HAA severity (no HAA 266 3.5%, mild HAA 260 3.9%, moderate HAA 222 8.1%, and severe HAA 148 18.3%, P < .001). The adjusted odds of in-hospital death were greater in patients with moderate (odds ratio 1.38, 95% CI 1.10-1.73) and severe HAA (3.39, 95% CI 2.59-4.44) versus no HAA. Conclusions Moderate and severe HAAs are independently associated with higher in-hospital mortality during AMI. Studies are needed to determine whether HAA is preventable and if preventing HAA improves outcomes.
Beyond Medication Prescription as Performance Measures Arnold, Suzanne V., MD, MHA; Spertus, John A., MD, MPH; Masoudi, Frederick A., MD, MSPH ...
Journal of the American College of Cardiology,
11/2013, Letnik:
62, Številka:
19
Journal Article
Recenzirano
Odprti dostop
Objectives The aim of this study was to examine the prescribing patterns of medications quantified by the performance measures for acute myocardial infarction (AMI). Background Current performance ...measures for AMI are designed to improve quality by quantifying the use of evidence-based treatments. However, these measures only assess medication prescription. Whether patients receive optimal dosing of secondary prevention medications at the time of and after discharge after AMI is unknown. Methods We assessed treatment doses of beta-blockers, statins, and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) at discharge and 12 months after AMI among 6,748 patients from 31 hospitals enrolled in 2 U.S. registries (2003 to 2008). Prescribed doses were categorized as none, low (<50% target defined from seminal clinical trials), moderate (50% to 74% target), or goal (≥75% target). Patients with contraindications were excluded from analyses for that medication. Results Most eligible patients (>87%) were prescribed some dose of each medication at discharge, although only 1 in 3 patients were prescribed these medications at goal doses. Of patients not discharged on goal doses, up-titration during follow-up occurred infrequently (approximately 25% of patients for each medication). At 12 months, goal doses of beta-blockers, statins, and ACEI/ARBs were achieved in only 12%, 26%, and 32% of eligible patients, respectively. After multivariable adjustment, prescription of goal dose at discharge was strongly associated with being at goal dose at follow-up: beta-blockers, adjusted odds ratio (OR): 6.08 (95% confidence interval CI: 3.70 to 10.01); statins, adjusted OR: 8.22 (95% CI: 6.20 to 10.90); ACEI/ARBs, adjusted OR: 5.80 (95% CI: 2.56 to 13.16); p < 0.001 for each. Conclusions Although nearly all patients after an AMI are discharged on appropriate secondary prevention medications, dose increases occur infrequently, and most patients are prescribed doses below those with proven efficacy in clinical trials. Integration of dose intensity into performance measures might help improve the use of optimal medical therapy after AMI.
Intensive (longer and more frequent) hemodialysis has emerged as an alternative to conventional hemodialysis for the treatment of patients with end-stage renal disease. However, given the differences ...in dialysis delivery and models of care associated with intensive dialysis, alternative approaches to patient management may be required. The purpose of this work was to develop a clinical practice guideline for the Canadian Society of Nephrology. We applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for guideline development and performed targeted systematic reviews and meta-analysis (when appropriate) to address prioritized clinical management questions. We included studies addressing the treatment of patients with end-stage renal disease with short daily (≥5 days per week, <3 hours per session), long (3-4 days per week, ≥5.5 hours per session), or long-frequent (≥5 days per week, ≥5.5 hours per session) hemodialysis. We included clinical trials and observational studies with or without a control arm (1990 and later). Based on a prioritization exercise, 6 interventions of interest included optimal vascular access type, buttonhole cannulation, antimicrobial prophylaxis for buttonhole cannulation, closed connector devices, and dialysate calcium and dialysate phosphate additives for patients receiving intensive hemodialysis. We developed 6 recommendations addressing the interventions of interest. Overall quality of the evidence was very low and all recommendations were conditional. We provide detailed commentaries to guide in shared decision making. The main limitation was the very low overall quality of evidence that precluded strong recommendations. Most included studies were small single-arm observational studies. Three randomized controlled trials were applicable, but provided only indirect evidence. Published information for patient values and preference was lacking. In conclusion, we provide 6 recommendations for the practice of intensive hemodialysis. However, due to very low-quality evidence, all recommendations were conditional. We therefore also highlight priorities for future research.
