Resource use and cost associated with computerized decision support system and usual care in managing patients with atrial fibrillation: analysis of IMPACT-AF randomized trial data.

BACKGROUND: IMPACT-AF is a prospective, randomized, cluster design trial comparing atrial fibrillation (AF) management with a computerized decision support system (CDS) to usual care (control) in the primary care setting of Nova Scotia, Canada. The objective of this analysis was to compare the resource use and costs between CDS and usual care groups. METHODS: Case costing data, 12-month self-administered questionnaires, and monthly diaries from IMPACT-AF were used in this analysis. Descriptive statistics were used to compare costs and resource use between groups. All costs are presented in 2021 Canadian dollars and cover the 12-month period of participation in the study. RESULTS: A total of 1,145 patients enrolled in the trial. Case costing data were available for 466 participants (41.1%), 12-month self-administered questionnaire data for 635 participants (56.0%) and monthly diary data for 223 participants (19.7%). Emergency department visits and hospitalizations comprised the most expensive component of AF care. Across all three datasets, there were no statistically significant differences in costs or resource use between CDS and usual care groups. CONCLUSIONS: Although there were no significant differences in resource use or costs among CDS and usual care groups in the IMPACT-AF trial, this study provides insight into the methodology and practical challenges of collecting economic data alongside a trial. REGISTRATION: Clinicaltrials.gov (registration number: NCT01927367, date of registration: 2013-08-20).

An Update on the Development and Feasibility Assessment of Canadian Quality Indicators for Atrial Fibrillation and Atrial Flutter.

BACKGROUND: In 2010, the Canadian Cardiovascular Society Atrial Fibrillation/Atrial Flutter (AF/AFL) quality indicator (QI) working group was established to develop QIs and assess feasibility of measurement. After extensive review, 3 priority QIs were selected. However, none were measurable at a national level. METHODS: The working group reconvened in 2017 to review the relevance of previously proposed QIs, identify opportunities to develop new QIs, and propose an initial strategy for measuring and reporting. RESULTS: Two additional priority QIs were added to the previous 3: proportion of patients with nonvalvular (NV) AF/AFL sorted by stroke risk stratum and annual rate of hospitalization for a new heart failure diagnosis. An environmental scan was undertaken to determine the potential of existing databases to provide national and provincial estimates. On the basis of validated administrative codes, the Canadian Institute for Health Information discharge abstract database can be used for inpatients. In collaboration with the Canadian Primary Care Sentinel Surveillance Network, 2 of the 5 QIs can be assessed in outpatients (patients with NVAF/AFL sorted by stroke risk stratum and high risk for stroke NVAF/AFL receiving oral anticoagulation). Stroke prevention therapy can be further measured in selected provinces with linked databases including prescriptions. CONCLUSIONS: This first step could provide a better initial understanding of the quality of AF/AFL care in Canada, but important gaps in the meaningful measurement of QIs remain. The AF/AFL QI working group has limited capacity to make progress without national level leadership and the resources to support data aggregation, data analysis, and pan-Canadian reporting.

CONTEXTE: En 2010, le groupe de travail des indicateurs de qualité (IQ) de la Société canadienne de cardiologie sur la fibrillation auriculaire (FA) et le flutter auriculaire (FLA) a été mis sur pied pour élaborer des IQ et évaluer la faisabilité d'utiliser ces IQ comme outils de mesure. Après un examen approfondi, trois IQ prioritaires ont été sélectionnés, mais aucun n'a pu être mesuré à l'échelle nationale. MÉTHODOLOGIE: Le groupe de travail s'est réuni à nouveau en 2017 afin d'examiner la pertinence des IQ proposés au départ, de recenser des occasions d'élaborer de nouveau IQ et de proposer une stratégie initiale de mesure et de production de rapports à cet égard. RÉSULTATS: Deux IQ prioritaires supplémentaires ont été ajoutés aux trois premiers : la proportion de patients atteints de FA non valvulaire (FANV) ou de FLA ayant fait l'objet d'un tri selon la strate de risque d'AVC et le taux annuel d'hospitalisations attribuables à un nouveau diagnostic d'insuffisance cardiaque. Une analyse de l'environnement a été réalisée afin de déterminer si les bases de données existantes pouvaient fournir des estimations nationales et provinciales. Dans le cas de patients hospitalisés, on peut utiliser la Base de données sur les congés des patients de l'Institut canadien d'information sur la santé en se servant de codes administratifs validés. Dans le cas de patients non hospitalisés (patients atteints de FANV/FLA, triés par strate de risque, exposés à un risque élevé d'AVC en raison d'une FANV ou d'un FLA et recevant une anticoagulation orale), on peut mesurer deux des cinq IQ, en collaboration avec le Réseau canadien de surveillance sentinelle en soins primaires. Le traitement préventif de l'AVC peut continuer à faire l'objet de mesures dans certaines provinces grâce aux bases de données interreliées, comme les bases de données sur les ordonnances. CONCLUSIONS: Cette première étape a permis d'obtenir une meilleure compréhension initiale de la qualité de la prise en charge de la FA et du FLA au Canada, mais d'importantes lacunes restent à combler pour rendre pertinente la mesure des IQ. Le groupe de travail des IQ sur de la FA et le FLA n'a pas toutes les capacités requises pour réaliser des progrès en l'absence de leadership national et de ressources permettant de soutenir le regroupement et l'analyse des données, ainsi que la production de rapports à l'échelle pancanadienne.

