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Atrial fibrillation after coronary surgery: comparison between different health care systems
Silja Majahalme1, Michael H Kim, David Bruckman
1Tampere University Hospital, Department of Internal Medicine, Division of Cardiology, P.O. Box 2000, 33521 Tampere, Finland. llsima@uta.fi
Insights
Postoperative atrial fibrillation (AF) incidence was similar in US and Finnish bypass surgery patients, despite different management. Increasing age and radial artery use independently predicted AF. Beta-blocker use varied significantly between countries.
Area of Science:
- Cardiology
- Health Services Research
- Comparative Effectiveness
Background:
- Atrial fibrillation (AF) is a common complication after cardiac surgery.
- Management strategies and health insurance systems vary globally.
- No prior studies compared postoperative AF incidence across different healthcare environments.
Purpose of the Study:
- To compare the incidence and treatment of postoperative AF in primary coronary bypass surgery patients.
- To evaluate the influence of differing health insurance environments on AF management.
Main Methods:
- Observational study comparing two institutions: University of Michigan Health Center (USA, private insurance) and Tampere University Hospital (Finland, public funding).
- Data collected on patient demographics, comorbidities, preoperative and postoperative treatments, and outcomes.
- Propensity analysis used to adjust for site and selection biases.
Main Results:
- Finnish patients had higher rates of preoperative (93% vs. 68%) and postoperative (97% vs. 66%) beta-blocker use.
- Atrial fibrillation incidence was higher in Finnish patients (38% vs. 29%, P=0.037).
- Increasing age and radial artery use were independent predictors of postoperative AF (P<0.0001 and P=0.032, respectively).
Conclusions:
- Significant practice variations exist in coronary bypass surgery management between US and Finnish institutions.
- Despite these variations, postoperative AF incidence was similar.
- Routine beta-blocker use did not fully prevent AF, and postoperative AF did not significantly impact length of stay.
Aims:
No studies have evaluated the influence of management strategies in different health insurance environments on atrial fibrillation (AF). This observational study compared the incidence of and treatment strategies for postoperative AF after primary coronary bypass surgery.
Methods And Results:
One insurance and one public funded location was compared: University of Michigan Health Center (USA, n=272) and Tampere University Hospital (Finland, n=314). USA patients had more co-morbidities and were treated more aggressively after acute myocardial infarction. More Finns were on beta-blockers both preoperatively (93 vs. 68%, P<0.001) and postoperatively (97 vs. 66%, P<0.001). However, AF was more frequent among Finns (38 vs. 29%, P=0.037) and present on 4.6% of cases when transferred postoperatively. No USA patients had AF at time of discharge. Mean length of stay was 8.6 days at USA, and not affected by AF. The incidence of in-hospital death, strokes and multiorgan failures was similar. Multivariable analysis, adjusted for site and selection biases (propensity analysis) revealed increasing age [OR=1.063 (1.042, 1.084), P<0.0001] and use of radial arteries [OR=2.175 (1.071, 4.417), P=0.032) to be independent predictors to the incidence of postoperative AF.
Conclusions:
We found several major differences in patient selection and treatment strategies among primary coronary bypass patients managed in the two institutions. Despite the marked practice variation, the incidence of postoperative AF was rather similar. Despite routine use of beta-blockers, AF occurred in 29-38% of patients. However, the length of stay was not particularly affected by postoperative AF.