Bridging Anticoagulation Before Colonoscopy: Results of a Multispecialty Clinician Survey | Atrial Fibrillation | JAMA Cardiology | JAMA Network
[Skip to Navigation]
Sign In
Table.  Survey Vignettes and Responsesa
Survey Vignettes and Responsesa
1.
Bates  DW, Cullen  DJ, Laird  N,  et al; ADE Prevention Study Group.  Incidence of adverse drug events and potential adverse drug events: implications for prevention.  JAMA. 1995;274(1):29-34.PubMedGoogle ScholarCrossref
2.
Budnitz  DS, Shehab  N, Kegler  SR, Richards  CL.  Medication use leading to emergency department visits for adverse drug events in older adults.  Ann Intern Med. 2007;147(11):755-765.PubMedGoogle ScholarCrossref
3.
Douketis  JD, Spyropoulos  AC, Kaatz  S,  et al; BRIDGE Investigators.  Perioperative bridging anticoagulation in patients with atrial fibrillation.  N Engl J Med. 2015;373(9):823-833.PubMedGoogle ScholarCrossref
4.
Gage  BF, Waterman  AD, Shannon  W, Boechler  M, Rich  MW, Radford  MJ.  Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.  JAMA. 2001;285(22):2864-2870.PubMedGoogle ScholarCrossref
5.
Gerson  LB, Michaels  L, Ullah  N, Gage  B, Williams  L.  Adverse events associated with anticoagulation therapy in the periendoscopic period.  Gastrointest Endosc. 2010;71(7):1211-1217.e2.PubMedGoogle ScholarCrossref
6.
Steinberg  BA, Peterson  ED, Kim  S,  et al; Outcomes Registry for Better Informed Treatment of Atrial Fibrillation Investigators and Patients.  Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF).  Circulation. 2015;131(5):488-494.PubMedGoogle ScholarCrossref
Research Letter
December 2016

Bridging Anticoagulation Before Colonoscopy: Results of a Multispecialty Clinician Survey

Author Affiliations
  • 1Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor
  • 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 3Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
  • 4VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan
  • 5Department of Internal Medicine, Henry Ford Hospital, Ann Arbor, Michigan
JAMA Cardiol. 2016;1(9):1076-1077. doi:10.1001/jamacardio.2016.2409

Long-term anticoagulant therapy is essential for stroke prevention among patients with atrial fibrillation, but increasing evidence also points to substantial risk for adverse events, especially when anticoagulation is temporarily interrupted.1,2 The recently published Effectiveness of Bridging Anticoagulation for Surgery Trial confirmed prior observational evidence that using short-acting anticoagulants periprocedurally increases bleeding risk without any reduction in stroke risk.3 Little is known about how medical specialists coordinate the complex decision of which patients to bridge. To investigate this question, we conducted a regional multispecialty, multicenter survey study regarding bridging practices.

Methods

Between July 29, 2015, and September 8, 2015, we surveyed all primary care physicians (PCPs), cardiologists, and gastroenterologists at the University of Michigan (primary site) and 4 other health care centers (secondary sites) participating in the Blue Cross Blue Shield of Michigan–sponsored Michigan Anticoagulation Quality Improvement Initiative.2 Participants were excluded if they reported no involvement in patient care or bridging decisions. Clinicians were presented with 4 hypothetical vignettes of patients with atrial fibrillation who must temporarily discontinue warfarin for an upcoming colonoscopy (Table). The vignettes varied in number of stroke risk factors and were presented in random order to each participant to minimize assimilation effect bias.4 Clinicians were asked to indicate whether they would recommend bridging with low-molecular-weight heparin for each vignette. Clinicians were also asked about their current experience with periprocedural anticoagulation management, as well as who should be responsible for anticoagulation bridging decisions. Multivariable logistic regression models and Wald tests were used to assess adjusted response rate differences between clinician specialties. This study was deemed exempt by the institutional review board at the University of Michigan; consent was implied through participation in the optional survey.

Results

A total of 127 of 262 clinicians (48.5%) at the primary site and 80 of 496 clinicians (16.1%) at the secondary sites completed the survey. Respondents were well distributed across medical specialties and reported high levels of participation in bridging anticoagulation management (72.5% reported at least once per month). For intermediate-risk patients (CHADS2 [congestive heart failure, hypertension, age ≥75 years, diabetes, prior stroke or transient ischemic attack] score = 3), there was significant variation in the recommendation to use bridging anticoagulation among specialties (Table). Notably, all specialties were more likely to recommend bridging for a patient with a CHADS2 score of 3 if the patient had a prior ischemic stroke compared with a patient with equal risk but no prior ischemic stroke (73.9% vs 37.2%; P < .001).

