Cox, Margueritte

Background: Efforts to improve prescription of oral anticoagulation (OAC) drugs in patients with atrial fibrillation have had limited success in improving guideline adherence. Methods: We evaluated adherence to the American College of Cardiology/American Heart Association performance measures for OAC in eligible patients with a CHA 2 DS 2 -VASc score ≥2 and trends in prescription over time in the American Heart Association’s Get With The Guidelines–AFIB (atrial fibrillation) registry. Adjusted associations with in-hospital outcomes were also determined. The cohort included 33 235 patients with a CHA 2 DS 2 -VASc score ≥2 who were admitted for atrial fibrillation and were enrolled at 115 sites between January 1, 2013, and September 31, 2017. Results: The median (25th, 75th percentile) age was 73 years (65, 81 years); 51% were female; and the median (25th, 75th percentile) CHA 2 DS 2 -VASc score was 4 (3, 5). At admission, 16 206 (59.5%) of 27 221 patients with a previous diagnosis of atrial fibrillation were taking OAC agents, and OAC drug use at admission was associated with a lower adjusted odds of in-hospital ischemic stroke (odds ratio, 0.38; 95% CI, 0.24–0.59; P <0.0001). At discharge, prescription of OAC in eligible patients (no contraindications) was 93.5% (n=25 499 of 27 270). In a sensitivity analysis, when excluding only strict contraindications (4.6%, n=1497 of 32 806), OAC prescription at discharge was 80.3%. OAC prescription at discharge was higher in those aged ≤75 years, men, those with heart failure, those with previous atrial fibrillation ablation, and those with rhythm control ( P <0.0001 for all). OAC use was lowest in Hispanic patients (90.2%, P <0.0001). Prescription of OAC at discharge in eligible patients improved over time from 79.9% to 96.6% ( P <0.0001). Conclusions: Among hospitals participating in the GWTG-AFIB quality improvement program, OAC prescription at discharge in eligible guideline-indicated patients increased significantly and improved consistently over time. These data confirm that high-level adherence to guideline-recommended stroke prevention is achievable.

BACKGROUNDThe Centers for Medicare & Medicaid Services rewards hospitals that have low 30‐day risk‐standardized mortality rates (RSMR) for heart failure (HF).OBJECTIVETo describe the use of early comfort care for patients with HF, and whether hospitals that more commonly initiate comfort care have higher 30‐day mortality rates.DESIGNA retrospective, observational study.SETTINGAcute care hospitals in the United States.PATIENTSA total of 93,920 fee‐for‐service Medicare beneficiaries admitted with HF from January 2008 to December 2014 to 272 hospitals participating in the Get With The Guidelines‐Heart Failure registry.EXPOSUREEarly comfort care (defined as comfort care within 48 hours of hospitalization) rate.MEASUREMENTSA 30‐day RSMR.RESULTSHospitals' early comfort care rates were low for patients admitted for H F, with no change over time (2.5% to 2.6%, from 2008 to 2014, P = .56). Rates varied widely (0% to 40%), with 14.3% of hospitals not initiating comfort care for any patients during the first 2 days of hospitalization. Risk‐standardized early comfort care rates were not correlated with RSMR (median RSMR = 10.9%, 25th to 75th percentile = 10.1% to 12.0%; Spearman's rank correlation = 0.13; P = .66).CONCLUSIONSHospital use of early comfort care for HF varies, has not increased over time, and on average, is not correlated with 30‐day RSMR. This suggests that current efforts to lower mortality rates have not had unintended consequences for hospitals that institute early comfort care more commonly than their peers.

Background and Purpose— The recommended treatment for ischemic stroke is tPA (tissue-type plasminogen activator). Although sickle cell disease (SCD) represents no known contraindication to tPA, National Heart Lung and Blood Institute of the National Institutes of Health recommended acute exchange transfusion for stroke in SCD, not tPA. Data on safety and outcomes of tPA in patients are needed to guide tPA use in SCD. Methods— We matched patients from the American Heart Association and American Stroke Association Get With The Guidelines-Stroke registry with SCD to patients without SCD and compared usage, complications, and discharge outcomes after tPA. Multivariable logistic regression models using generalized estimating equations were used to assess outcomes. Results— From 2 016 652 stroke patients admitted to Get With The Guidelines-Stroke sites in the United States, 832 SCD and 3328 non-SCD controls with no differences in admission National Institutes of Health Stroke Scale or blood pressure were identified. Neither the fraction receiving thrombolytic therapy (8.2% for SCD versus 9.4% non-SCD) nor symptomatic intracranial hemorrhage (4.9% of SCD versus 3.2% non-SCD; P =0.4502) was different. There was no difference in a prespecified set of outcome measures for those with SCD compared with controls. Conclusions— Coexistent SCD had no significant impact on the safety or outcome of thrombolytic therapy in acute ischemic stroke. Although the sample size is relatively small, these data suggest that adults with SCD and acute ischemic stroke should be treated with thrombolysis, if they otherwise qualify. Addition studies, however, should track the intracranial hemorrhage rate and provide information on other SCD-related care such as transfusion.