Unnecessary overuse. Study of “inadvisable practices” for patients with atrial fibrillation

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Estudio de los «no hacer» en pacientes con fibrilación auricular" ] ] "textoCompleto" => "BackgroundSince 2007 when The National Institute for Health and Care Excellence (NICE) presented a series of recommendations on relatively common but inappropriate clinical practices,<a class="elsevierStyleCrossRef" href="#bib0255">1</a> the “Less is More Medicine” movement has grown in all countries in the hands of scientific societies, professional schools and institutions and healthcare administrations, as a response to “inappropriate overuse”.<a class="elsevierStyleCrossRef" href="#bib0260">2</a> The project “Do No Harm”<a class="elsevierStyleCrossRef" href="#bib0265">3</a> in Colorado (USA), “Slow Medicine”<a class="elsevierStyleCrossRef" href="#bib0270">4</a> in Italy, “Choosing Wisely”<a class="elsevierStyleCrossRef" href="#bib0275">5</a> in Canada and the USA and “Smarter Medicine”<a class="elsevierStyleCrossRef" href="#bib0280">6</a> in Switzerland are examples of this commitment to better healthcare, which attempt to eradicate inefficient or harmful practice for patients, known as inappropriate overuse.In 2013, the Spanish Society of Internal Medicine and the Ministry of Health, Social Services and Equality launched the project “Commitment to the Quality of Scientific Societies” (“Compromiso por la calidad de las Sociedades Científicas”)<a class="elsevierStyleCrossRef" href="#bib0285">7</a> in Spain, to which 39 of these scientific societies have joined, with the aim of decreasing the interventions that have not shown efficacy, have little or questionable effectiveness or are not cost-effective.The healthcare staff has been the priority objective of these recommendations. In 2010, the Advancing Medical Professionalism to Improve Health Care (ABIM) foundation in the USA lead the campaign “Choosing Wisely”, focused on the appropriate use of therapeutic resources, directed to both clinicians and patients.In the specific case of atrial fibrillation (AF), “do not do” recommendations have not been developed, either for practitioners of both healthcare levels (primary care and specialized) or for patients.AF is the most common arrhythmia in Western countries and the leading cause for thromboembolic events.<a class="elsevierStyleCrossRef" href="#bib0290">8</a> The prevalence of AF is high and is similar for both sexes, reaching 4.4% in individuals older than 40 years. The rate gradually increases after 60 years of age.<a class="elsevierStyleCrossRef" href="#bib0295">9</a> The diagnosis of AF requires an assessment of the thromboembolic risk for a correct indication of the anticoagulant therapy.<a class="elsevierStyleCrossRef" href="#bib0300">10</a> The high prevalence of this arrhythmia, the effectiveness of oral anticoagulant therapy (OAT) in preventing embolic events (with a clear risk-benefit ratio favoring the prevention of stroke compared with the risk of major bleeding events) and the incorporation into clinical practice of direct oral anticoagulants (DOAs) make this arrhythmia an especially relevant target when identifying inappropriate practices.For the approach to patients with AF, we need to know both the anticoagulant therapy and the indicated treatment for heart rate and rhythm control, and we need to eliminate a number of inappropriate practices due to their ineffectiveness, inefficiency or risk. Patients also play an essential role in achieving proper control of OAT. Misconceptions or inappropriate practices in their self-care increase the risks associated with treatment and decrease its effectiveness.<a class="elsevierStyleCrossRef" href="#bib0305">11</a>The aim of this study is to identify “do not do” recommendations for patients with AF regarding diagnostic, therapeutic and self-care practices that are inappropriate, of questionable effectiveness or are not cost-effective.MethodQualitative research study. Initially, the “Metaplan” technique was applied to obtain proposals for diagnostic practices, therapeutic practices (with vitamin K antagonists [VKA] or DOAs) and care practices and for actions by the patients themselves that provided no value, whose risks clearly outweigh the benefits and for which there was scientific evidence that they should not be recommended (“do not do” recommendations), following as an example that proposed by NICE.<a class="elsevierStyleCrossRef" href="#bib0310">12</a>Each of the proposals were assessed individually by participating experts for the current rate of each of the inadvisable practices (inappropriate overuse) and the quality of the evidence that advised against this practice. In both cases, we employed a scale of 1 to 5 points, assigning 1 to the uncommon practices or those without sufficient evidence to be discarded and 5 to the relatively common or to those that clearly should not be recommended based on the evidence. To arrange each proposal from lower to higher, we calculated the product of the assessments of rate and quality of the evidence. In the analysis of these recommendations, we also considered the number of times the same idea was proposed by different participants (spontaneity) and the degree of agreement among the participants (coefficient of variation). We discarded those recommendations with a score lower than 3.5 points for not reaching a sufficiently high degree of agreement.Using the consensus conference technique, we conducted online meetings to outline and agree on the recommendations based on the previous information. For each of the proposals agreed upon in this manner, we obtained an operational description of the recommendation and the presentation of the level of evidence that justified the proposal (for patient proposals, this was based on the documentation on patient education and on the clinical experience). The participants could also propose changes and clarifications to the initially drafted proposal. In this phase, the participants had information on the degree of consensus achieved for each recommendation during the previous phase (mean, spontaneity and coefficient of variation). Each of the recommendations was assessed by the participants using a continuous scale from 0 to 10 points. A minimum score of 0 points represented a practice that had insufficient evidence to not recommend it or, in the case of patients, a belief or behavior for which there was insufficient consensus to not recommend it. A maximum score of 10 indicated a practice that should not be recommended based on the evidence or, in the case of patients, a belief or behavior not recommended by clinical experience.A fact sheet was prepared for each recommendation (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), which included the following: definition of the recommendation of “do not do”; operational definition of the practice, indication or behavior included in the description of the “do not do”; justification or clarifications; and, lastly, the references that support this recommendation.