Patients with atrial fibrillation (afib) have a high rate of serious complications including stroke and decompensated heart failure. While patients with afib are five times more likely to suffer a stroke in their lifetime than the general population, this risk can be reduced by 64% with appropriate anticoagulation using warfarin or approved novel oral anticoagulants (NOACs). Reducing the morbidity and mortality from excess strokes is a common interest nationwide due to unsustainable healthcare costs, increasing human resource gaps in medicine, and payment reforms that hold physicians and healthcare organizations financially accountable for having poor outcomes. Our project aims to investigate the success in achieving appropriate anticoagulation therapy for afib patients in the University of South Florida (USF) Internal Medicine resident clinics. Our goal is to achieve a 90% success rate for both linkage to follow-up and anticoagulation.
Our project identified all patients in the USF Internal Medicine clinics greater than 18 years of age who were discharged from Tampa General Hospital (TGH) between January 1, 2016 and December 31, 2016 and are diagnosed with atrial fibrillation. It investigated the percentage of eligible patients prescribed an anticoagulant (eligibility was determined by CHADSVASC criteria), as well as the percentage of patients who returned for follow-up at least once post-discharge.
Our query identified 49 patients with atrial fibrillation who met our search criteria. Of these, 28 (57%) were appropriately anticoagulated as per CHADSVASC criteria. Unfortunately, 21 patients (43%) who should have been on anticoagulation were not. Twelve patients (24%) were either lost to follow-up or were unavailable to contact. Eight (16%) were deceased since starting our project. Per chart review, zero deaths were related to afib or bleeding.
Our study revealed a significant gap in care for atrial fibrillation patients at USF resident clinics. With just over half being appropriately anticoagulated, we implemented a bundle of quality improvement methodologies. We reached out to our patients and scheduled 29 follow-up appointments in the coming months to discuss their anticoagulation. We created a best practices reminder in the electronic medical record to alert prescribers if a patient has afib in their problem list but does not have an anticoagulant in their medication list. We also plan to review the registry of afib patients yearly to schedule appointments for the patients who have no anticoagulation prescriptions. This way, we will catch patients who are newly diagnosed within the past year or those who have had a transition of care and may have had their medication inadvertently discontinued. We hope these interventions will move us closer to our goals of 90% linkage to care and anticoagulation.