Guideline adherence to anticoagulation in atrial fibrillation seems to be more difficult compared to other quality measures in cardiology practice. William Lewis (chair of the Get With The Guidelines-AFIB Clinical Work Group) explains how the Get With The Guidelines-AFIB, a national quality improvement programme, led by the American Heart Association, is contributing to address this challenge and other areas of care and prevention for atrial fibrillation patients in the USA.
Primum non nocere (first, do no harm) is a Latin phrase physicians have used to guide practice for centuries. Unfortunately, in practising medicine, we are forced to compromise this phrase to “do much more good than harm”. Patients clearly benefit from treatments that carry risk with them. We know that coronary bypass grafting carries risk, but in most cases, improves outcomes. We also know that prescribing anticoagulants to high risk patients with atrial fibrillation lowers the risk of stroke dramatically.
Unfortunately, this benefit comes with a risk of serious, occasionally fatal, bleeding complications. Choudhry and colleagues (BMJ 2006;332:141-145) found that if a patient experiences a major bleed, their treating physician’s continued adherence to anticoagulation guidelines is diminished by as much as 40% and does not improve until one year later. On the contrary, the same authors found that if a physician experiences a stroke in one of his or her patients, there is not a corresponding increase in the use of anticoagulants over time.
Most people, including physicians, are more accepting of a negative outcome, which occurs by natural reasons compared with negative outcomes, which occur as a result of an iatrogenic reason. This is described as an act of omission versus an act of commission. The classic scenario is this: “If I vaccinated my child and he died, I would be more responsible for his or her death than if I failed to vaccinate him or her and he or she died from a pathogen.” This is fundamentally why guideline adherence to anticoagulation in atrial fibrillation is more difficult compared to other quality measures such as beta blockers after a myocardial infarction or ACE inhibitors in the treatment of heart failure. Physicians feel responsible for intracranial bleeding caused by anticoagulants.
Despite six randomised clinical trials proving the effectiveness of anticoagulation in atrial fibrillation published since the mid 1990’s, only about 60% of eligible patients receive anticoagulation therapy (Am J Med 2010;123:638-645). The novel oral anticoagulants are easier to administer and monitor and their effect varies less with dietary and medication changes. Unfortunately, they are still associated with significant bleeding complications and the gains in adherence will be blunted by the same fear of acts of commission. In fact, Kirley and colleagues (Circ Cardiovasc Qual Outcomes 2012:5:615-21) demonstrated that many of the prescriptions for novel oral anticoagulants are being given to replace warfarin, not to increase adherence to un-anticoagulated patients.
We know that quality improvement programmes increase adherence to guidelines. Get With The Guidelines (GWTG) is a US national quality improvement initiative by the American Heart Association to increase guideline adherence in heart disease. GWTG increases adherence by organising treatment using order sets, educating physicians and feeding back benchmark data. This allows physicians to work within a framework and provides real time peer data to measure themselves against. Additionally, GWTG provides patient education on anticoagulation which improves the safety of these drugs.
In the Get With The Guidelines-Stroke (GWTG-Stroke) module, adherence to anticoagulation in stroke patients with atrial fibrillation was 95% (Am Heart J 2011;162:692-699). This increase in adherence was achieved while decreasing the rate of documented contraindications to anticoagulation. Thus, these results were not achieved by just improving documentation. Overall, in this module, more patients received guideline indicated anticoagulation.
Because of the success of the GWTG-Stroke programme in improving adherence to anticoagulation in atrial fibrillation, the American Heart Association has launched the Get With The Guidelines-AFIB (GWTG-AFIB) programme to improve guideline adherence in patients with atrial fibrillation who are fortunate enough to have never experienced a stroke. GWTG-AFIB will also guide hospitals to improve adherence to rate control guidelines to reduce the risk of heart failure and to assure the appropriate use of antiarrhythmic medications.
The GWTG-AFIB programme was launched in June 2013 and is currently enrolling hospitals to participate. Patients with atrial fibrillation or atrial flutter are eligible to be entered into the quality improvement module if they have atrial fibrillation as their primary or secondary diagnosis. There have been 2,949 patients entered into the tool as of 3 November 2014. Additionally, unlike previous GWTG modules, patients admitted or only in observation status can also be entered. As with other GWTG modules, performance achievement awards are given to hospitals that achieve 85% adherence to guidelines. As of 2014, the first Bronze Performance Achievement award has already been bestowed. Additionally, the GWTG-AFIB programme will provide a robust registry of atrial fibrillation patients and provides opportunities for research in this disorder to improve treatment.
Atrial fibrillation is the most prevalent arrhythmia in the world. Complications of atrial fibrillation include congestive heart failure and stroke. Adherence to guidelines can reduce the risk of these complications and improve outcomes. Unfortunately, adherence to guidelines has been poor. Quality improvement programmes such as GWTG-AFIB can improve adherence and reduce the morbidity and mortality associated with atrial fibrillation.
For more information on Get With The Guidelines-AFIB visit: heart.org/focusonafib
William R Lewis is professor of Medicine at Case Western Reserve University, chief of Cardiology and director of the Heart & Vascular Center, MetroHealth Medical Center, Cleveland, USA, and chair of the Get With The Guidelines-AFIB Clinical Work Group