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Six healthcare practitioners with more than 10 years of experience in treating patients with AF participated in this study. The specialists covered cardiology, hematology, neurology, internal medicine, family medicine and nursing, with direct care for this patient profile. The selection of participants aimed to include different experiences in clinical practice, considering levels (primary care and hospital) and healthcare profiles (physician specialists and nursing).ResultsUsing the “Metaplan” method, we obtained a total of 67 “do not do” proposals, 59 of which were distinct. In the subsequent open debate, 18 were discarded for not reaching a sufficient degree of agreement or for being complementary.In the following phase, we analyzed and assessed 24 “do not do” recommendations for diagnosis and treatment in both healthcare levels and 17 patient-centered “do not do” recommendations. In the 2 successive rounds of group work, this list was reduced to 19 “do not do” recommendations for diagnosis and treatment (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) and to 13 “do not do” recommendations for patients to ensure effective self-care (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Among the first set of recommendations, we identified “do not do” recommendations regarding the diagnosis (e.g., do not repeat the capillary or venous INR on the same day, except for analytical or preanalytical errors), the treatment (e.g., do not routinely indicate acetylsalicylic acid to prevent stroke) and the care (e.g., do not systematically perform echocardiograms or Holter ECG for all patients). Most of the patient-directed recommendations (Appendix A; See the supplementary material) were related to the correct use of drugs (e.g., do not compensate a missed dose by doubling the physician-indicated dose the following day). However, physician-related “do not do” recommendations were included (e.g., do not assume that the physician has all the information, such as dietary changes, maternity, etc., and do not forget the list of drugs being taken at home when going to the doctor's office).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThis study came to a consensus on 19 diagnostic and therapeutic indications whose risks outweigh the benefits. We also detected 13 self-care practices (beliefs and behaviors) by patients that unwillingly expose them to risks, due to the practices’ lack of usefulness or even their ability to be harmful.This type of study, which presents a description of interventions and behaviors that are advisable not to keep performing, represents a complementary approach to the analysis of overuse.<a class="elsevierStyleCrossRef" href="#bib0260">2</a> In this case, recommendations were prepared that can define specific contents for the healthcare education of these patients. This approach is complementary to those of other studies that recommend the implementation of appropriate practices using clinical guidelines.The clinical guidelines provide direction on actions for appropriate diagnoses, treatments and follow-ups, depending on the level of knowledge at each moment. Their level of implementation among the various practitioners involved in the care of patients with AF is increasing, with positive results in primary care.<a class="elsevierStyleCrossRef" href="#bib0315">13</a> Despite the growing implementation of the clinical guidelines, the inappropriate overuse of certain practices, which entail risks for the patients and cost overruns, continues to occur in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0320">14</a> It seems appropriate therefore to include algorithms in the clinical decision-making support systems that consider this type of “do not do” recommendations.The “do not do” recommendations will hopefully contribute to reducing overuse resulting from gaps in our understanding, defensive medicine, pressure from patients and due to other reasons.<a class="elsevierStyleCrossRefs" href="#bib0275">5–8</a> It is also hoped that the recommendations will change the harmful beliefs and behaviors of patients.In the case of patients, the habits, beliefs and behaviors learned during other disease processes reside with the appropriate self-care behaviors when an OAT is followed. The inadvisable practices (“do not do”) identified in this study have a direct relationship with erroneous beliefs adopted by patients.The dissemination and implementation of these recommendations requires that health professionals and patients accept them as reasonable and appropriate. Changes in behavior are known to be difficult to achieve. Even when the recommendations are considered effective and efficient, they are not easily implemented.<a class="elsevierStyleCrossRef" href="#bib0325">15</a> Acting according to custom is not uncommon, either among clinicians or patients.<a class="elsevierStyleCrossRef" href="#bib0330">16</a> The challenge facing healthcare organizations is how to effectively transfer these “do not do” recommendations to clinical practice and how to assess their impact.This study has a number of limitations. The study was contextualized to the reality of healthcare practice in Spain. The results could therefore be different in other countries. We did not analyze the rate of each activity that was recommended against in the clinical practice or in the patients’ behavior. Nevertheless, the study's approach focused on clinical practices and self-care behavior that stood out for persisting over time. Given that we only included those clinical practices with 2+ scientific evidence support (recommendation strength C, on a scale of A to D proposed by the Scottish Intercollegiate Guidelines Network)<a class="elsevierStyleCrossRef" href="#bib0335">17</a> or greater, it is possible that there are other practices that could be considered as inappropriate overuse that were not included. We did not conduct a quantitative study on the degree of agreement of these “do not do” recommendations among the groups of professionals or patient representatives.The work in a multidisciplinary team has helped identify diagnostic, therapeutic and care indications that, despite the evidence against them, persist in the care of patients with AF. It has also helped identify patient beliefs and behaviors that negatively affect the outcome of their care, either because the beliefs and behaviors limit the effect of the care or because they are directly harmful. Healthcare quality improves not only when things are done right but also when we stop doings things that do not contribute to the expected result or are harmful to the patients and practitioners.FundingThe study was sponsored by the Madrid Association for Quality Care and funded by an unconditional grant from Boehringer Ingelheim Laboratories.Conflict of interestsThe authors declare that they have no conflicts of interest." 