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Prevalence and Quality of Warfarin Use for Patients With Atrial Fibrillation in the Long-term Care Setting
Danny McCormick, MD, MPH;
Jerry H. Gurwitz, MD;
Robert J. Goldberg, PhD;
Richard Becker, MD;
Janet P. Tate, MPH;
Anne Elwell, RN;
Martha J. Radford, MD
Arch Intern Med. 2001;161:2458-2463.
Background Evidence-based clinical practice guidelines recommend the use of warfarin
sodium for stroke prevention in most patients with atrial fibrillation (AF)
who do not have risk factors for hemorrhagic complications, irrespective of
age.
Methods The medical records of all residents of a convenience sample of long-term
care facilities in Connecticut (n = 21) were reviewed. The percentages of
all patients with AF (AF patients) and ideal candidates for warfarin therapy
(ie, AF patients with no risk factors for hemorrhage) who received warfarin
were determined; for patients receiving warfarin, the percentage of days spent
in the therapeutic range of international normalized ratio (INR) values (2.0-3.0)
was also assessed. The relationship between receipt of warfarin and the presence
of stroke and bleeding risk factors was assessed in multivariate models.
Results Atrial fibrillation was present in 429 (17%) of the 2587 long-term care
residents. Overall, 42% of AF patients were receiving warfarin. However, only
44 (53%) of 83 ideal candidates were receiving this therapy. In residents
who received warfarin therapy, the therapeutic range of INR values was maintained
only 51% of the time. The odds of receiving warfarin in the study sample decreased
with increasing number of risk factors for bleeding and increased (nonsignificant
trend) with increasing number of stroke risk factors present.
Conclusions Atrial fibrillation is very common among residents of long-term care
facilities. Even among apparently ideal candidates, warfarin therapy is underused
for stroke prevention in patients with AF. Prescribing decisions and monitoring
related to warfarin therapy in the long-term care setting warrant improvement.
From the Department of Medicine, Cambridge Hospital, Cambridge, Mass,
and Harvard Medical School, Boston, Mass (Dr McCormick); Meyers Primary Care
Institute (Drs Gurwitz and Goldberg) and the Department of Cardiology (Drs
Goldberg and Becker), University of Massachusetts Medical School, Worcester;
the Fallon Healthcare System, Worcester (Drs Gurwitz and Goldberg); Qualidigm
Inc, Middletown, Conn (Mss Tate and Elwell and Dr Radford); and the Yale Health
System, New Haven, Conn (Dr Radford).
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