Open Access Research article

Implementing hospital guidelines improves warfarin use in non-valvular atrial fibrillation: a before-after study

Simona Bo1*, Susanna Valpreda1, Luca Scaglione1, Daniela Boscolo1, Marina Piobbici2, Mario Bo3 and Giovannino Ciccone2

Author Affiliations

1 Department of Internal Medicine, University of Torino, Italy

2 Unit of Cancer Epidemiology, San Giovanni Battista Hospital, Torino, Italy

3 Department of Geriatrics, University of Torino, Italy

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BMC Public Health 2007, 7:203  doi:10.1186/1471-2458-7-203

Published: 10 August 2007

Abstract

Background

The use of oral anticoagulant therapy (OAT) to prevent non-valvular atrial fibrillation (NVAF) related-strokes is often sub-optimal. We aimed to evaluate whether implementing guidelines on antithrombotic therapy (AT) by a multifaceted strategy may improve appropriateness of its prescription in NVAF-patients discharged from a large tertiary-care hospital.

Methods

A survey was conducted on all consecutive NVAF patients discharged before (1st January–30th June 2000, n = 313) and after (1st January–30th June 2004, n = 388) guideline development and implementation.

Results

When strongly recommended, OAT use increased from 56.6% (60/106 in 2000) to 81.9% (86/105 in 2004), with an absolute difference of +25.3% (95%CI: 15% 35%). In patients for whom the choice OAT/acetylsalicylic acid should be individualised, those discharged without any AT were 33.7% (34/101) in 2000 and 16.9% (21/124) in 2004 (-16.7%;95%CI: -26.2% -7.2%). In a logistic regression model, OAT prescription in 2004 was increased by 2.11 times (95%CI: 1.47 3.04), after accounting for stroke risk, presence of contraindications (OR = 0.18; 0.13 0.27), older age (OR = 0.30; 0.21 0.45), prophylaxis at admission (OR = 3.03; 2.08 4.43). OAT was positively associated with the stroke risk in the 2004 sample only.

Conclusion

The guideline implementation has substantially improved the appropriateness of OAT at discharge, through a better evaluation at patient's individual level of the benefit-to-risk ratio.