Survey of confidence in use of stroke and bleeding risk calculators, knowledge of anticoagulants, and comfort with prescription of anticoagulation in challenging scenarios: SUPPORT-AF II study

Implementing pharmacist-prescriber collaboration to improve evidence-based anticoagulant use: a randomized trial

BACKGROUND

Direct oral anticoagulant medications are commonly used to treat or prevent thrombotic conditions, such as pulmonary embolism, deep vein thrombosis, and atrial fibrillation. However, up to 10-15% of patients receiving these medications get unsafe doses based on a patient's kidney or liver function, potential interactions with other medications, and indication for taking the medication. Alert systems may be beneficial for improving evidence-based prescribing, but can be burdensome and are not currently able to provide monitoring after the initial prescription is written.

METHODS/DESIGN

This study will improve upon existing alert systems by testing novel medication alerts that encourage collaboration between prescribers (e.g., physicians, nurse practitioners, physician assistants) and expert pharmacists working in anticoagulation clinics. The study will also improve upon the existing alert system by incorporating dynamic long-term monitoring of patient needs and encouraging collaboration between prescribers and expert pharmacists working in anticoagulation clinics. Incorporating state-of-the-art user-centered design principles, prescribing healthcare providers will be randomized to different types of electronic health record medication alerts when a patient has an unsafe anticoagulant prescription. We will identify which alerts are most effective at encouraging evidence-based prescribing and will test moderators to tailor alert delivery to when it is most beneficial. The aims of the project are to (1) determine the effect of notifications targeting existing inappropriate DOAC prescriptions; (2) examine the effect of alerts on newly prescribed inappropriate DOACs; and (3) examine changes in the magnitude of effects over time for both the new prescription alerts and existing prescription notifications for inappropriate DOACs over the 18-month study period.

DISCUSSION

Findings from this project will establish a framework for implementing prescriber-pharmacist collaboration for high-risk medications, including anticoagulants. If effectively implemented at the more than 3000 anticoagulation clinics that exist nationally, hundreds of thousands of patients taking direct oral anticoagulants stand to benefit from safer, evidence-based healthcare.

TRIALS REGISTRATION

NCT05351749.

Prescribing of anticoagulation for atrial fibrillation in primary care

Atrial fibrillation (AF) is common in primary care patients. Many patients who could benefit from anticoagulation do not receive it. The objective of this study was to describe anticoagulation prescribing by primary care physicians. We conducted an observational study in the Cleveland Clinic Health System among patients with AF and ≥ 1 primary care appointment between 2015 and 2018 and their physicians. We estimated differences in the odds of an eligible patient receiving anticoagulation versus not and a DOAC versus warfarin using two mixed effects logistic regression models, adjusted for patient sociodemographic factors, history of falls or dementia, and CHA2DS2-VASc and HAS-BLED scores. We categorized physicians into prescribing tertiles, based on their adjusted prescribing rate, which we included as predictors in the models. Among 5253 patients, 47% received anticoagulation. Of those, 56% received a DOAC. CHA2DS2-VASc and HAS-BLED scores were not associated with anticoagulation prescription. Black race was negatively associated with receiving anticoagulation overall (aOR:0.71; 95%CI:0.56-0.89) and with prescription for a DOAC (aOR:0.65; 95%CI:0.45-0.93). Among 195 physicians, the anticoagulation prescribing rate ranged from 27% to 57% and DOAC rates ranged from 34% to 69%. Physician prescribing tertile was associated with odds of a patient receiving anticoagulation overall (aOR:1.51; 95%CI: 1.13-2.01 for the highest versus lowest tertile), but not DOAC prescriptions. When prescribing anticoagulation, physicians appear not to consider risk of stroke or bleeding but patient race is an important determinant. Seeing a physician with a high anticoagulation prescribing rate was strongly associated with a patient receiving it, suggesting a lack of individualization.

GPs' familiarity with and use of cardiovascular clinical prediction rules: a UK survey study

BACKGROUND

Clinical prediction rules (CPRs) can help general practitioners (GPs) address challenges in cardiovascular disease. A survey published in 2014 evaluated GPs' awareness and use of CPRs in the UK. However, many new CPRs have been published since and it is unknown which cardiovascular CPRs are currently recognised and used.

AIM

To identify cardiovascular CPRs recognised and used by GPs, and to assess how GPs' familiarity and use have changed over time.

DESIGN & SETTING

An online survey of GPs in the UK was undertaken.

METHOD

Using comparable methods to the 2014 survey, GPs were recruited from a network of doctors in the UK. They were asked how familiar they were with cardiovascular CPRs, how frequently they used them, and why they used them. The results were compared with the 2014 survey.

RESULTS

Most of 401 GPs were familiar with QRISK scores, ABCD scores, CHADS scores, HAS-BLED score, Wells scores for deep vein thrombosis, and Wells scores for pulmonary embolism. The proportions of GPs using these CPRs were 96.3%, 65.1%, 97.3%, 93.0%, 92.5%, and 82.0%, respectively. GPs' use increased by 31.2% for QRISK scores, by 13.5% for ABCD scores, by 54.6% for CHADS scores, by 33.2% for Wells scores for deep vein thrombosis, and by 43.6% for Wells scores for pulmonary embolism; and decreased by 45.9% for the Joint British Societies (JBS) risk calculator, by 38.7% for Framingham risk scores, and by 8.7% for New Zealand tables. GPs most commonly used cardiovascular CPRs to guide therapy and referral.

CONCLUSION

The study found GPs' familiarity and use of cardiovascular CPRs changed substantially. Integrating CPRs into guidelines and practice software might increase familiarity and use.

SUPPORT-AF II: Supporting Use of Anticoagulants Through Provider Profiling of Oral Anticoagulant Therapy for Atrial Fibrillation

Background:

Previous provider-directed electronic messaging interventions have not by themselves improved anticoagulation use in patients with atrial fibrillation. Direct engagement with providers using academic detailing coupled with electronic messaging may overcome the limitations of the prior interventions.

Methods and Results:

We randomized outpatient providers affiliated with our health system in a 2.5:1 ratio to our electronic profiling/messaging combined with academic detailing intervention. In the intervention, we emailed providers monthly reports of their anticoagulation percentage relative to peers for atrial fibrillation patients with elevated stroke risk (CHA 2 DS 2 -VASc ≥2). We also sent electronic medical record-based messages shortly before an appointment with an anticoagulation-eligible but untreated atrial fibrillation patient. Providers had the option to send responses with explanations for prescribing decisions. We also offered to meet with intervention providers using an academic detailing approach developed based on knowledge gaps discussed in provider focus groups. To assess feasibility, we tracked provider review of our messages. To assess effectiveness, we measured the change in anticoagulation for patients of intervention providers relative to controls. We identified 85 intervention and 34 control providers taking care of 3591 and 1908 patients, respectively; 33 intervention providers participated in academic detailing. More than 80% of intervention providers read our emails, and 98% of the time a provider reviewed our in-basket messages. Replies to messages identified patient refusal as the most common reason for patients not being on anticoagulation (11.2%). For the group of patients not on anticoagulation at baseline assigned to an intervention versus control provider, the adjusted percent increase in the use of anticoagulation over 6 months was 5.2% versus 7.4%, respectively ( P =0.21).

Conclusions:

Our electronic messaging and academic detailing intervention was feasible but did not increase anticoagulation use. Patient-directed interventions or provider interventions targeting patients declining anticoagulation may be necessary to raise the rate of anticoagulation.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov . Unique identifier: NCT03583008.