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MethodThe study was based on qualitative research techniques. Using the “Metaplan” technique, we identified and ordered potentially inappropriate, ineffective and inefficient practices. By means of a consensus conference, we then established a number of “inadvisable practice” measures (relatively common practices that should be eliminated based on the scientific evidence or clinical experience). Professionals from the specialties of cardiology, hematology, neurology, internal medicine, family medicine and nursing participated in the consensus. ResultsWe developed a catalog of 19 “inadvisable practices” related to the diagnosis, treatment and care of anticoagulated patients that were inappropriate, had questionable effectiveness or were ineffective, as well as 13 beliefs or behaviors for anticoagulated patients that could result in injury or were useless or inefficient. ConclusionThe “inadvisable practices” approach helps identify practices that represent greater risks than benefits for patients. It seems appropriate to include algorithms in the clinical decision-making support systems that consider this information for the diagnosis, treatment and for home care. For this last case, recommendations have also been prepared that define specific contents for the healthcare education of these patients." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoIdentificar la sobreutilización inadecuada (prácticas diagnósticas, terapéuticas o de autocuidados que suponen riesgos mayores que los beneficios potenciales) en pacientes con fibrilación auricular. MétodoEstudio basado en técnicas de investigación cualitativa. Mediante la técnica «Metaplan» se identificaron y ordenaron posibles prácticas inadecuadas, inefectivas o ineficientes. Después, mediante una conferencia de consenso se establecieron una serie de medidas de «no hacer» (prácticas relativamente frecuentes, que se aconseja erradicar en función de la evidencia científica o la experiencia clínica). Participaron profesionales de las especialidades de Cardiología, Hematología, Neurología, Medicina Interna, Medicina de Familia y Enfermería. ResultadosSe ha elaborado un catálogo de 19 prácticas de «no hacer» relacionadas con el diagnóstico, el tratamiento o los cuidados del paciente anticoagulado, que resultan inadecuadas, de dudosa efectividad o inefectivas, y 13 creencias o conductas del paciente anticoagulado que pueden ocasionarle daño, son inútiles o ineficientes. ConclusiónEl enfoque «no hacer» contribuye a identificar prácticas que suponen más riesgos que beneficios para los pacientes. Parece sensato incluir algoritmos en los sistemas de apoyo a la toma de decisiones clínicas que tengan en cuenta esta información para el diagnóstico, el tratamiento o los cuidados en el hogar. En este último caso, además, se formulan recomendaciones que pueden definir contenidos concretos sobre los que incidir en la educación sanitaria de estos pacientes." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Ortiz MM, Llamas P, Sanmartín M, Egido JA, del Toro J, Egocheaga MI, et al. Sobreutilización innecesaria. Estudio de los «no hacer» en pacientes con fibrilación auricular. Rev Clin Esp. 2017;217:181–187." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: AF, atrial fibrillation; ASA, acetylsalicylic acid; CHA2DS2-VASc, thrombotic risk scale." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Definition: Do not routinely indicate treatment with ASA in AF to prevent stroke. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Description: Do not prescribe ASA without a specific indication for anticoagulated patients. There is an overvaluation of the hemorrhagic risk due to falls. The CHA2DS2-VASc scale should be employed, and ASA (rather than anticoagulants) should only be employed when the score is 1. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rationale/clarification: The combination of antiplatelets and the combination of antiplatelets and anticoagulant therapy increases the risk of hemorrhage. In general, the thromboembolic risk in elderly patients is much greater than the risk of severe hemorrhage. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1406561.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Fact sheet for the recommendation of “Do Not Do” practices in anticoagulated patients with atrial fibrillation." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Spontaneity: The number of times that the same recommendation arises independently among the participants.Degree of agreement: Determined through the score for the coefficient of variation obtained by prioritizing each recommendation. The lower the value of the coefficient of variation the greater the homogeneity in the assessments and therefore the greater the degree of agreement.Intensity of the recommendation: Mean score on a scale of 1–5, where 5 indicates that the practice should clearly not be recommended. The greater the mean score, the higher or more intense the recommendation.Abbreviations: AF, atrial fibrillation; AHT, arterial hypertension; CHA2DS2-VASc, thrombotic risk scale; DA, degree of agreement; ECG, electrocardiogram; GHAS-BLED: hemorrhagic risk scale; INR, international normalized ratio; INT, intensity of the recommendation; SP, spontaneity; OAT, oral anticoagulant therapy; VKA, vitamin K antagonists." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Indications included in the “do not do” recommendations \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Prioritization “Metaplan” technique</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Prioritization consensus conference</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">INT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SP \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">INT<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DA \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Diagnosis</td><td class="td" title="table-entry " align="left" valign="top">Do not base the diagnosis of AF on only the physical examination.<a class="elsevierStyleCrossRefs" href="#bib0300">10,18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not perform cardioversion (electrical or pharmaceutical) on nonanticoagulated patients with a presentation longer than 48h (without having performed a transesophageal echocardiogram)<a class="elsevierStyleCrossRef" href="#bib0340">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not refer all patients diagnosed with AF to the emergency department or urgently.<a class="elsevierStyleCrossRef" href="#bib0345">19</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not repeat the capillary or venous INR reading on the same day (except in the event of an analytical or preanalytical error).<a class="elsevierStyleCrossRef" href="#bib0345">19</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not trust the precision of portable coagulometers after an INR >4.5.<a class="elsevierStyleCrossRefs" href="#bib0300">10,18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.29 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="9" align="left" valign="top">Treatment</td><td class="td" title="table-entry " align="left" valign="top">Do not routinely indicate treatment with acetylsalicylic acid in AF to prevent stroke.