Health Care Provider Satisfaction With a New Electronic Progress Note Format: SOAP vs APSO Format

Comment. The continued, steady decline in ischemic stroke rates between 1992 and 2007 in patients with prevalent AF is extremely encouraging. This decrease was associated with increasing warfarin use (26.7% in 1992; 63.1% in 2007), which is noteworthy. These data indicate continued dissemination of evidence-based medicine from clinical trials into routine practice. While causality cannot be established on the basis of these observational data, one can hypothesize that diffusion of warfarin into clinical practice likely contributed substantially to reduction in ischemic stroke rates in this time frame, in combination with better control of modifiable atherosclerotic cardiovascular risk factors. Mercaldi et al reported that 41.5% of Medicare patients with nonvalvular AF do not receive anticoagulation; this is concordant with our data showing that 37% of Medicare beneficiaries with AF did not receive warfarin for anticoagulation therapy in 2007. In this patient subset, substantial numbers likely had a personal preference to forego anticoagulation or logistical constraints, making warfarin therapy not feasible. This group of patients might benefit from the advent of newer anticoagulants that do not require frequent monitoring and have a lower reported risk of significant bleeding. This study is limited owing to the observational design; the declining rates of ischemic stroke with increasing warfarin use reflect temporal associations and not necessarily the effect of anticoagulation. We used a surrogate method to ascertain warfarin use, which could result in underestimating numbers of individuals undergoing testing in alternative settings. In conclusion, ischemic stroke rates continue to decrease in the Medicare population, parallel to increases in warfarin use, although these rates appear to have leveled off. On the basis of these data, the 37% of Medicare beneficiaries not currently receiving warfarin for anticoagulation may offer a window of opportunity for further reduction in ischemic stroke rates and should be targeted in future studies.