An analysis of too little too late

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An analysis of too little too late

This was a single-centre, retrospective, observational study that included patients admitted in with newly diagnosed AF ICD I There were patients hospitalised with newly documented AF. Out of the patients considered for anticoagulation, only patients were intended to receive OAC therapy: Outpatient anticoagulation is associated with poor uptake and significant delays.

Introduction Atrial fibrillation AF is the most common cardiac arrhythmia with a reported worldwide prevalence of 0.

In this patient group, OAC can be initiated either during the inpatient stay or following hospital discharge. There are no published data comparing these two strategies in relation to time to initiation of OAC, length of hospital stay, patient outcomes, or cost.

Nor do current clinical guidelines specify the preferred strategy for initiation of OAC in hospitalised patients with newly diagnosed AF. This study described the strategies used to initiate OAC in hospitalised patients with newly diagnosed AF, and the rate of uptake and time delay in initiating OAC in this group of patients.

In addition, we aimed to determine whether there were factors that influenced the strategy used. Method This was a single-centre, observational, cohort study based in a district general hospital in London. The study cohort comprised all patients admitted between 1 January to 31 December for more than 24 hours, with one of the primary diagnoses being newly documented AF or atrial flutter.

We did not differentiate between AF and atrial flutter because the indications for OAC are the same for both arrhythmias. Figure 1 demonstrates the data collection process.

An analysis of too little too late

Pre-existing AF was identified from previous discharge diagnosis coding data, paper health records, or from electrocardiogram ECG or Holter-monitor reports. In the outpatient group, we identified the rate of uptake, time delay and reason s for lack of initiation of therapy through directly contacting GPs and anticoagulation clinics.

The occurrence of cerebrovascular and major bleeding events during a mean follow-up of around six months after hospital discharge were recorded in all patients. The data collection process Clinical information was obtained from paper and electronic health records. The following baseline clinical characteristics were recorded: IHD was defined by a history of angina, myocardial infarction, myocardial revascularisation, or by use of anti-anginals.

PVD was defined by self-reported lower limb claudication or a history of lower limb arterial angioplasty or bypass surgery. Statistical analysis Continuous variables with a normal distribution were compared using the student t-test, and the Mann Whitney U-test was used to compare non-normal data.

Categorical variables were compared using the Z-test. Odds ratios and relative risks were also calculated. All analyses were conducted using SPSS statistical software. Their baseline characteristics are shown in table 1.

Too Little, Too Late – Foreign Policy

In the remaining 22 patients, there was no documentation to suggest that stroke risk had been assessed or that OAC therapy had been considered. None of these patients were commenced on OAC therapy. Initiation of oral anticoagulation Table 2. Contraindications to oral anticoagulation Among the patients who were considered for OAC therapy, 61 had documented contraindications or declined therapy table 2.

Three further patients were not anticoagulated inappropriately because of the paroxysmal nature of their AF. The remaining patients were intended to receive OAC: Cardiologist compared with non-cardiologist was not more likely to use inpatient initiation OR 1. Initiation of OAC as an outpatient was associated with poor uptake, with 18 patients failing to commence on therapy, and mean delays of 33 days as a whole, and 93 days in the primary care arm table 3.

The number of patients that were initiated on oral anticoagulant OAC therapy as an outpatient, the time taken, the reason s for lack of initiation and the number of cerebrovascular events during follow-up Clinical events during mean follow-up of days range 76—, table 3 In the two patients CHA2DS2-VASc score of 4 that suffered a stroke, OAC therapy was planned but was not started due to, either the GP not receiving the discharge summary, or failing to refer the patient for initiation of OAC therapy.

There were no reported episodes of major bleeding among the patients who were commenced on OAC. These data add to the considerable weight of evidence, which shows that OAC is underused in patients with AF,11 irrespective of the way in which they present.

Patients are only likely to receive OAC if their increased risk for stroke is recognised. This emphasises the importance of education.Silversea's expedition boats, where implied daily prices can exceed $1,, are relatively unique from Royal's main-line ships, nor is it a business that lends itself to scale.

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Too Little Too Late - Wikipedia