<a class="elsevierStyleCrossRefs" href="#bib0350">20,21</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not trust in the correctness of the patient information and treatments recorded in a single electronic history.<a class="elsevierStyleCrossRefs" href="#bib0360">22–26</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not withdraw anticoagulant therapy for minor surgery (e.g., prior to conventional tooth extraction).<a class="elsevierStyleCrossRef" href="#bib0385">27</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not extend the suspension of treatment with the standard anticoagulant before surgery.<a class="elsevierStyleCrossRefs" href="#bib0390">28–31</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Once OAT has been started, do not maintain antiplatelet therapy without a clear indication.<a class="elsevierStyleCrossRefs" href="#bib0300">10,18,32–34</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not trust in the clinical judgment, and do not stop applying thrombotic and hemorrhagic risk scales at the start and during the follow-up of OAT (CHA2DS2-VASc and HAS-BLED)<a class="elsevierStyleCrossRefs" href="#bib0425">35,36</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not stop systematic anticoagulation for elderly patients due to the risk of falls.<a class="elsevierStyleCrossRef" href="#bib0340">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not indicate an anticoagulant without having performed a prior analytical study.<a class="elsevierStyleCrossRef" href="#bib0345">19</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not start anticoagulation in cases of AHT until the hypertension has been properly controlled (systolic blood pressure <160mm Hg)<a class="elsevierStyleCrossRefs" href="#bib0340">18,37–40</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Care</td><td class="td" title="table-entry " align="left" valign="top">Do not use inappropriate automatic equipment for periodic blood pressure checks at the start and during follow-up of OAT.<a class="elsevierStyleCrossRefs" href="#bib0345">19,41–46</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not routinely perform echocardiograms and Holter ECGs on all patients.<a class="elsevierStyleCrossRef" href="#bib0345">19</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not spread out the INR checks by more than 1-week in the event of values significantly above or below the therapeutic range.<a class="elsevierStyleCrossRef" href="#bib0340">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not routinely indicate dietary restrictions (e.g., withdrawing food rich in vitamin K from patients undergoing treatment with AVK).<a class="elsevierStyleCrossRefs" href="#bib0385">27,47,48</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not trust that the patient is properly following the therapeutic regimen, and do not fail to check the level of therapeutic compliance.<a class="elsevierStyleCrossRefs" href="#bib0495">49,50</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.21 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1406562.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Intensity of the recommendation: Mean score on a scale of 0–10, where 10 indicates a practice that should clearly not be recommended based on the evidence. The greater the mean score, the greater the priority or intensity of the recommendation." ] ] ] "descripcion" => array:1 [ "en" => "Inappropriate Overuse in the Diagnosis, Treatment or During the Care of Patients with Atrial Fibrillation Undergoing Anticoagulant Therapy." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Spontaneity: The number of times that the same recommendation arises independently among the participants.Degree of agreement: Determined through the score for the coefficient of variation obtained by prioritizing each recommendation. The lower the value of the coefficient of variation the greater the homogeneity in the assessments and therefore the greater the degree of agreement.Intensity of the recommendation: Mean score on a scale of 1–5, where 5 indicates that the practice should clearly not be recommended. The greater the mean score, the higher or more intense the recommendation.Abbreviations: ASA, acetylsalicylic acid; NSAIDs, anti-inflammatory nonsteroidal drugs; SP, spontaneity; DA, degree of agreement; INT, intensity of the recommendation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Behaviors included in the “Do not do” recommendations \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Prioritization metaplan technique</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Prioritization consensus conference</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">INT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SP \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">INT<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DA \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not self-medicate (with drugs, natural medicine, NSAIDS, ASA, etc.) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not compensate for missed doses. Do not modify the prescribed dosage. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not assume that the healthcare practitioner knows the patient's personal or clinical condition (e.g., maternity, start of a weight-loss diet without medical advice, travel, seasonal changes). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not take oral anticoagulants at irregular times. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not leave unsupervised the taking of medication at home by elderly patients or those with cognitive difficulties. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not tamper with the medication at home. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not postpone the checks and supply of anticoagulant drugs when traveling (both to Spain and abroad) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not follow the advice of other anticoagulated patients because they could have different profiles and therapeutic needs. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not forget to bring the list of drugs being taken at home when going to the doctor's office for a consultation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not attend a consultation without a companion if you have cognitive deficits. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not stop taking the drug to respect fasting when visiting a healthcare center for laboratory tests. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not engage in high-risk sports. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not change the anticoagulation regimen to perform interventionist procedures whose follow-up we cannot perform (e.g., major surgery and invasive diagnostic procedures in other healthcare centers) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.22 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1406560.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Intensity of the recommendation: Mean score on a scale of 0–10, where 10 indicates a practice that should clearly not be recommended based on the evidence. 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Original article

