REAL-TIME ESTIMATES OF NET CLINICAL BENEFIT OF ANTITHROMBOTIC THERAPY FOR PATIENTS WITH ATRIAL FIBRILLATION
Tuesday, October 21, 2014
Mark Eckman, MD, MS1, Ruth Wise, MSN, MDes
1, Barbara Speer, BS
2, Megan Sullivan, MS
3, Nita Walker, MD
4, Gregory Lip, MD
5, Brett Kissela, MD, MS
6, Matthew Flaherty, MD
7, Dawn Kleindorfer, MD
7, Faisal Khan, MD
8, John Kues, PhD
9, Peter Baker, BS
10, Robert Ireton, BS
10, David Hoskins, BS
10, Brett Harnett, MS-IS
10, Carlos Aguilar, MD, MS
10, Anthony Leonard, PhD
11, Rajan Prakash, MD
4, Lora Arduser, PhD
12 and Alexandru Costea, MD
8, (1)University of Cincinnati, Division of General Internal Medicine and Center for Clinical Effectiveness, Cincinnati, OH, (2)University of Cincinnati, Department of Family and Community Medicine, Cincinnati, OH, (3)UC Health, Cincinnati, OH, (4)University of Cincinnati, Division of General Internal Medicine, Cincinnati, OH, (5)University of Birmingham, Birmingham, United Kingdom, (6)University of Cincinnati, Cincinnati, OH, (7)University of Cincinnati, Department of Neurology, Cincinnati, OH, (8)University of Cincinnati, Division of Cardiology, Cincinnati, OH, (9)University of Cincinnati, Department of Community and Family Medicine, Cincinnati, OH, (10)University of Cincinnati, Division of General Internal Medicine and Center for Health Informatics, Cincinnati, OH, (11)Department of Community and Family Medicine, Cincinnati, OH, (12)University of Cincinnati, Department of English, Cincinnati, OH
Purpose: Guidelines for anticoagulant therapy in patients with atrial fibrillation (AF) are based upon stroke risk as calculated by either the CHADS
2 or the CHA
2DS
2VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision-making about antithrombotic therapy.
Methods: Retrospective cohort study of 1,876 adults with non-valvular AF or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for QALE were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy (QALE) between current treatment and treatment recommended by an Atrial Fibrillation Decision Support Tool (AFDST).
Result: Recommended treatment was discordant from current treatment in 931 patients. A clinically significant gain in QALE (defined as ≥ 0.1 quality-adjusted life years or QALYs) was projected in 832 patients. Subgroups were examined. For example, oral anticoagulant therapy was recommended for 188 who currently were receiving no antithrombotic therapy. For the entire cohort, a total of 736 QALYs could be gained were treatment changed to that recommended by the AFDST.
Conclusion: Use of a decision support tool that integrates patient-specific stroke and bleeding risk could result in significant gains in quality-adjusted life expectancy for a primary care population of patients with AF.
