Background: Atrial fibrillation (AFIB) is the most common recognized arrhythmia in the United States. Currently affecting more than 6 million people, this number is expected to double by 2050. Along with increased costs ($26 billion/year), it is associated with a 5-fold risk for stroke and 2-fold risk for all-cause mortality, independent of comorbid conditions. In an attempt to improve patient care and reduce costs, the ACC/AHA taskforce published clinical performance and quality measures for adults with Atrial fibrillation in 2016. We consider its application particularly important in an economically challenged region as ours, a border town, where healthcare disparities are a constant struggle. Moreover, our unique population primarily of Hispanics also includes a subgroup of Caucasians, the “Winter Texans”. Our study aims to evaluate the management of AFIB based on the 2016 guidelines in our dynamic population.
Methods: This is a retrospective study; data was obtained through chart review of patients admitted between June and December 2017 with a new diagnosis or history of Atrial fibrillation at a hospital in South Texas. We evaluated the demographics of our population and presence of major risk factors including: diabetes (DM), hypertension (HTN), dyslipidemia (DLD), COPD, obstructive sleep apnea (OSA), coronary artery disease (CAD), cerebrovascular disease (CVA), chronic kidney disease (CKD). Using the 2016 guideline recommendations, we assessed inpatient performance status and inpatient quality measures.
Results: A total of 431 people [252 males (58%) and 179 females (42%)] with AFIB were assessed. The average age was 69 +/- 8.6. The most common co-morbidities included HTN (78%), DLD (64%), DM (53%), CKD (46%), CAD (44%), and rheumatic diseases (5%). CVA (15%) was seen in 77 patients (90% ischemic, 10% hemorrhagic). 65 patients (15%) were found to have OSA/OHS, out of which only 19 (30%) had a CPAP.
Our findings demonstrate the most deficient performance measures were reporting the CHA2DS2-VASc score (29%) ages [<65 (32%) vs. ≥65 (28%)] and PT/INR follow up (34%) ages [<65 (42%) vs. ≥65 (32%)]. However, 72% of those with a documented CHA2DS2-VASc score ≥2 were prescribed an anticoagulant (DOACs 63% vs. warfarin 37%) upon discharge and this finding was irrespective of insurance status (self pay vs insured).
In regards to quality measures, in patients with EF <40%, 60% received ACEi or ARBs and 66% beta blockers upon discharge. The rate of inappropriate prescription of a nondihydropiridine CCB was 53%. 13% of patients were on antiplatelet and anticoagulation without CAD and/or vascular disease during hospitalization.
Conclusions: There was a significant variability across measures independent of socio economic status. We should place special attention on males ≥65 with multimorbidities (>3) who were at the lowest spectrum of meeting performance measures. Also, there was a suboptimal prescription of ACEi or ARBs which may be attributed to a large number of people with CKD/ESRD.
It is a challenge to provide efficient care in a population where low health literacy, poverty, and multi morbidities reign. An approach with focus on education is needed to improve compliance with AFIB measures. To achieve our goals we propose the following interventions- posting checklists, upgrading the EMR, presenting data at the hospital quality improvement meetings and repeating the study in the next quarter to achieve better health care among our population.