The Development and Feasibility Assessment of Canadian Quality Indicators for Atrial Fibrillation.

In 2010, the Canadian Cardiovascular Society embarked on an initiative to develop pan-Canadian quality indicators (QIs) and standardized data definitions with the ultimate goal of monitoring, comparing, and contrasting national cardiovascular care and its outcomes. One of the first working groups to be established was tasked with identifying and then defining a set of QIs for atrial fibrillation/flutter (AF/AFL). The Canadian Cardiovascular Society "Best Practices for Developing Cardiovascular Quality Indicators" methodology was used to develop an initial catalogue of 25 QIs intended to measure critical issues around access, process, and outcomes relating to AF/AFL management. This list was subsequently pared down to 5 QIs felt to have the greatest relative importance for quality assurance and measurability so as to facilitate early adoption. Three of these QIs were finally selected to assess the feasibility of their measurement using existing administrative datasets. These were the number of patients with a diagnosis of nonvalvular AF/AFL at high risk of stroke (75 years or older, or CHADS2 ≥ 2) receiving an oral anticoagulant, and the rates of stroke and major haemorrhage in patients with nonvalvular AF/AFL according to CHA2DS2-VASc score and anticoagulant use. Despite their clear importance in assessing AF/AFL care, none of these 3 QIs were found to be readily measurable across Canada using existing national datasets. Investment in new medical data infrastructure is required to facilitate regular monitoring of QIs to improve cardiovascular care.

Aligning health care policy with evidence-based medicine: the case for funding direct oral anticoagulants in atrial fibrillation.

Misalignment between evidence-informed clinical care guideline recommendations and reimbursement policy has created care gaps that lead to suboptimal outcomes for patients denied access to guideline-based therapies. The purpose of this article is to make the case for addressing this growing access barrier to optimal care. Stroke prevention in atrial fibrillation (AF) is discussed as an example. Stroke is an extremely costly disease, imposing a significant human, societal, and economic burden. Stroke in the setting of AF carries an 80% probability of death or disability. Although two-thirds of these strokes are preventable with appropriate anticoagulation, this has historically been underprescribed and poorly managed. National and international guidelines endorse the direct oral anticoagulants as first-line therapy for this indication. However, no Canadian province has provided these agents with an unrestricted listing. These decisions appear to be founded on silo-based cost assessment-the drug costs rather than the total system costs-and thus overlook several important cost-drivers in stroke. The discordance between best scientific evidence and public policy requires health care providers to use a potentially suboptimal therapy in contravention of guideline recommendations. It represents a significant obstacle for knowledge translation efforts that aim to increase the appropriate anticoagulation of Canadians with AF. As health care professionals, we have a responsibility to our patients to engage with policy-makers in addressing and resolving this barrier to optimal patient care.

A novel approach to cardiovascular health by optimizing risk management (ANCHOR): behavioural modification in primary care effectively reduces global risk.