Unnecessary overuse. Study of “inadvisable practices” for patients with atrial fibrillation

Sobreutilización innecesaria. Estudio de los «no hacer» en pacientes con fibrilación auricular

M.M. Ortiza,b, P. Llamasc, M. Sanmartínd, J.A. Egidoe, J. del Torof, M.I. Egocheagag, M.S. Estévezh, I.M. Navarroi,

Corresponding author

inavarro@umh.es

Corresponding author.

, J.J. Mirai,j,k

a Unidad de Calidad, Hospital Universitario de Fuenlabrada, Madrid, Spain

b Asociación Madrileña de Calidad Asistencial, Madrid, Spain

c Hematología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain

d Cardiología, Hospital Ramón y Cajal, Madrid, Spain

e Neurología, Hospital Clínico San Carlos, Madrid, Spain

f Medicina Interna, Hospital Gregorio Marañón, Madrid, Spain

g Medicina de Familia, Centro de Salud Isla de Oza, Madrid, Spain

h Enfermería, Hospital Universitario Fundación Alcorcón, Madrid, Spain

i Universidad Miguel Hernández de Elche, Alicante, Spain

j Departamento de Salud Alicante-Sant Joan, Alicante, Spain

k REDISSEC Red Enfermedades crónicas, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Since 2007 when The National Institute for Health and Care Excellence &#40;NICE&#41; presented a series of recommendations on relatively common but inappropriate clinical practices&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">1</span></a> the &#8220;Less is More Medicine&#8221; movement has grown in all countries in the hands of scientific societies&#44; professional schools and institutions and healthcare administrations&#44; as a response to &#8220;inappropriate overuse&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">2</span></a> The project &#8220;Do No Harm&#8221;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">3</span></a> in Colorado &#40;USA&#41;&#44; &#8220;Slow Medicine&#8221;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">4</span></a> in Italy&#44; &#8220;Choosing Wisely&#8221;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">5</span></a> in Canada and the USA and &#8220;Smarter Medicine&#8221;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">6</span></a> in Switzerland are examples of this commitment to better healthcare&#44; which attempt to eradicate inefficient or harmful practice for patients&#44; known as inappropriate overuse&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In 2013&#44; the Spanish Society of Internal Medicine and the Ministry of Health&#44; Social Services and Equality launched the project &#8220;Commitment to the Quality of Scientific Societies&#8221; &#40;&#8220;<span class="elsevierStyleItalic">Compromiso por la calidad de las Sociedades Cient&#237;ficas</span>&#8221;&#41;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">7</span></a> in Spain&#44; to which 39 of these scientific societies have joined&#44; with the aim of decreasing the interventions that have not shown efficacy&#44; have little or questionable effectiveness or are not cost-effective&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The healthcare staff has been the priority objective of these recommendations&#46; In 2010&#44; the Advancing Medical Professionalism to Improve Health Care &#40;ABIM&#41; foundation in the USA lead the campaign &#8220;Choosing Wisely&#8221;&#44; focused on the appropriate use of therapeutic resources&#44; directed to both clinicians and patients&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the specific case of atrial fibrillation &#40;AF&#41;&#44; &#8220;do not do&#8221; recommendations have not been developed&#44; either for practitioners of both healthcare levels &#40;primary care and specialized&#41; or for patients&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">AF is the most common arrhythmia in Western countries and the leading cause for thromboembolic events&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">8</span></a> The prevalence of AF is high and is similar for both sexes&#44; reaching 4&#46;4&#37; in individuals older than 40 years&#46; The rate gradually increases after 60 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">9</span></a> The diagnosis of AF requires an assessment of the thromboembolic risk for a correct indication of the anticoagulant therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">10</span></a> The high prevalence of this arrhythmia&#44; the effectiveness of oral anticoagulant therapy &#40;OAT&#41; in preventing embolic events &#40;with a clear risk-benefit ratio favoring the prevention of stroke compared with the risk of major bleeding events&#41; and the incorporation into clinical practice of direct oral anticoagulants &#40;DOAs&#41; make this arrhythmia an especially relevant target when identifying inappropriate practices&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">For the approach to patients with AF&#44; we need to know both the anticoagulant therapy and the indicated treatment for heart rate and rhythm control&#44; and we need to eliminate a number of inappropriate practices due to their ineffectiveness&#44; inefficiency or risk&#46; Patients also play an essential role in achieving proper control of OAT&#46; Misconceptions or inappropriate practices in their self-care increase the risks associated with treatment and decrease its effectiveness&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The aim of this study is to identify &#8220;do not do&#8221; recommendations for patients with AF regarding diagnostic&#44; therapeutic and self-care practices that are inappropriate&#44; of questionable effectiveness or are not cost-effective&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><p id="par0040" class="elsevierStylePara elsevierViewall">Qualitative research study&#46; Initially&#44; the &#8220;Metaplan&#8221; technique was applied to obtain proposals for diagnostic practices&#44; therapeutic practices &#40;with vitamin K antagonists &#91;VKA&#93; or DOAs&#41; and care practices and for actions by the patients themselves that provided no value&#44; whose risks clearly outweigh the benefits and for which there was scientific evidence that they should not be recommended &#40;&#8220;do not do&#8221; recommendations&#41;&#44; following as an example that proposed by NICE&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">12</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Each of the proposals were assessed individually by participating experts for the current rate of each of the inadvisable practices &#40;inappropriate overuse&#41; and the quality of the evidence that advised against this practice&#46; In both cases&#44; we employed a scale of 1 to 5 points&#44; assigning 1 to the uncommon practices or those without sufficient evidence to be discarded and 5 to the relatively common or to those that clearly should not be recommended based on the evidence&#46; To arrange each proposal from lower to higher&#44; we calculated the product of the assessments of rate and quality of the evidence&#46; In the analysis of these recommendations&#44; we also considered the number of times the same idea was proposed by different participants &#40;spontaneity&#41; and the degree of agreement among the participants &#40;coefficient of variation&#41;&#46; We discarded those recommendations with a score lower than 3&#46;5 points for not reaching a sufficiently high degree of agreement&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Using the consensus conference technique&#44; we conducted online meetings to outline and agree on the recommendations based on the previous information&#46; For each of the proposals agreed upon in this manner&#44; we obtained an operational description of the recommendation and the presentation of the level of evidence that justified the proposal &#40;for patient proposals&#44; this was based on the documentation on patient education and on the clinical experience&#41;&#46; The participants could also propose changes and clarifications to the initially drafted proposal&#46; In this phase&#44; the participants had information on the degree of consensus achieved for each recommendation during the previous phase &#40;mean&#44; spontaneity and coefficient of variation&#41;&#46; Each of the recommendations was assessed by the participants using a continuous scale from 0 to 10 points&#46; A minimum score of 0 points represented a practice that had insufficient evidence to not recommend it or&#44; in