Abstract Background Patients with paroxysmal and persistent atrial fibrillation experience a similar risk of thromboembolism. Therefore, consensus guidelines recommend anticoagulant therapy in those ...at risk for thromboembolism irrespective of atrial fibrillation classification. We sought to examine whether there are differences in rates of appropriate oral anticoagulant treatment among patients with paroxysmal vs persistent atrial fibrillation in real-world cardiology practices. Methods We studied 71,316 outpatients with atrial fibrillation and intermediate to high thromboembolic risk (CHADS2 score ≥2) enrolled in the American College of Cardiology PINNACLE Registry between 2008 and 2012. Using hierarchical modified Poisson regression models adjusted for patient characteristics, we examined whether anticoagulant treatment rates differed between patients with paroxysmal vs persistent atrial fibrillation. Results The majority of outpatients (78.4%, n = 55,905) had paroxysmal atrial fibrillation. In both unadjusted and multivariable adjusted analyses, patients with paroxysmal atrial fibrillation were less frequently prescribed oral anticoagulant therapy than those with persistent atrial fibrillation (50.3% vs 64.2%; adjusted risk ratio RR 0.74; 95% confidence interval CI, 0.72-0.76). Instead, patients with paroxysmal atrial fibrillation were prescribed more frequently only antiplatelet therapy (35.1% vs 25.0%; adjusted RR 1.77; 95% CI, 1.69-1.86) or neither antiplatelet nor anticoagulant therapy (14.6% vs 10.8%; adjusted RR 1.35; 95% CI, 1.26-1.44; P < .0001 for differences across all 3 comparisons). Conclusions In a large, real-world cardiac outpatient population, patients with paroxysmal atrial fibrillation with a moderate to high risk of stroke were less likely to be prescribed appropriate oral anticoagulant therapy and more likely to be prescribed less effective or no therapy for thromboembolism prevention.
Hospital-acquired anemia (HAA) is common, often develops in the absence of bleeding, and is associated with poor outcomes in patients with acute myocardial infarction (AMI). It is unknown whether red ...cell distribution width (RDW) and mean corpuscular volume (MCV), which are routinely available markers of iron deficiency, are associated with development of HAA during AMI. We studied 15,133 patients with AMI without anemia at admission. HAA was defined by nadir hemoglobin levels below age-, gender-, and race-specific thresholds and moderate–severe HAA was defined as nadir hemoglobin ≤11 g/dl. We examined the association between low MCV (<80 fL) and/or increased RDW (>15%) on patients' initial complete blood cell count and moderate–severe HAA using multivariable modified Poisson regression. Moderate–severe HAA was more common in patients with high RDW and low MCV (45.5%), high RDW and MCV ≥80 fL (33.0%), and normal RDW and low MCV (28.0%) than in those with normal RDW and MCV (18.3%, p <0.001). Compared to patients with normal RDW and MCV, those with increased RDW and low MCV (relative risk 1.72, 95% confidence interval 1.57 to 1.87), increased RDW and MCV ≥80 fL (relative risk 1.28, 95% confidence interval 1.16 to 1.42), or normal RDW and low MCV (relative risk 1.34, 95% confidence interval 1.08 to 1.65) were independently more likely to develop moderate–severe HAA. In conclusion, increased RDW and low MCV were independent predictors of moderate–severe HAA.
Rotavirus vaccine effectiveness in Hong Kong children Yeung, Karene Hoi Ting, BSc; Tate, Jacqueline E., PhD; Chan, Ching Ching, MBChB, FHKAM, FHKCPaed ...
