Advertisement
Canadian Journal of Cardiology

The Relationship Between Cardiologist Care and Clinical Outcomes in Patients With New-Onset Atrial Fibrillation

  • Sheldon M. Singh
    Correspondence
    Corresponding author: Sheldon M. Singh, MD, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada. Tel.: +1-416-480-6100; fax: +1-416-480-6913.
    Affiliations
    Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
  • Feng Qiu
    Affiliations
    Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
    Search for articles by this author
  • Lauren Webster
    Affiliations
    Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
    Search for articles by this author
  • Peter C. Austin
    Affiliations
    Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada

    Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
  • Dennis T. Ko
    Affiliations
    Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

    Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada

    Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
  • Jack V. Tu
    Affiliations
    Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

    Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada

    Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
  • Harindra C. Wijeysundera
    Affiliations
    Schulich Heart Centre, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

    Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada

    Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author

      Abstract

      Background

      Increased mortality is well described in patients with atrial fibrillation (AF), primarily related to death from cardiovascular causes. One may hypothesize that cardiology care may be associated with a reduction in cardiovascular deaths in patients with AF, thereby improving their overall survival. The aim of this study was to assess the association between cardiologist care and clinical outcomes, including all-cause mortality, in patients with new-onset AF.

      Methods

      This was a retrospective population-level, propensity score–matched cohort study of patients aged 20-80 years with new-onset AF presenting to an emergency department in Ontario, Canada between 2010 and 2012. Patients who saw a cardiologist within 1 year of the initial diagnosis were matched to patients who did not see a cardiologist. Linked administrative databases were used for cohort construction and allow for 1-year follow-up to assess for the clinical end points of death, hospitalization for AF, stroke syndromes, bleeding, and heart failure.

      Results

      Cardiologist care was associated with a lower 1-year rate of death (5.3% vs 7.7%; hazard ratio, 0.68; 95% confidence interval, 0.55-0.84), despite an increased rate of hospitalizations for AF (17.9% vs 8.2%), stroke syndromes (1.7% vs 0.5%), bleeding (3.1% vs 2.0%), and heart failure (3.2% vs 1.4%).

      Conclusions

      Cardiologist care was associated with a reduction in death in patients with new-onset AF. Further study to obtain a greater understanding of the processes of care associated with the observed survival improvement is warranted.

      Résumé

      Introduction

      L’augmentation de la mortalité est bien décrite chez les patients atteints de fibrillation auriculaire (FA), principalement liée au décès d’origine cardiovasculaire. On peut émettre l’hypothèse que les soins en cardiologie peuvent être associés à une réduction des décès d’origine cardiovasculaire chez les patients atteints de FA et, par conséquent, améliorer leur survie globale. L’objectif de la présente étude était d’évaluer l’association entre les soins des cardiologues et les résultats cliniques, y compris la mortalité toutes causes confondues chez les patients atteints d’une FA d’apparition récente.

      Méthodes

      Il s’agissait d’une étude de cohorte populationnelle rétrospective appariée par score de propension regroupant des patients de 20 à 80 ans atteints d’une FA d’apparition récente qui s’étaient présentés dans un service des urgences de l’Ontario, au Canada, entre 2010 et 2012. Nous avons apparié les patients qui avaient vu un cardiologue durant l’année du diagnostic initial aux patients qui n’avaient pas vu de cardiologue. Nous avons utilisé des bases de données administratives liées pour former la cohorte et prévu 1 an de suivi pour évaluer les critères de jugements cliniques de mortalité, d’hospitalisations en raison de FA, de syndromes d’accident vasculaire cérébral, d’hémorragies et d’insuffisance cardiaque.

      Résultats

      Nous avons associé les soins des cardiologues à un taux de mortalité plus faible après 1 an (5,3 % vs 7,7 % ; rapport de risque, 0,68 ; intervalle de confiance à 95 %, 0,55-0,84), en dépit d’une augmentation du taux d’hospitalisation en raison de FA (17,9 % vs 8,2 %), des syndromes d’accidents vasculaires cérébraux (1,7 % vs 0,5 %), des hémorragies (3,1 % vs 2,0 %) et de l’insuffisance cardiaque (3,2 % vs 1,4 %).