the case of patients&#44; a belief or behavior for which there was insufficient consensus to not recommend it&#46; A maximum score of 10 indicated a practice that should not be recommended based on the evidence or&#44; in the case of patients&#44; a belief or behavior not recommended by clinical experience&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A fact sheet was prepared for each recommendation &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; which included the following&#58; definition of the recommendation of &#8220;do not do&#8221;&#59; operational definition of the practice&#44; indication or behavior included in the description of the &#8220;do not do&#8221;&#59; justification or clarifications&#59; and&#44; lastly&#44; the references that support this recommendation&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Six healthcare practitioners with more than 10 years of experience in treating patients with AF participated in this study&#46; The specialists covered cardiology&#44; hematology&#44; neurology&#44; internal medicine&#44; family medicine and nursing&#44; with direct care for this patient profile&#46; The selection of participants aimed to include different experiences in clinical practice&#44; considering levels &#40;primary care and hospital&#41; and healthcare profiles &#40;physician specialists and nursing&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">Using the &#8220;Metaplan&#8221; method&#44; we obtained a total of 67 &#8220;do not do&#8221; proposals&#44; 59 of which were distinct&#46; In the subsequent open debate&#44; 18 were discarded for not reaching a sufficient degree of agreement or for being complementary&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In the following phase&#44; we analyzed and assessed 24 &#8220;do not do&#8221; recommendations for diagnosis and treatment in both healthcare levels and 17 patient-centered &#8220;do not do&#8221; recommendations&#46; In the 2 successive rounds of group work&#44; this list was reduced to 19 &#8220;do not do&#8221; recommendations for diagnosis and treatment &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; and to 13 &#8220;do not do&#8221; recommendations for patients to ensure effective self-care &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Among the first set of recommendations&#44; we identified &#8220;do not do&#8221; recommendations regarding the diagnosis &#40;e&#46;g&#46;&#44; do not repeat the capillary or venous INR on the same day&#44; except for analytical or preanalytical errors&#41;&#44; the treatment &#40;e&#46;g&#46;&#44; do not routinely indicate acetylsalicylic acid to prevent stroke&#41; and the care &#40;e&#46;g&#46;&#44; do not systematically perform echocardiograms or Holter ECG for all patients&#41;&#46; Most of the patient-directed recommendations &#40;Appendix A&#59; See the supplementary material&#41; were related to the correct use of drugs &#40;e&#46;g&#46;&#44; do not compensate a missed dose by doubling the physician-indicated dose the following day&#41;&#46; However&#44; physician-related &#8220;do not do&#8221; recommendations were included &#40;e&#46;g&#46;&#44; do not assume that the physician has all the information&#44; such as dietary changes&#44; maternity&#44; etc&#46;&#44; and do not forget the list of drugs being taken at home when going to the doctor&#39;s office&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">This study came to a consensus on 19 diagnostic and therapeutic indications whose risks outweigh the benefits&#46; We also detected 13 self-care practices &#40;beliefs and behaviors&#41; by patients that unwillingly expose them to risks&#44; due to the practices&#8217; lack of usefulness or even their ability to be harmful&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">This type of study&#44; which presents a description of interventions and behaviors that are advisable not to keep performing&#44; represents a complementary approach to the analysis of overuse&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">2</span></a> In this case&#44; recommendations were prepared that can define specific contents for the healthcare education of these patients&#46; This approach is complementary to those of other studies that recommend the implementation of appropriate practices using clinical guidelines&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The clinical guidelines provide direction on actions for appropriate diagnoses&#44; treatments and follow-ups&#44; depending on the level of knowledge at each moment&#46; Their level of implementation among the various practitioners involved in the care of patients with AF is increasing&#44; with positive results in primary care&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">13</span></a> Despite the growing implementation of the clinical guidelines&#44; the inappropriate overuse of certain practices&#44; which entail risks for the patients and cost overruns&#44; continues to occur in clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">14</span></a> It seems appropriate therefore to include algorithms in the clinical decision-making support systems that consider this type of &#8220;do not do&#8221; recommendations&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The &#8220;do not do&#8221; recommendations will hopefully contribute to reducing overuse resulting from gaps in our understanding&#44; defensive medicine&#44; pressure from patients and due to other reasons&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">5&#8211;8</span></a> It is also hoped that the recommendations will change the harmful beliefs and behaviors of patients&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In the case of patients&#44; the habits&#44; beliefs and behaviors learned during other disease processes reside with the appropriate self-care behaviors when an OAT is followed&#46; The inadvisable practices &#40;&#8220;do not do&#8221;&#41; identified in this study have a direct relationship with erroneous beliefs adopted by patients&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The dissemination and implementation of these recommendations requires that health professionals and patients accept them as reasonable and appropriate&#46; Changes in behavior are known to be difficult to achieve&#46; Even when the recommendations are considered effective and efficient&#44; they are not easily implemented&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">15</span></a> Acting according to custom is not uncommon&#44; either among clinicians or patients&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">16</span></a> The challenge facing healthcare organizations is how to effectively transfer these &#8220;do not do&#8221; recommendations to clinical practice and how to assess their impact&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">This study has a number of limitations&#46; The study was contextualized to the reality of healthcare practice in Spain&#46; The results could therefore be different in other countries&#46; We did not analyze the rate of each activity that was recommended against in the clinical practice or in the patients&#8217; behavior&#46; Nevertheless&#44; the study&#39;s approach focused on clinical practices and self-care behavior that stood out for persisting over time&#46; Given that we only included those clinical practices with 2&#43; scientific evidence support &#40;recommendation strength <span class="elsevierStyleSmallCaps">C</span>&#44; on a scale of A to D proposed by the Scottish Intercollegiate Guidelines Network&#41;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">17</span></a> or greater&#44; it is possible that there are other practices that could be considered as inappropriate overuse that were not included&#46; We did not conduct a quantitative study on the degree of agreement of these &#8220;do not do&#8221; recommendations among the groups of professionals or patient representatives&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The work in a multidisciplinary team has helped identify diagnostic&#44; therapeutic and care indications that&#44; despite the evidence against them&#44; persist in the care of patients with AF&#46; It has also helped identify patient beliefs and behaviors that negatively affect the outcome of their care&#44; either because the beliefs and behaviors limit the effect of the care or because they are directly harmful&#46; Healthcare quality improves not only when things are done right but also when we stop doings things that do not contribute to the expected result or are harmful to the patients and practitioners&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall">The study was sponsored by the Madrid Association for Quality Care and funded by an unconditional grant from Boehringer Ingelheim Laboratories&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2016-09-20"
