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Torres Roldan VD, Brand-McCarthy SR, Ponce OJ, Belluzzo T, Urtecho M, Espinoza Suarez NR, Toloza FJK, Thota AD, Organick PW, Barrera F, Liu-Sanchez C, Jaladi S, Prokop L, Ozanne EM, Fagerlin A, Hargraves IG, Noseworthy PA, Montori VM, Brito JP. Shared Decision Making Tools for People Facing Stroke Prevention Strategies in Atrial Fibrillation: A Systematic Review and Environmental Scan. Med Decis Making 2021; 41:540-549. [PMID: 33896270 PMCID: PMC8191170 DOI: 10.1177/0272989x211005655] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Shared decision making (SDM) tools can help implement guideline recommendations for patients with atrial fibrillation (AF) considering stroke prevention strategies. We sought to characterize all available SDM tools for this purpose and examine their quality and clinical impact. METHODS We searched through multiple bibliographic databases, social media, and an SDM tool repository from inception to May 2020 and contacted authors of identified SDM tools. Eligible tools had to offer information about warfarin and ≥1 direct oral anticoagulant. We extracted tool characteristics, assessed their adherence to the International Patient Decision Aids Standards, and obtained information about their efficacy in promoting SDM. RESULTS We found 14 SDM tools. Most tools provided up-to-date information about the options, but very few included practical considerations (e.g., out-of-pocket cost). Five of these SDM tools, all used by patients prior to the encounter, were tested in trials at high risk of bias and were found to produce small improvements in patient knowledge and reductions in decisional conflict. CONCLUSION Several SDM tools for stroke prevention in AF are available, but whether they promote high-quality SDM is yet to be known. The implementation of guidelines for SDM in this context requires user-centered development and evaluation of SDM tools that can effectively promote high-quality SDM and improve stroke prevention in patients with AF.
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Affiliation(s)
- Victor D Torres Roldan
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah R Brand-McCarthy
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Oscar J Ponce
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tereza Belluzzo
- General Medicine, Charles University in Prague, Medical Faculty of Hradec Králové, Hradec Kralove, Czech Republic
| | - Meritxell Urtecho
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Freddy J K Toloza
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anjali D Thota
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paige W Organick
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francisco Barrera
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), School of Medicine, Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | | | - Soumya Jaladi
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Larry Prokop
- Department of Library-Public Services, Mayo Clinic, Rochester MN, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA.,Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation
| | - Ian G Hargraves
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Peter A Noseworthy
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Humphries B, León-García M, Bates S, Guyatt G, Eckman M, D'Souza R, Shehata N, Jack S, Alonso-Coello P, Xie F. Decision Analysis in SHared decision making for Thromboprophylaxis during Pregnancy (DASH-TOP): a sequential explanatory mixed methods pilot study protocol. BMJ Open 2021; 11:e046021. [PMID: 33753445 PMCID: PMC7986891 DOI: 10.1136/bmjopen-2020-046021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Decision analysis is a quantitative approach to decision making that could bridge the gap between decisions based solely on evidence and the unique values and preferences of individual patients, a feature especially important when existing evidence cannot support clear recommendations and there is a close balance between harms and benefits for the treatments options under consideration. Low molecular weight heparin (LMWH) for the prevention of venous thromboembolism (VTE) during pregnancy represents one such situation. The objective of this paper is to describe the rationale and methodology of a pilot study that will explore the application of decision analysis to a shared decision-making process involving prophylactic LMWH for pregnant women or those considering pregnancy who have experienced a VTE. METHODS AND ANALYSIS We will conduct an international, mixed methods, explanatory, sequential study, including quantitative data collection and analysis followed by qualitative data collection and analysis. In step I, we will ask women who are pregnant or considering pregnancy and have experienced VTE to participate in a shared decision-making intervention for prophylactic LMWH. The intervention consists of three components: a direct choice exercise, a values elicitation exercise and a personalised decision analysis. After administration of the intervention, we will ask women to make a treatment decision and measure decisional conflict, self-efficacy and satisfaction. In step II, which follows the analysis of quantitative data, we will use the results to inform the qualitative interview. Step III will be a qualitative descriptive study that explores participants' experiences and perceptions of the intervention. In step IV, we will integrate findings from the qualitative and quantitative analyses to obtain meta-inferences. ETHICS AND DISSEMINATION Site-specific ethics boards have approved the study. All participants will provide informed consent. The research team will take an integrated approach to knowledge translation.