BACKGROUND: Primary care is well positioned to facilitate cardiovascular risk improvement and reduce future cardiovascular disease (CVD) burden. METHODS: The efficacy of risk factor screening, behavioural counselling, and pharmacological treatment to lower CVD risk was assessed via a prospective pre- and postintervention health risk assessment, individualized intervention with behaviour modification, risk factor treatment, and linkage to community programs, with 1-year follow-up and final health risk assessment. Primary outcome was the proportion of subjects with moderate and high baseline Framingham Risk Score (FRS) reducing their risk by 10% and 25%, respectively; the secondary end point was the proportion dropping ≥ 1 risk category. RESULTS: Patients were enrolled (N = 1509) from March 2006 through October 2008 and 72% completed the study. This analysis focuses on 563 subjects with moderate or high baseline FRS, and excluded 325 low-risk patients and 205 with established CVD or diabetes mellitus. Median age was 56 years, 57.7% were female. The primary outcome was achieved in 31.8% (N = 112; 95% confidence interval [CI], 26.9%-36.6%) of moderate risk FRS participants and 47.9% (N = 101; 95% CI, 41.2%-54.6%) of high-risk participants. The secondary outcome was achieved by 37.2% (N = 210; 95% CI, 33.2%-41.2%). Prevalence of metabolic syndrome fell from 79.2% (N = 446; 95% CI, 75.9%-82.6%) at entry to 52.8% (N = 303; 95% CI, 48.7%-56.9%) at study end. Significant improvements in all modifiable risk factors occurred through lifestyle modification. CONCLUSIONS: Global cardiovascular risk can be effectively decreased via lifestyle changes informed by readiness to change assessment and individualized counselling targeting specific behaviours. TRIAL REGISTRATION: ClinicalTrials.gov number NCT01620996.

Assessment and management of acute coronary syndromes (ACS): a Canadian perspective on current guideline-recommended treatment--part 1: non-ST-segment elevation ACS.

Despite the reduction of coronary heart disease mortality over the past 40 years, hospital admissions for acute coronary syndromes (ACS) continue to increase. The goal of this 2-part article is to review the issues at each stage of assessment and management of the ACS patient, and to propose an optimal treatment strategy for the individual patient in the context of the realities, culture, and delivery of healthcare in Canada. ACS patients are categorized as either ST segment elevation myocardial infarction (STEMI) or non-ST-elevation ACS (NSTE-ACS). For the patients with NSTE-ACS, prevention of recurrent ischemic events is the primary goal. Assessment of risk for recurrent ischemic and bleeding events helps to determine the net benefit of early cardiac catheterization and percutaneous coronary intervention (PCI) and intensive antiplatelet and anticoagulant treatment. Those with higher ischemic risk features should be considered for an early invasive strategy and receive both dual antiplatelet therapy and an anticoagulant at the time of first medical assessment. Patients without high-risk features could be considered for medical treatment and a selectively invasive strategy; with coronary angiography and revascularization only if high-risk features become apparent. Long-term vascular protection with lifestyle modification (especially smoking cessation), lipid lowering, blood pressure and glycemic control, and the use of renin angiotensin aldosterone system (RAAS) blockade to prevent recurrent ischemic events, is important in all patients with ACS.

Assessment and management of acute coronary syndromes (ACS): a Canadian perspective on current guideline-recommended treatment--part 2: ST-segment elevation myocardial infarction.

Acute ST-segment elevation myocardial infarction (STEMI) accounts for approximately 30% of all acute coronary syndromes (ACS). The high early mortality for patients with STEMI is largely due to the extent of the ischemic injury. However, immediate reperfusion either pharmacologically with fibrinolysis or mechanically by primary percutaneous coronary intervention (PCI) limits the size of the infarction and reduces mortality. Reperfusion therapy by primary PCI reduces mortality and the risk of reinfarction, beyond the benefits achieved by fibrinolysis, especially when the primary PCI is initiated within 90 minutes of first medical contact. The use of adjuvant therapy with antiplatelet and anticoagulant agents is essential to enhance the results of reperfusion, and/or maintain vessel patency following either mode of reperfusion. This review discusses the assessment and management of the patient with an acute STEMI, using recommendations from the most recent American College of Cardiology/American Heart Association, European Society of Cardiology, and existing Canadian guidelines. It provides an updated perspective and critical appraisal with practical application of the recommendations within the Canadian Healthcare system.

A novel approach to cardiovascular health by optimizing risk management (ANCHOR): a primary prevention initiative examining the impact of health risk factor assessment and management on cardiac wellness.

