Practice-level variation in warfarin use among outpatients with atrial fibrillation (from the NCDR PINNACLE program)

Abstract

Warfarin is a complex but highly effective treatment for decreasing thromboembolic risk in atrial fibrillation (AF). We examined contemporary warfarin treatment rates in AF before the expected introduction of newer anticoagulants and extent of practice-level variation in warfarin use. Within the National Cardiovascular Data Registry Practice Innovation and Clinical Excellence program from July 2008 through December 2009, we identified 9,113 outpatients with AF from 20 sites who were at moderate to high risk for stroke (congestive heart failure, hypertension, age, diabetes, stroke score >1) and would be optimally treated with warfarin. Using hierarchical models, the extent of site-level variation was quantified with the median rate ratio, which can be interpreted as the likelihood that 2 random practices would differ in treating "identical" patients with warfarin. Overall rate of warfarin treatment was only 55.1% (5,018 of 9,913). Untreated patients and treated patients had mean congestive heart failure, hypertension, age, diabetes, stroke scores of 2.5 (p = 0.38) and similar rates of heart failure, hypertension, diabetes mellitus, and previous stroke, suggesting an almost "random" pattern of treatment. At the practice level, however, there was substantial variation in treatment ranging from 25% to 80% (interquartile range for practices 50 to 65), with a median rate ratio of 1.31 (1.22 to 1.55, p <0.001). In conclusion, within the Practice Innovation and Clinical Excellence registry, we found that warfarin treatment in AF was suboptimal, with large variations in treatment observed across practices. Our findings suggest important opportunities for practice-level improvement in stroke prevention for outpatients with AF and define a benchmark treatment rate before the introduction of newer anticoagulant agents.

Copyright © 2011 Elsevier Inc. All rights reserved.

Figures

Figure 1. Variation in Treatment Rates with Warfarin Across Practices

The median practice treatment rate with warfarin was 61%, with a range from 25% to 80% and an inter-quartile range of 50% to 65%.

Figure 2. Practice Rate of Antiplatelet Therapy

There was little correlation between a practice’s rate of warfarin treatment and its rate of antiplatelet (aspirin or thienopyridines) therapy.

Figure 3. Patient Predictors of Warfarin Treatment

Patient characteristics were not strong predictors of warfarin treatment, including components of the CHADS2 score. The median rate ratio for site-level variation of 1.31 was larger than the estimates of effect for any of the patient factors, suggesting that practice level variation explained a larger proportion of the variance in warfarin treatment than individual patient factors.