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Affiliation(s)
- Brittany Humphries
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Montserrat León-García
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Catalunya, Spain
| | - Shannon Bates
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mark Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rohan D'Souza
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Nadine Shehata
- Departments of Medicine, Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, University of Toronto, Division of Hematology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Susan Jack
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
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Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF): A cluster randomized trial of a computerized clinical decision support tool. Am Heart J 2020; 224:35-46. [PMID: 32302788 DOI: 10.1016/j.ahj.2020.02.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/09/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Clinical decision support (CDS) tools designed to digest, filter, organize, and present health data are becoming essential in providing clinical and cost-effective care. Many are not rigorously evaluated for benefit before implementation. We assessed whether computerized CDS for primary care providers would improve atrial fibrillation (AF) management and outcomes as compared to usual care. METHODS Overall, 203 primary care providers were recruited, randomized, and then cluster stratified by location (urban, rural) to usual care (n = 99) or CDS (n = 104). Providers recruited 1,145 adult patients with AF to participate. The intervention was access to an evidenced-based, point-of-care computerized CDS designed to support guideline-based AF management. The primary efficacy outcome was a composite of unplanned cardiovascular hospitalizations and AF-related emergency department visits; the primary safety outcome was major bleeding, both over 1 year. Patients were the units of intention-to-treat analysis. RESULTS No significant effects on the primary efficacy (130 control, 118 CDS, hazard ratio: 0.98 [95% CI 0.71-1.37], P = .926) or safety (n = 7 usual care, n = 8 CDS, 1.3% total, P = .939) outcomes were observed at 12-months. CONCLUSIONS IMPACT-AF rigorously assessed a CDS tool in a highly representative sample of primary care providers and their patients; however, no impact on outcomes was observed. Considering the proliferating use of CDS applications, this study highlights the need for efficacy assessments prior to adoption and clinical implementation.
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Sheibani R, Nabovati E, Sheibani M, Abu-Hanna A, Heidari-Bakavoli A, Eslami S. Effects of Computerized Decision Support Systems on Management of Atrial Fibrillation: A Scoping Review. J Atr Fibrillation 2017; 10:1579. [PMID: 29250222 DOI: 10.4022/jafib.1579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 06/05/2017] [Accepted: 06/22/2017] [Indexed: 12/12/2022]
Abstract
Background Potential role of computerized decision support system on management of atrial fibrillation is not well understood. Objectives To systematically review studies that evaluate the effects of computerized decision support systems and decision aids on aspects pertaining to atrial fibrillation. Data Sources We searched Medline, Scopus and Cochrane database. Last date of search was 2016, January 10. Selection criteria Computerized decision support systems that help manage atrial fibrillation and decision aids that provide useful knowledge for patients with atrial fibrillation and help them to self-care. Data collection and analysis Two reviewers extracted data and summarized findings. Due to heterogeneity, meta-analysis was not feasible; mean differences of outcomes and confidence intervals for a difference between two Means were reported. Results Seven eligible studies were included in the final review. There was one observational study without controls, three observational studies with controls, one Non-Randomized Controlled Trial and two Randomized Controlled Trials. The interventions were three decision aids that were used by patients and four computerized decision support systems. Main outcomes of studies were: stroke events and major bleeding (one article), Changing doctor-nurse behavior (three articles), Time in therapeutic International Normalized Ratio range (one article), decision conflict scale (two articles), patient knowledge and anxiety about stroke and bleeding (two articles). Conclusions A computerized decision support system may decrease decision conflict and increase knowledge of patients with atrial fibrillation (AF) about risks of AF and AF treatments. Effect of computerized decision support system on outcomes such as changing doctor-nurse behavior, anxiety about stroke and bleeding and stroke events could not be shown.We need more studies to evaluate the role of computerized decision support system in patients with atrial fibrillation.