      Conclusions

      Nous avons associé les soins des cardiologues à une réduction de la mortalité chez les patients atteints d’une FA d’apparition récente. Des études subséquentes pour acquérir une meilleure compréhension des processus de soins associés à l’observation d’une amélioration de la survie sont justifiées.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Chugh S.S.
        • Havmoeller R.
        • Narayan K.
        • et al.
        Worldwide epidemiology of atrial fibrillation.
        Circulation. 2014; 129: 837-847
        • Conen D.
        • Chae C.U.
        • Glynn R.J.
        • et al.
        Risk of death and cardiovascular events in healthy women with new-onset atrial fibrillation.
        JAMA. 2011; 305: 2080-2087
        • Miyasaka Y.
        • Barnes M.E.
        • Bailey K.R.
        • et al.
        Mortality trends in patients diagnosed with first atrial fibrillation: a 21-year community-based study.
        J Am Coll Cardiol. 2007; 49: 986-992
        • Kim E.J.
        • Yin X.
        • Fontes J.D.
        • et al.
        Atrial fibrillation without comorbidities: prevalence, incidence and prognosis (from the Framingham Heart Study).
        Am Heart J. 2016; 177: 138-144
        • Turakhia M.P.
        • Hoang D.D.
        • Xu X.
        • et al.
        Differences and trends in stroke prevention anticoagulation in primary care vs cardiology speciality management of new atrial fibrillation.
        Am Heart J. 2013; 165: 93-101
        • Fosbol E.L.
        • Holmes D.N.
        • Piccini J.P.
        • et al.
        Provider speciality and atrial fibrillation treatment strategies in United States community practice.
        J Am Heart Assoc. 2013; 2: e000110
        • Healey J.S.
        • Oldgren J.
        • Ezekowitz M.
        • et al.
        Occurrence of death and stroke in patients in 47 countries 1 year after presenting with atrial fibrillation.
        Lancet. 2016; 388: 1161-1169
        • Guigliano R.P.
        • Ruff C.T.
        • Wivott S.D.
        • et al.
        Mortality in patients with atrial fibrillation randomized to edoxaban or warfarin.
        Am J Med. 2016; 129: 850-857
        • Pokorney S.D.
        • Piccini J.P.
        • Stevens S.R.
        • et al.
        Causes of death and predictors of all-cause mortality in anticoagulated patients with non-valvular atrial fibrillation.
        J Am Heart Assoc. 2016; 5: e002197
        • Bassand J.P.
        • Accetta G.
        • Camm A.J.
        • et al.
        Two-year outcomes of patients with newly diagnosed atrial fibrillation.
        Eur Heart J. 2016; 37: 2882-2889
        • Atzema C.L.
        • Austin P.C.
        • Chong A.S.
        • Dorian P.
        Factors associated with 90-day death after emergency department discharge for atrial fibrillation.
        Ann Emerg Med. 2013; 61: 539-548
        • Singh S.M.
        • Wang X.
        • Austin P.C.
        • Parekh R.S.
        • Lee D.S.
        Prophylactic defibrillators in patients with severe kidney disease.
        JAMA Intern Med. 2014; 174: 995-996
        • Oldgren J.
        • Alings M.
        • Darius H.
        • et al.
        Risk for stroke, bleeding, death in patients with atrial fibrillation receiving dabigatran or warfarin in relation to the CHADS2 score.
        Ann Intern Med. 2011; 155: 660-667
        • Austin P.C.
        • van Walraven C.
        • Wodchis W.P.
        • Newman A.
        • Anderson G.M.
        Using the Johns Hopkins Aggregated Diagnosis Groups (ADGs) to predict mortality in a general adult population cohort in Ontario, Canada.
        Med Care. 2011; 49: 932-939
        • Tu J.V.
        • Chu A.
        • Donovan L.R.
        • et al.