There was wide consensus across specialties that a nongastroenterologist should be responsible for making bridging decisions (197 of 207; 95.2%), with large numbers of respondents believing that PCPs (51 of 207; 24.6%) or cardiologists (100 of 207; 48.3%) should be responsible. Notably, 32.2% of PCPs (39 of 121) felt uncomfortable managing periprocedural anticoagulation. Among PCPs, 81.8% (99 of 121) indicated that their institutions could do more to support perioperative anticoagulation and 87.6% (106 of 121) supported anticoagulation clinic management of this clinical situation.

Discussion

A high proportion of clinicians who frequently manage periprocedural anticoagulation continue to recommend bridging anticoagulation for intermediate-risk patients despite the recent publication of a high-quality randomized trial demonstrating net harm from this practice. Furthermore, there is little consensus about whether PCPs or cardiologists should be responsible for making the complex decision of whether to bridge or not. Our data suggest that this is especially important because the 2 groups have significantly different approaches to bridging, and a substantial proportion of PCPs reported being uncomfortable making bridging decisions. Prior work has highlighted use of bridging anticoagulation for up to 25% of warfarin-treated patients undergoing colonoscopy.5,6

The results were consistent across a range of medical centers (academic and nonacademic). The generalizability of these findings, while limited by the few sites surveyed and the low response rate at the secondary sites, is bolstered by the potential bias for more informed clinicians to respond to a survey about anticoagulation management, for which they routinely make clinical decisions.

These results should encourage robust implementation efforts to standardize periprocedural anticoagulation management. Because periprocedural bridging is by nature complex and multidisciplinary, clinical leaders and policy makers need to assess the readiness of different specialists and support anticoagulation clinics to manage periprocedural anticoagulation.

Back to top
Article Information

Corresponding Author: Geoffrey D. Barnes, MD, MSc, Division of General Internal Medicine, Department of Internal Medicine, University of Michigan Health System, 2800 Plymouth Rd, Bldg 14, Room G101, Ann Arbor, MI 48109-2800 (gbarnes@umich.edu).

Published Online: September 14, 2016. doi:10.1001/jamacardio.2016.2409

Author Contributions: Drs Barnes and Kurlander had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Barnes, Kurlander, Kaatz, Froehlich.

Acquisition, analysis, or interpretation of data: Barnes, Kurlander, Haymart, Saini, Froehlich.

Drafting of the manuscript: Barnes, Kurlander.

Critical revision of the manuscript for important intellectual content: All Authors.

Statistical analysis: Barnes, Kurlander.

Obtaining funding: Barnes, Froehlich.

Administrative, technical, or material support: Barnes, Haymart.

Study supervision: Barnes, Froehlich.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Barnes is supported by grant T32-HL007853 from the National Institutes of Health/National Heart, Lung, and Blood Institute and a grant from Blue Cross Blue Shield of Michigan and has received grants and personal fees from Bristol-Myers Squibb/Pfizer, Portola, and Aralez. Dr Kaatz has received a grant from Blue Cross Blue Shield of Michigan and personal fees from CSL Behring, Daiichi Sankyo, and Portola. Dr Saini reports personal fees from FMS Inc. Dr Froehlich has received personal fees from Pfizer, Merck, Boehringer-Ingelheim, Novartis, and Janssen. No other disclosures were reported.

References
1.
Bates  DW, Cullen  DJ, Laird  N,  et al; ADE Prevention Study Group.  Incidence of adverse drug events and potential adverse drug events: implications for prevention.  JAMA. 1995;274(1):29-34.PubMedGoogle ScholarCrossref
2.
Budnitz  DS, Shehab  N, Kegler  SR, Richards  CL.  Medication use leading to emergency department visits for adverse drug events in older adults.  Ann Intern Med. 2007;147(11):755-765.PubMedGoogle ScholarCrossref
3.
Douketis  JD, Spyropoulos  AC, Kaatz  S,  et al; BRIDGE Investigators.  Perioperative bridging anticoagulation in patients with atrial fibrillation.  N Engl J Med. 2015;373(9):823-833.PubMedGoogle ScholarCrossref
4.
Gage  BF, Waterman  AD, Shannon  W, Boechler  M, Rich  MW, Radford  MJ.  Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.  JAMA. 2001;285(22):2864-2870.PubMedGoogle ScholarCrossref
5.
Gerson  LB, Michaels  L, Ullah  N, Gage  B, Williams  L.  Adverse events associated with anticoagulation therapy in the periendoscopic period.  Gastrointest Endosc. 2010;71(7):1211-1217.e2.PubMedGoogle ScholarCrossref
6.
Steinberg  BA, Peterson  ED, Kim  S,  et al; Outcomes Registry for Better Informed Treatment of Atrial Fibrillation Investigators and Patients.  Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF).  Circulation. 2015;131(5):488-494.PubMedGoogle ScholarCrossref
×