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            0 => "Fibrilaci&#243;n auricular"
            1 => "Sobreutilizaci&#243;n innecesaria"
            2 => "Calidad asistencial"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To identify overuse &#40;diagnostic&#44; therapeutic and self-care practices that represent risks that outweigh the potential benefits&#41; in patients with atrial fibrillation&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The study was based on qualitative research techniques&#46; Using the &#8220;Metaplan&#8221; technique&#44; we identified and ordered potentially inappropriate&#44; ineffective and inefficient practices&#46; By means of a consensus conference&#44; we then established a number of &#8220;inadvisable practice&#8221; measures &#40;relatively common practices that should be eliminated based on the scientific evidence or clinical experience&#41;&#46; Professionals from the specialties of cardiology&#44; hematology&#44; neurology&#44; internal medicine&#44; family medicine and nursing participated in the consensus&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We developed a catalog of 19 &#8220;inadvisable practices&#8221; related to the diagnosis&#44; treatment and care of anticoagulated patients that were inappropriate&#44; had questionable effectiveness or were ineffective&#44; as well as 13 beliefs or behaviors for anticoagulated patients that could result in injury or were useless or inefficient&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The &#8220;inadvisable practices&#8221; approach helps identify practices that represent greater risks than benefits for patients&#46; It seems appropriate to include algorithms in the clinical decision-making support systems that consider this information for the diagnosis&#44; treatment and for home care&#46; For this last case&#44; recommendations have also been prepared that define specific contents for the healthcare education of these patients&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
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            "titulo" => "Method"
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          2 => array:2 [
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Identificar la sobreutilizaci&#243;n inadecuada &#40;pr&#225;cticas diagn&#243;sticas&#44; terap&#233;uticas o de autocuidados que suponen riesgos mayores que los beneficios potenciales&#41; en pacientes con fibrilaci&#243;n auricular&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio basado en t&#233;cnicas de investigaci&#243;n cualitativa&#46; Mediante la t&#233;cnica &#171;Metaplan&#187; se identificaron y ordenaron posibles pr&#225;cticas inadecuadas&#44; inefectivas o ineficientes&#46; Despu&#233;s&#44; mediante una conferencia de consenso se establecieron una serie de medidas de &#171;no hacer&#187; &#40;pr&#225;cticas relativamente frecuentes&#44; que se aconseja erradicar en funci&#243;n de la evidencia cient&#237;fica o la experiencia cl&#237;nica&#41;&#46; Participaron profesionales de las especialidades de Cardiolog&#237;a&#44; Hematolog&#237;a&#44; Neurolog&#237;a&#44; Medicina Interna&#44; Medicina de Familia y Enfermer&#237;a&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se ha elaborado un cat&#225;logo de 19 pr&#225;cticas de &#171;no hacer&#187; relacionadas con el diagn&#243;stico&#44; el tratamiento o los cuidados del paciente anticoagulado&#44; que resultan inadecuadas&#44; de dudosa efectividad o inefectivas&#44; y 13 creencias o conductas del paciente anticoagulado que pueden ocasionarle da&#241;o&#44; son in&#250;tiles o ineficientes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El enfoque &#171;no hacer&#187; contribuye a identificar pr&#225;cticas que suponen m&#225;s riesgos que beneficios para los pacientes&#46; Parece sensato incluir algoritmos en los sistemas de apoyo a la toma de decisiones cl&#237;nicas que tengan en cuenta esta informaci&#243;n para el diagn&#243;stico&#44; el tratamiento o los cuidados en el hogar&#46; En este &#250;ltimo caso&#44; adem&#225;s&#44; se formulan recomendaciones que pueden definir contenidos concretos sobre los que incidir en la educaci&#243;n sanitaria de estos pacientes&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Ortiz MM&#44; Llamas P&#44; Sanmart&#237;n M&#44; Egido JA&#44; del Toro J&#44; Egocheaga MI&#44; et al&#46; Sobreutilizaci&#243;n innecesaria&#46; Estudio de los &#171;no hacer&#187; en pacientes con fibrilaci&#243;n auricular&#46; Rev Clin Esp&#46; 2017&#59;217&#58;181&#8211;187&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; AF&#44; atrial fibrillation&#59; ASA&#44; acetylsalicylic acid&#59; CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc&#44; thrombotic risk scale&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Definition&#58; Do not routinely indicate treatment with ASA in AF to prevent stroke&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Description&#58; Do not prescribe ASA without a specific indication for anticoagulated patients&#46; There is an overvaluation of the hemorrhagic risk due to falls&#46; The CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc scale should be employed&#44; and ASA &#40;rather than anticoagulants&#41; should only be employed when the score is 1&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rationale&#47;clarification&#58; The combination of antiplatelets and the combination of antiplatelets and anticoagulant therapy increases the risk of hemorrhage&#46; In general&#44; the thromboembolic risk in elderly patients is much greater than the risk of severe hemorrhage&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Fact sheet for the recommendation of &#8220;Do Not Do&#8221; practices in anticoagulated patients with atrial fibrillation&#46;</p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Spontaneity&#58; The number of times that the same recommendation arises independently among the participants&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Degree of agreement&#58; Determined through the score for the coefficient of variation obtained by prioritizing each recommendation&#46; The lower the value of the coefficient of variation the greater the homogeneity in the assessments and therefore the greater the degree of agreement&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Intensity of the recommendation&#58; Mean score on a scale of 1&#8211;5&#44; where 5 indicates that the practice should clearly not be recommended&#46; The greater the mean score&#44; the higher or more intense the recommendation&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; AF&#44; atrial fibrillation&#59; AHT&#44; arterial hypertension&#59; CHA<span class="elsevierStyleInf">2</span>DS2-VASc&#44; thrombotic risk scale&#59; DA&#44; degree of agreement&#59; ECG&#44; electrocardiogram&#59; GHAS-BLED&#58; hemorrhagic risk scale&#59; INR&#44; international normalized ratio&#59; INT&#44; intensity of the recommendation&#59; SP&#44; spontaneity&#59; OAT&#44; oral anticoagulant therapy&#59; VKA&#44; vitamin K antagonists&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Indications included in the &#8220;do not do&#8221; recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Prioritization &#8220;Metaplan&#8221; technique</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Prioritization consensus conference</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">INT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">INT<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Diagnosis</td><td class="td" title="table-entry  " align="left" valign="top">Do not base the diagnosis of AF on only the physical examination&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">10&#44;18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not perform cardioversion &#40;electrical or