Cardiovascular disease (CVD) represents an increasing burden to health care systems. Modifiable risk factors figure prominently in the population-attributable risk for premature coronary artery disease. Primary care is well placed to facilitate CVD risk improvement. We plan to evaluate the ability of a novel primary care intervention providing systematic risk factor screening, risk-weighted behavioural counselling and pharmacological intervention to achieve 2 objectives: (1) optimized management of global CVD risk of patients and (2) increased patient adherence to lifestyle and pharmaceutical interventions aimed at decreasing global CVD risk. A pre-post longitudinal prospective design with a nonrandomized comparison group is being undertaken in 2 geographically diverse primary care practices in Nova Scotia with differing reimbursement models. Participants will complete a readiness to change and pre-post health risk assessment (HRA), that will trigger a 1-year intervention individualized around risk and readiness. The primary outcome will be the proportion of participants with Framingham moderate and high-risk strata that reduce their absolute risk by 10% and 25%, respectively. The secondary outcome will be the proportion of moderate and high-risk participants who reduce their risk category. The impact of the intervention on clinical and behavioural variables will also be examined. Low risk participants will be separately analyzed. Data from participants unable to change from the high risk category because of diabetes mellitus or established atherosclerotic disease will also be analyzed separately, with changes in clinical measures from baseline being assessed. A health economic analysis is planned.

The potential economic impact of restricted access to angiotensin-receptor blockers.

BACKGROUND: The use of angiotensin-receptor blockers increased by more than 4000% in Canada from 1996 to 2006. The benefit of these medications over angiotensin-converting-enzyme (ACE) inhibitors has not been proven aside from a reduction in dry cough. We estimated the potential cost savings that might have been achieved had access to angiotensin-receptor blockers been restricted. METHODS: We performed a cost-minimization analysis with a decision-tree model using a societal perspective over a one-year period. Sources of data for model parameters included IMS Health Canada data collected from one-third of all retail pharmacies for the cost and use of angiotensin-receptor blockers and ACE inhibitors in each province, as well as published studies for administrative costs and incidence of dry cough. We used Monte Carlo simulations with 10 000 iterations to test the impact of several model parameters (e.g., drug prices, administrative costs and the incidence of dry cough). All data are in 2006 Canadian dollars. RESULTS: A policy that would have restricted access to angiotensin-receptor blockers might have saved more than $77 million in Canada in 2006. The simulations yielded similar savings for the year (mean $58.3 million, 95% confidence interval $29.3 million to $90.8 million). Every simulation showed a cost savings. INTERPRETATION: Had access to angiotensin-receptor blockers been restricted, the potential cost savings to the Canadian health care system might have been more than $77 million in 2006, likely without any adverse effect on cardiovascular health.

Long-term trends in use of and expenditures for cardiovascular medications in Canada.

BACKGROUND: Medication expenditures have become the fastest growing sector of costs within the Canadian health care system. Evaluation of the use of cardiovascular medications is important to determine the magnitude of the growth, to identify which medications dominate the landscape and to detect interprovincial differences in utilization. We describe long-term trends in the use of and expenditures for cardiovascular medications in Canada, by drug class and by province. METHODS: For these analyses, we used volume and expenditure data related to prescriptions for cardiovascular medications obtained from IMS Health Canada's CompuScript Audit database for the period 1996-2006. Here, we describe national and provincial patterns of utilization and expenditures for specified classes of cardiovascular medications. RESULTS: The use of cardiovascular medications increased sharply in Canada during the study period, with related costs rising by over 200% during this period to surpass $5 billion in 2006. Changes in population demographics, risk factors and inflation appeared to account for about two-thirds of the observed growth in expenditures. Use of newer medication classes (statins, angiotensin-receptor blockers, angiotensin-converting-enzyme inhibitors), for which patented brand name medications predominate, accounted for almost one-third of the cost increases. Interprovincial differences in total expenditures for cardiovascular drugs portrayed a descending gradient from east to west, with greatest variability for the newer drug classes. INTERPRETATION: Prescriptions and expenditures for cardiovascular medications in Canada escalated over the study period. Projected increases may reach potentially unsustainable levels. Greater emphasis on the use of cost-effective medications is required to limit further increases. Factors influencing interprovincial differences warrant further study.

Drug reimbursement policies in Canada--need for improved access to critical therapies.

Public drug programs in Canada are increasingly implementing cost management strategies. A multidisciplinary review of these strategies--specifically, the special authorization (SA) process--found that implementation of the SA practice is costly and causes inequity in access, underutilization, and delays in treatment for urgently required therapies, all potentially leading to negative health outcomes. We present potential solutions and a set of recommendations for decision-makers to base reimbursement decisions on the best clinical evidence, eliminate regional variability in access, ensure timely access to urgently required treatments, and monitor the impact of reimbursement policies on health outcomes.

Population-based evaluation of the management of antithrombotic therapy for atrial fibrillation.

