Protected: Qi03 – Stroke or TIA and atrial fibrillation

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Operationalisation

Denominator

All patients who survived a hospitalisation for ischemic stroke (ICD-10 I63 or I64) or transient ischemic attack (TIA) (ICD-10 G45) who had a diagnosis of atrial fibrillation or flutter (ICD-10 I48)

Numerator

All defined in the denominator who were dispensed anticoagulant medication (listed below) at least once within 6 months of the end of the hospital care episode:

  • vitamin K antagonist warfarin (ATC B01AA03), or
  • direct oral anticoagulants (DOACs) dabigatran (ATC B01AE07), rivaroxaban (B01AF01/B01AF51), apixaban (B01AF02), or edoxaban (B01AF03)

Exclusions (Numerator, denominator)

Patients aged below 18 at the end of the year of hospital discharge.
Patients who die or emigrate within 6 months (180 days) of the discharge.

Notes

If a patient has had multiple qualifying events during the year, the first one is included.

Sources of Data

  • Population register
  • Secondary care patient registers
  • Outpatient medication dispensations register

Information about the indicator set

Purpose

  • The quality indicator set is intended for comparison of effectiveness and/or safety aspects of prescribing across Nordic countries and subnational regions.
  • Further comparisons across population subgroups (e.g., socioeconomic position, immigration background) can inform equity considerations.
  • Further comparisons in relation to expenditures can inform efficiency considerations

Limitations

  • The indicators in the set use medication dispensings and/or sales data as a proxy for appropriate prescribing and medication use. This is to allow comparisons using register data, which have the advantage of being readily available and comprehensive in terms of population coverage and over time (5–7).
  • Register data are not without limitations. Medications may have been prescribed, but not collected from the pharmacy by the user. Collected medications may not have been (appropriately) used by the patient. Sales data may not be fully comparable across countries.
  • Register data are collected primarily for other purposes than quality assessment. Thus, discontinuities over time due to, e.g., legislative changes and administrative reforms need to be acknowledged in the interpretation of the results.
  • Indicators need to be updated regularly because clinical guidelines and the range of available medications change over time.
  • ATC-codes are based on WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD Index version 2024

Background and literature related to the proposed indicator

Clinical guidelines

The European Stroke Organisation (ESO) guideline (16)

  • Non-vitamin K antagonist oral anticoagulants as the preferred treatment for secondary prevention of recurrent stroke or thromboembolism in patients with atrial fibrillation and ischemic stroke or transient ischemic attack.
  • Oral anticoagulants reduce the risk of recurrence over antiplatelets or no antithrombotic treatment.
  • Non-vitamin K antagonist oral anticoagulants are preferred over vitamin K antagonists because they have a lower risk of major bleeding and death.

The Finnish Current Care guideline (17)

  • Anticoagulation recommended to patients with atrial fibrillation and stroke or TIA.

Similar or related indicators in Nordic or European quality assessment

Key Performance Measures of the Quality of Acute Stroke Care in Western Europe (18)

  • Proportion of patients with ischemic stroke and atrial fibrillation prescribed an oral anticoagulant on discharge.
  • Proportion of patients with TIA and atrial fibrillation prescribed an oral anticoagulant.

Norwegian Directorate of Health & quality register Norsk hjerneslagregister (19,20)

  • Anticoagulants for patients with atrial fibrillation after cerebral infarction.

Swedish Association of Local Authorities and Regions quality indicators (Vården i siffror) and/or Riksstroke quality register

  • Share of patients with atrial fibrillation and risk factors who were prescribed anticoagulants (21,22)
  • Share of patients with atrial fibrillation hospitalised for stroke who were dispensed anticoagulants 12–18 months after hospital discharge (23)
  • Share of patients with atrial fibrillation hospitalised for TIA who were prescribed anticoagulants at discharge (Riksstroke quality register (24))
  • Share of patients with atrial fibrillation hospitalised for stroke who were prescribed anticoagulants at discharge (Riksstroke quality register (25))

Set quality targets

The Norwegian quality register Norsk hjerneslagregister targets:

  • ≥95% of patients with atrial fibrillation and cerebral infarction prescribed anticoagulants at discharge (20).

