Atrial Fibrillation in Rural Adults: An Inpatient Evaluation of Clinical Guidelines Adherence

Abstract

Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with a higher incidence in older adults (Iwasaki, Nishida, Kato,& Nattel, 2011). There are limited data regarding AF care for adults in rural communities with AF. Purpose: The purpose of this study was to determine whether patients in a rural community hospital received AF care based on American Heart Association (AHA) Get with the Guidelines-Atrial Fibrillation (GWTG-AF) standardized guidelines and whether use of these guidelines was associated with improved thirty day outcomes. Methods: A retrospective medical records review was used. Medical records of patients with AF as primary or secondary diagnoses in inpatient or emergency department admissions were reviewed to determine whether AF guideline care was provided during the hospital stay. AHA GWTG-AF was used to evaluate guideline based care (January, et al., 2014). Results: The results from this study showed that while quality care is provided to rural patients with AF, standardized guideline care is not consistently provided. Preventative care, such as use of angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB) was only provided for 50% of patients who required it. Evaluation of thromboembolism risk was not consistently provided for AF patients. Use of the congestive heart failure, hypertension, age, diabetes, stroke, vascular disease, age, sex category (CHADS₂/CHA₂DS₂VASc) score was not used in the emergency department or observation units (ED/OBS) and limited use of CHADS₂/CHA₂DS₂VASc score was shown in the inpatient environment, with only 19.5% of patients receiving assessment of thromboembolism risk. Bleeding risk was not documented by clinicians, such as the hypertension, abnormal renal/liver function, stroke bleeding predisposition, labile INR, elderly, drugs/alcohol (HAS-BLED) score. Thromboembolism medications were administered to 156 (78%) of the patients without documentation of these risk factors. Rate control strategies were used more frequently than rhythm control strategies (76% compared to 15%). There were three readmissions for minor bleeding during the pre-selected readmission window, and did not exhibit enough data to generalize whether immediate 30 day outcomes are affected by adherence to guideline care. Conclusions: While some of the GWTG-AF guidelines are followed for AF patients in this rural environment, there are significant areas where adherence to the guidelines is limited. Use of preventative care measures, thromboembolism risk, bleeding risk, and appropriate anticoagulation administration for patients at risk were areas that did not have adequate guideline adherence. Future research is needed to evaluate what barriers may exist to using guideline based care. Such research can also serve as the basis for education programs for clinicians to increase adherence to guideline care. In addition, future research may include a longer readmission period to evaluate for improved outcomes.