Vaccine,
09/2016, Letnik:
34, Številka:
41
Journal Article
Recenzirano
Odprti dostop
Highlights • Rotavirus vaccine was 89%–96% effective in preventing rotavirus hospitalisations. • Vaccine effectiveness in Hong Kong is similar to that in other high-income settings. • Universal ...rotavirus vaccination could significantly benefit Hong Kong children.
Background Patients treated with conventional hemodialysis (HD) develop disorders of mineral metabolism that are associated with increased morbidity and mortality. More frequent and longer HD has ...been associated with improvement in hyperphosphatemia that may improve outcomes. Study Design Systematic review and meta-analysis to inform the clinical practice guideline on intensive dialysis for the Canadian Society of Nephrology. Setting & Population Adult patients receiving outpatient long (≥5.5 hours/session; 3-4 times per week) or long-frequent (≥5.5 hours/session, ≥5 sessions per week) HD. Selection Criteria for Studies We included clinical trials, cohort studies, case series, case reports, and systematic reviews. Interventions Dialysate calcium concentration ≥1.5 mmol/L and/or phosphate additive. Outcomes Fragility fracture, peripheral arterial and coronary artery disease, calcific uremic arteriolopathy, mortality, intradialytic hypotension, parathyroidectomy, extraosseous calcification, markers of mineral metabolism, diet liberalization, phosphate-binder use, and muscle mass. Results 21 studies were identified: 2 randomized controlled trials, 2 reanalyses of data from the randomized controlled trials, and 17 observational studies. Dialysate calcium concentration ≥1.5 mmol/L for patients treated with long and long-frequent HD prevents an increase in parathyroid hormone levels and a decline in bone mineral density without causing harm. Both long and long-frequent HD were associated with a reduction in serum phosphate level of 0.42-0.45 mmol/L and a reduction in phosphate-binder use. There was no direct evidence to support the use of a dialysate phosphate additive. Limitations Almost all the available information is related to changes in laboratory values and surrogate outcomes. Conclusions Dialysate calcium concentration ≥1.5 mmol/L for most patients treated with long and long-frequent dialysis prevents an increase in parathyroid hormone levels and decline in bone mineral density without increased risk of calcification. It seems prudent to add phosphate to the dialysate for patients with a low predialysis phosphate level or very low postdialysis phosphate level until more evidence becomes available.
Objectives The objective of this study was to compare the consistency in appropriate use criteria (AUC) ratings among a broad range of practicing cardiologists and the AUC Technical Panel. Background ...AUC for coronary revascularization have been developed by selected experts. Methods Before AUC publication, 85 cardiologists from 10 U.S. institutions assessed the appropriateness of coronary revascularization for 68 indications that had been evaluated by the AUC Technical Panel. Each indication was classified as appropriate, uncertain, or inappropriate, based on the physician group's median rating. Rates of concordance between the physician group and the AUC Technical Panel (i.e., same appropriateness category assignment) and rates of nonagreement within the physician group (≥25% of panelists' ratings outside the group's appropriateness category assessment) were determined. Results Overall concordance between the 2 groups was 84%. Among indications classified as appropriate by the AUC Technical Panel, concordance between the 2 groups was excellent (94% 34 of 36); however, nonagreement within the physician group was 44% (16 of 36). Among indications classified as uncertain, there was 73% (16 of 22) concordance between the 2 groups. Among inappropriate indications, concordance was moderate (70% 7 of 10), but nonagreement occurred frequently (70% 7 of 10). Moreover, there was substantial variation in appropriateness ratings between individual physicians and the AUC Technical Panel (weighted kappa range: 0.05 to 0.76). Conclusions Although there was good concordance in assessments of appropriateness for coronary revascularization between physicians and the AUC Technical Panel, nonagreement within the physician group was common and there was marked variation in ratings between individual physicians and the AUC Technical Panel.
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