BACKGROUND: Oral anticoagulation is an effective therapy for the prevention of cardioembolic complications in patients with atrial fibrillation. However, previous practice reviews have indicated that oral anticoagulants are often underused in this setting. Most of those reports have focused on reviews of hospitalized and institutionalized patients, or small geographical areas. OBJECTIVES: To determine the use of antithrombotic therapy for the treatment of atrial fibrillation in Nova Scotia and to survey the knowledge of antithrombotic therapy for atrial fibrillation among a concurrent cohort of primary care and specialist physicians involved in the management of patients with atrial fibrillation. PATIENTS AND METHODS: Patients with atrial fibrillation were identified through outpatient electrocardiography clinics held throughout Nova Scotia. Following consent of the primary care physicians, patients were contacted and completed a survey about their current management. Family physicians and specialists in Nova Scotia were also surveyed about the management of atrial fibrillation with antithrombotic therapy through the receipt of one of four case scenarios. RESULTS: Four hundred twenty-five patients participated in the cross-sectional survey. The mean patient age was 70.6 years, 255 (60%) were male and 398 (93.6%) had at least one risk factor for stroke in addition to atrial fibrillation. Two hundred ninety-four patients (69.2%) were receiving oral anticoagulants either alone (61.9%) or in combination with acetylsalicylic acid (ASA) (7.3%). An additional 85 patients (20%) received ASA alone. There was no difference in the rates of prescription of oral anticoagulants between elderly patients (75 years of age and older) and those younger than 75 years (71.7% versus 67.3%, 95% CI -13.1% to 4.5%; P=0.34). Overall, 72.0% of patients were receiving antithrombotic therapy in accordance with the 2001 guidelines of the American College of Chest Physicians, with no difference in the rates between individuals younger than 75 years (72.2%) and those over 75 years of age (71.7%) (absolute difference -0.5%, 95% CI -9.2% to 8.1%). Physician responses to case scenarios indicated that knowledge was high among both general practitioners and specialists regarding the appropriate use of oral anticoagulants for the prevention of thrombotic complications associated with atrial fibrillation. CONCLUSIONS: The appropriate use of oral antithrombotic therapy for the prevention of thrombotic complications of atrial fibrillation occurs in approximately 72% of patients studied in Nova Scotia, and physician knowledge about this indication is high. There was no bias against prescribing oral anticoagulants to elderly patients. The findings suggest that with time, education and evidence have positively impacted the use of antithrombotic therapy in these patients.

Identifying opportunities to address the congestive heart failure burden: the Improving Cardiovascular Outcomes in Nova Scotia (ICONS) study.

BACKGROUND: Medical, social and economic costs of congestive heart failure (CHF) continue to rise. There exists a 'care gap' between what the optimal care populations with CHF should receive and actually do receive. Central to the goal to develop effective strategies against the 'care gap' is accurate measurement of the CHF burden. Administrative data are limited in detail and accuracy and clinical databases suffer from limited size. Improving Cardiovascular Outcomes in Nova Scotia (ICONS) is a province-wide population-based disease management study with access to all patient health data including outcomes. METHODS: Medical records of all patients admitted to any Nova Scotia health care institution with a cardiovascular disorder were prospectively examined by trained abstractors. Patients were followed up and health outcomes measured through assignment of unique identifier numbers and linkage with Vital Statistics Nova Scotia. This report summarizes baseline data for the population admitted to hospital with a diagnosis of CHF between October 15, 1997 and October 14, 1998. RESULTS: There were 2637 unique patients enrolled with 3547 hospitalizations. The median length of stay was eight days, with in-hospital mortality of 18.2%; 10.8% were discharged to long term care. The mortality rate was 38.7% at 12 months and the rehospitalization rate was 39.9%. Average age was 75 +/- 10 years (median 76) and 52% were female. There were 4.5 comorbidities per patient. Left ventricular ejection fraction (LVEF) was measured in fewer than 40%; of these, fewer than 39% had a documented ejection fraction less than 40%. At discharge, 61.3% of survivors were prescribed angiotensin-converting enzyme (ACE) inhibitors, 6.0% angiotensin blockers, 42.1% beta-blockers, 75.6% diuretics, 26.1% calcium channel blockers and 19.3% warfarin. Females were older and had lower rate of LVEF testing and ACE and warfarin usage. CONCLUSION: The burden of disease for CHF in Nova Scotia is large and affects an elderly population with multiple comorbidities. Adverse outcomes such as death, rehospitalization and admission to a chronic care facility are common. Measurement of the 'care gap' requires consideration of these factors and of elderly and female patients regardless of left ventricular function. Successful strategies will likely be multidisciplinary in scope with a focus toward improving access to care.