October 14, 2011
Agency for Healthcare Research and Quality
Effective Health Care Program
Scientific Resource Center, Oregon EPC
Mail Code: BICC
3181 S.W. Sam Jackson Park Road
Portland, Oregon 97239-3098
RE: Comment on Key Questions for Stroke Prevention in Atrial Fibrillation
Dear Sir or Madam:
Thank you for the opportunity to comment on AHRQ’s key questions related to the Effective Health Care Program’s comparative effectiveness review of stroke prevention in atrial fibrillation. We believe this is an important time to review in light of the growing impact atrial fibrillation has on our aging population and the uncertainty that exists about the best way to treat older patients with the condition.
Atrial fibrillation is associated with an approximate doubling of mortality risk, in large part due to the increased risk of stroke. With as many as 1 in 10 Americans afflicted with atrial fibrillation by age 80, it is an increasingly pressing problem for our health care system as the Silver Tsunami of older Americans and chronic disease begins to impact Medicare.
Atrial fibrillation can be treated and the risk of thrombosis reduced with appropriate medication and monitoring. However, effective tools to assess stroke and bleeding risk and their proper utilization is critical to appropriately treating patients and reducing the human and economic burdens associated with the condition. In nonvalvular atrial fibrillation patients, successful use of antithrombotic therapy depends on patient-tailored assessments that evaluate both stroke and bleeding risks. However, current tools for assessing risks have substantial limitations including inadequate recognition of individual patient characteristics, poor practical value or ease of use, and areas of subjectivity. These problems are further amplified by conflicting guidelines and endorsements which lead to confusion about what tools to use and how best to use them. The result is commonly the underutilization of antithrombotics in patients of perceived high risk of bleeding (e.g. patients between the ages of 65 and 74).
A task force of 11 leading organizations in the thrombosis world, including those listed below, has recently formed in order to explore these issues and promote optimal stroke prevention in atrial fibrillation. Participants in this task force represent various audiences—from patients to health care providers—but we are unified by the desire to improve the way that stroke and bleeding risk are currently assessed and ensure the proper treatment of patients with atrial fibrillation. The task force will be convening an expert panel in early 2012 to identify the gaps in the current stroke and bleeding risk assessment tools and to forge consensus on what needs to be done to ensure that these tools properly assess both. The expert panel will consider the strengths and weaknesses of these tools—from the perspective of both existing treatments and treatments in the pipeline. After the expert consensus is developed, the task force will consider ways that this consensus can inform any appropriate guideline changes, educational efforts on best practices, changes in quality measures, and additional efforts that may improve treatment. We hope that the work of the task force will be considered when AHRQ issues the final report on this review.
We appreciate AHRQ and the Effective Health Care Program examining this important but complex topic for a condition that affects more than 5 million Americans. Please contact Cynthia Bens at the Alliance for Aging Research should you have any questions—[email protected] or 202-293-2856.
Alliance for Aging Research
Men’s Health Network
The National Forum for Heart Disease and Stroke Prevention
National Stroke Association
Preventive Cardiovascular Nurses Association
Society for Women’s Health Research