        The cardiovascular health in ambulatory care research team (CANHEART): using big data to measure and improve cardiovascular health and healthcare services.
        Circ Cardiovasc Qual Outcomes. 2015; 8: 204-212
        • Kwong J.C.
        • Manuel D.G.
        Using OHIP physician billing claims to ascertain individual influenza vaccination status.
        Vaccine. 2007; 25: 1270-1274
        • Macle L.
        • Cairns J.
        • Leblanc K.
        • et al.
        2016 Focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation.
        Can J Cardiol. 2016; 32: 1170-1185
        • Cox J.L.
        • Dai S.
        • Gong Y.
        • et al.
        The development and feasibility assessment of Canadian quality indicators for atrial fibrillation.
        Can J Cardiol. 2016; 32: 1566-1569
        • Pink G.H.
        • Bolley H.B.
        Physicians in health care management: 1. Case mix groups and resource intensity weights.
        Can Med Assoc J. 1994; 150: 889-894
        • Austin P.C.
        Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity score matched samples.
        Stat Med. 2009; 28: 3083-3107
        • Austin P.C.
        The performance of different propensity score methods for estimating marginal hazard ratios.
        Stat Med. 2013; 32: 2837-2849
        • Austin P.C.
        • Lee D.S.
        • Fine J.P.
        Introduction to the analysis of survival data in the presence of competing risks.
        Circulation. 2006; 133: 601-609
        • Perino A.C.
        • Fan J.
        • Schmitt S.K.
        • et al.
        Treating speciality and outcomes in newly diagnosed atrial fibrillation.
        J Am Coll Cardiol. 2017; 70: 78-86
        • Oldgren J.
        • Healey J.S.
        • Ezekowitz M.D.
        • et al.
        Variations in cause and management of atrial fibrillation in a prospective registry of 15,400 emergency department patients in 46 countries.
        Circulation. 2014; 129: 1568-1576
        • Chaikriangkrai K.
        • Valderbanno M.
        • Bala S.K.
        • et al.
        Prevalence and implications of subclinical coronary artery disease in patients with atrial fibrillation.
        Am J Cardiol. 2015; 116: 1219-1223
        • Jong P.
        • Gong Y.
        • Liu P.P.
        • et al.
        Care and outcomes of patients newly hospitalized for heart failure in the community treated by cardiologists compared with other specialists.
        Circulation. 2003; 108: 184-191
        • Lee D.S.
        • Stuckel T.A.
        • Austin P.C.
        • et al.
        Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department.
        Circulation. 2010; 122: 1806-1814
        • Czarnecki A.
        • Chong A.
        • Lee D.S.
        • et al.
        Association between physician follow-up and outcomes of care after chest pain assessment in high-risk patients.
        Circulation. 2013; 127: 1386-1394
        • Schreiber T.L.
        • El-Khatib A.
        • Grines C.L.
        • et al.
        Cardiologist versus internist management of patients with unstable angina.
        J Am Coll Cardiol. 1995; 26: 577-582
        • Hendriks J.M.L.
        • de Wit R.
        • Crijns H.J.G.M.
        • et al.
        Nurse-led care vs usual care for patients with atrial fibrillation.
        Eur Heart J. 2012; 33: 2692-2699
        • McAlister F.A.
        The end of the risk-treatment paradox?.
        J Am Coll Cardiol. 2011; 58: 1766-1767
        • Steinberg B.A.
        • Shrader P.
        • Thomas L.
        • et al.
        Off-label dosing of non-vitamin K antagonists oral anticoagulants and adverse outcomes.
        J Am Coll Cardiol. 2016; 68: 2597-2604
        • Tu K.
        • Nieuwlaat R.
        • Cheng S.Y.
        • et al.
        Identifying patients with atrial fibrillation in administrative data.
        Can J Cardiol. 2016; 32: 1561-1565