心房颤动管理中的地区差异：IMPACT 心房颤动子研究

IF 2.5 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS CJC Open Pub Date : 2024-10-01 DOI:10.1016/j.cjco.2024.06.010

Joshua Hamlin BSc , Jafna Cox MD , Laura Hamilton MAHSR , Joanna Nemis-White BSc , James McKillop MD , Navjot Sandila MSc , Ratika Parkash MD, MSc, FRCPC

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引用次数: 0

摘要

背景在农村地区，心房颤动（AF）的治疗主要由当地的初级保健专业人员（PCP）负责。方法这项群集随机试验 "促进心房颤动社区治疗综合管理计划"（IMPACT-AF）的事后分析比较了临床决策支持系统和标准护理。患者被分为居住在农村（人口< 10,000）和城市两类。结果如下心房颤动相关急诊科（ED）就诊率、非计划性心血管（CV）住院率、心房颤动相关转诊率和心房颤动治疗指南遵守率。结果 2016年至2018年，共有1133名患者入选；54.1%（n = 613）的患者被归类为生活在农村地区。年龄（平均 72 ± 9.63 岁 vs 72.5 ± 10.42 岁）或充血性心力衰竭、高血压、年龄、糖尿病、卒中/短暂性脑缺血发作（CHADS2）评分（平均 2.1 ± 1.36 vs 2.16 ± 1.34）无差异。农村人口的普通内科医生转诊率更高（13.4% vs 3.9%，P < 0.001），而城市人口的心脏病学转诊率更高（10% vs 15%，P = 0.0098）。12 个月后，心房颤动相关急诊就诊和冠心病住院的综合结果无差异。城市组心房颤动相关急诊就诊和冠心病住院的复发率较低（发病率比 [IRR]，0.65 [95% 置信区间 (0.44, 0.95)，P = 0.0262）。农村组（IRR，3.7 ± 1.2）和城市组（IRR，3.6 ± 1.2；P = 0.11）遵守指南的发生率相似。需要进一步研究如何优化心房颤动相关的结果，以确保为所有加拿大人提供公平的医疗服务，而不论其地理位置如何。

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Regional Disparities in Atrial Fibrillation Management: An IMPACT-AF Substudy

Background

In rural regions, atrial fibrillation (AF) management is performed predominately by local primary care professionals (PCPs). Prior work has suggested that a disparity in outcomes in AF occurs for those patients living in a rural, vs urban, location.

Methods

This post hoc analysis of the cluster randomized trial Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) compared a clinical decision support system to standard of care. Patients were classified as living in a rural (population < 10,000) or urban location. The outcomes were as follows: AF-related emergency department (ED) visits, unplanned cardiovascular (CV) hospitalizations, AF-related referrals and guideline adherence for AF treatment.

Results

A total of 1133 patients were enrolled from 2016 to 2018; 54.1% (n = 613) were classified as living in a rural location. No differences were present in age (mean, 72 ± 9.63 vs 72.5 ± 10.42 years) or Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS₂) score (mean, 2.1 ± 1.36 vs 2.16 ± 1.34). Referral rates to general internists were higher in the rural population (13.4% vs 3.9%, P < 0.001), whereas the rate of cardiology referrals was higher in the urban population (10% vs 15%, P = 0.0098). At 12 months, no difference in the composite outcome of AF-related ED visits and CV hospitalizations was seen. Fewer recurrent AF-related ED visits and CV hospitalizations occurred in the urban group (incidence rate ratio [IRR], 0.65 [95% confidence interval (0.44, 0.95), P = 0.0262). The incidence of guideline adherence was similar between the rural (IRR, 3.7 ± 1.2) and urban (IRR, 3.6 ± 1.2; P = 0.11) groups.

Conclusions

AF patients living in rural locations had higher rates of recurrent AF-related ED visits and unplanned CV hospitalizations. Further research to optimize AF-related outcomes is needed to ensure equitable delivery of care to all Canadians, irrespective of geography.