pharmaceutical&#41; on nonanticoagulated patients with a presentation longer than 48<span class="elsevierStyleHsp" style=""></span>h &#40;without having performed a transesophageal echocardiogram&#41;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not refer all patients diagnosed with AF to the emergency department or urgently&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not repeat the capillary or venous INR reading on the same day &#40;except in the event of an analytical or preanalytical error&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not trust the precision of portable coagulometers after an INR &#62;4&#46;5&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">10&#44;18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="9" align="left" valign="top">Treatment</td><td class="td" title="table-entry  " align="left" valign="top">Do not routinely indicate treatment with acetylsalicylic acid in AF to prevent stroke&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">20&#44;21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not trust in the correctness of the patient information and treatments recorded in a single electronic history&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">22&#8211;26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not withdraw anticoagulant therapy for minor surgery &#40;e&#46;g&#46;&#44; prior to conventional tooth extraction&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not extend the suspension of treatment with the standard anticoagulant before surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">28&#8211;31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Once OAT has been started&#44; do not maintain antiplatelet therapy without a clear indication&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">10&#44;18&#44;32&#8211;34</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not trust in the clinical judgment&#44; and do not stop applying thrombotic and hemorrhagic risk scales at the start and during the follow-up of OAT &#40;CHA<span class="elsevierStyleInf">2</span>DS2-VASc and HAS-BLED&#41;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">35&#44;36</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not stop systematic anticoagulation for elderly patients due to the risk of falls&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not indicate an anticoagulant without having performed a prior analytical study&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not start anticoagulation in cases of AHT until the hypertension has been properly controlled &#40;systolic blood pressure &#60;160<span class="elsevierStyleHsp" style=""></span>mm Hg&#41;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">18&#44;37&#8211;40</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Care</td><td class="td" title="table-entry  " align="left" valign="top">Do not use inappropriate automatic equipment for periodic blood pressure checks at the start and during follow-up of OAT&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">19&#44;41&#8211;46</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not routinely perform echocardiograms and Holter ECGs on all patients&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not spread out the INR checks by more than 1-week in the event of values significantly above or below the therapeutic range&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not routinely indicate dietary restrictions &#40;e&#46;g&#46;&#44; withdrawing food rich in vitamin K from patients undergoing treatment with AVK&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">27&#44;47&#44;48</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not trust that the patient is properly following the therapeutic regimen&#44; and do not fail to check the level of therapeutic compliance&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">49&#44;50</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Intensity of the recommendation&#58; Mean score on a scale of 0&#8211;10&#44; where 10 indicates a practice that should clearly not be recommended based on the evidence&#46; The greater the mean score&#44; the greater the priority or intensity of the recommendation&#46;</p>"
            ]
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Inappropriate Overuse in the Diagnosis&#44; Treatment or During the Care of Patients with Atrial Fibrillation Undergoing Anticoagulant Therapy&#46;</p>"
        ]
      ]
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        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Spontaneity&#58; The number of times that the same recommendation arises independently among the participants&#46;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Degree of agreement&#58; Determined through the score for the coefficient of variation obtained by prioritizing each recommendation&#46; The lower the value of the coefficient of variation the greater the homogeneity in the assessments and therefore the greater the degree of agreement&#46;</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Intensity of the recommendation&#58; Mean score on a scale of 1&#8211;5&#44; where 5 indicates that the practice should clearly not be recommended&#46; The greater the mean score&#44; the higher or more intense the recommendation&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; ASA&#44; acetylsalicylic acid&#59; NSAIDs&#44; anti-inflammatory nonsteroidal drugs&#59; SP&#44; spontaneity&#59; DA&#44; degree of agreement&#59; INT&#44; intensity of the recommendation&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Behaviors included in the &#8220;Do not do&#8221; recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Prioritization metaplan technique</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Prioritization consensus conference</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">INT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">INT<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not self-medicate &#40;with drugs&#44; natural medicine&#44; NSAIDS&#44; ASA&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not compensate for missed doses&#46; Do not modify the prescribed dosage&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not assume that the healthcare practitioner knows the patient&#39;s personal or clinical condition &#40;e&#46;g&#46;&#44; maternity&#44; start of a weight-loss diet without medical advice&#44; travel&#44; seasonal changes&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not take oral anticoagulants at irregular times&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not leave unsupervised the taking of medication at home by elderly patients or those with cognitive difficulties&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not tamper with the medication at home&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not postpone the checks and supply of anticoagulant drugs when traveling &#40;both to Spain and abroad&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not follow the advice of other anticoagulated patients because they could have different profiles and therapeutic needs&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not forget to bring the list of drugs being taken at home when going to the doctor&#39;s office for a consultation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not attend a consultation without a companion if you have cognitive deficits&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not stop taking the drug to respect fasting when visiting a healthcare center for laboratory tests&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not engage in high-risk sports&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not change the anticoagulation regimen to perform interventionist procedures whose follow-up we cannot perform &#40;e&#46;g&#46;&#44; major surgery and invasive diagnostic procedures in other healthcare centers&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Intensity of the recommendation&#58; Mean score on a scale of 0&#8211;10&#44; where 10 indicates a practice that should clearly not be recommended based on the evidence&#46; The greater the mean score&#44; the higher or more intense the recommendation&#46;</p>"
            ]
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2017.02.003

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