Swedish Association of Local Authorities and Regions quality indicators (Vården i siffror) and/or Riksstroke quality register targets:

  • 70–80% of patients with atrial fibrillation and stroke prescribed anticoagulants at discharge (Riksstroke)

Similar or related indicators in international scientific literature

  • ER visit/hospitalization/long-term care placement due to thromboembolic cerebrovascular event in patients with history of chronic atrial fibrillation, and no use of warfarin or ASA (26)
  • Oral anticoagulants in patients with atrial fibrillation at high risk of stroke (CHADS2 score ≥3) CHADS2: Score for stroke risk assessment based on the following risk factors: cardiac failure, hypertension, age > 75, diabetes and stroke (27).
  • Thrombo-embolic prophylaxis in patients with atrial fibrillation at low/moderate risk of stroke. CHADS2: Score for stroke risk assessment based on the following risk factors: cardiac failure, hypertension, age > 75, diabetes and stroke (27)
  • Hospitalisation due to ischemic stroke for a patient with history of atrial fibrillation or stroke (in 2 years prior to admission) and no use of warfarin or aspirin (in 3 months prior to admission) (28)
  • % of patients with both an ischemic stroke and atrial fibrillation or flutter who are prescribed and dispensed anticoagulation therapy (warfarin or any direct oral anti-coagulant [DOAC]) at hospital discharge, and the proportion receiving anticoagulation that receive a DOAC (29)
  • Thromboembolic cerebrovascular event, with prior diagnosis of atrial fibrillation and no use of anticoagulant in the 3 months prior to admission in a patient with high risk according to CHA2Ds2Vasc score (30)
  • Inappropriate: % of patients with chronic atrial fibrillation receiving an oral anticoagulant who are prescribed antiplatelet agent(s) concomitantly (31)

References

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  12. Teppo K, Jaakkola J, Biancari F, Halminen O, Linna M, Haukka J, et al. Association of income and educational levels with adherence to direct oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study. Pharmacol Res Perspect. 2022;10(3):e00961.
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  16. Klijn CJ, Paciaroni M, Berge E, Korompoki E, Kõrv J, Lal A, et al. Antithrombotic treatment for secondary prevention of stroke and other thromboembolic events in patients with stroke or transient ischemic attack and non-valvular atrial fibrillation: A European Stroke Organisation guideline. Eur Stroke J. 2019 Sep;4(3):198–223.
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  20. SKDE – Kvalitetsregistre [Internet]. [cited 2024 Apr 24]. Available from: https://www.skde.no/kvalitetsregistre/hjerneslag/sykehus/?selected_row=hjerneslag_ut_antikoag
  21. Antikoagulantiabehandling vid förmaksflimmer och riskfaktorer [Internet]. [cited 2024 Apr 24]. Available from: https://vardenisiffror.se/indikator/251be3c3-c12c-4bc8-a35a-0346abfad255?datefrom=2012-01-01&dateto=2017-12-31&gender&periodtype=year&relatedmeasuresbyentry=keyword&relatedmeasuresbyid=lakemedelsbehandling&showtarget=false&units=07&units=06&units=13&units=01&units=05&units=20&units=19&units=09&units=22&units=10&units=14&units=21&units=18&units=04&units=17&units=03&units=08&units=23&units=25&units=12&units=24&units=se
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  23. Antikoagulantiabehandling vid förmaksflimmer 12-18 månader efter stroke [Internet]. [cited 2024 Apr 24]. Available from: https://vardenisiffror.se/indikator/2f2114be-834d-42fe-b4b0-ff2b512e4fb7?datefrom=2013-01-01&dateto=2017-12-31&gender&periodtype=year&relatedmeasuresbyentry=keyword&relatedmeasuresbyid=lakemedelsbehandling&showtarget=false&units=07&units=06&units=13&units=01&units=05&units=20&units=19&units=09&units=22&units=10&units=14&units=21&units=18&units=04&units=17&units=03&units=08&units=23&units=25&units=12&units=24&units=se
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  25. Antikoagulantiabehandling vid förmaksflimmer och ischemisk stroke [Internet]. [cited 2024 Apr 23]. Available from: https://vardenisiffror.se/indikator/e33263cc-0d3a-4370-846a-d9a442e14d1c?datefrom=2022-07-01&dateto=2023-12-31&gender&periodtype=quarter&relatedmeasuresbyentry=keyword&relatedmeasuresbyid=lakemedelsbehandling&showtarget=false&units=07&units=06&units=13&units=01&units=05&units=20&units=19&units=09&units=22&units=10&units=14&units=21&units=18&units=04&units=17&units=03&units=08&units=23&units=25&units=12&units=24&units=se
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  31. Dang CPL, Toh LS, Cooling N, Jackson S, Curtain C, Thompson A, et al. Updating and validating quality prescribing indicators for use in Australian general practice. Aust J Prim Health. 2019 Dec 23;