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Affiliation(s)
- Reza Sheibani
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ehsan Nabovati
- Health Information Management Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Mehdi Sheibani
- Clinical Research Development Center of Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Saeid Eslami
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Ogilvie IM, Cowell W, Lip GYH, Welner SA. Ischaemic stroke and bleeding rates in ‘real-world’ atrial fibrillation patients. Thromb Haemost 2017; 106:34-44. [PMID: 21614409 DOI: 10.1160/th10-10-0674] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 04/22/2011] [Indexed: 11/05/2022]
Abstract
SummaryStroke prevention guidelines recommend oral anticoagulants (OAC) for atrial fibrillation (AF) patients at moderate/high risk of stroke, and antiplatelet or no therapy for those at low/moderate risk. Outcomes for AF patients receiving antiplatelet/no therapy in ‘real-life’ clinical practice were explored. This study compared clinical event rates (stroke/bleeding) for AF patients treated with OAC therapy, antiplatelets or no therapy in usual clinical practice to event rates in OAC-treated AF patients from optimally-monitored ‘real-life’ settings (anticoagulation clinics). We searched biomedical literature (1994–2010) using PubMed to identify ‘real-world’ studies of clinical event rates for AF patients receiving OAC therapy, antiplatelets, or no therapy; event rates were extracted for each treatment and setting. We identified 136 studies of thromboembolic events and 86 of bleeding events. Ischaemic stroke rates (30 studies) were higher for AF patients receiving no therapy (median: 4.45/100 person-years; range: 0.25–5.9) or antiplatelet-therapy (median: 4.45/100 person-years; range: 2.0–10) compared to OACtreated patients monitored in anticoagulation clinics (median: 1.72/100 person-years; range: 0.97–2.00), or from a non-specialized setting (median 1.66/100 person-years; range: 0–4.9). Major bleeding rates (32 studies) for patients receiving antiplatelet/no therapy were similar to OAC-treated patients from both clinical settings. As in randomised clinical trials, AF patients in ‘real-world’ clinical practice receiving antiplatelet/no therapy have higher rates of ischaemic stroke than OAC-treated patients. Antiplatelet/no therapy was associated with similar bleeding rates to OAC therapy. Increasing utilisation of anticoagulants in clinical practice could improve patient outcomes.
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Lee TM, Ivers NM, Bhatia S, Butt DA, Dorian P, Jaakkimainen L, Leblanc K, Legge D, Morra D, Valentinis A, Wing L, Young J, Tu K. Improving stroke prevention therapy for patients with atrial fibrillation in primary care: protocol for a pragmatic, cluster-randomized trial. Implement Sci 2016; 11:159. [PMID: 27912776 PMCID: PMC5135743 DOI: 10.1186/s13012-016-0523-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 11/18/2016] [Indexed: 11/10/2022] Open
Abstract
Background The prevalence of atrial fibrillation (AF) is growing as the population ages, and at least 15% of ischemic strokes are attributed to AF. However, many high-risk AF patients are not offered guideline-recommended stroke prevention therapy due to a variety of system, provider, and patient-level barriers. Methods We will conduct a pragmatic, cluster-randomized controlled trial randomizing primary care clinics to test a “toolkit” of quality improvement interventions in primary care. In keeping with the recommendations of the chronic care model to simultaneously activate patients and facilitate proactive care by providers, the toolkit includes provider-focused strategies (education, audit and feedback, electronic decision support, and reminders) plus patient-directed strategies (educational letters and reminders). The trial will include two feedback cycles at baseline and approximately 6 months and a final data collection at approximately 12 months. The study will be powered to show a difference of 10% in the primary outcome of proportion of patients receiving guideline-recommended stroke prevention therapy. Analysis will follow the intention-to-treat principle and will be blind to treatment allocation. Unit of analysis will be the patient; models will use generalized estimating equations to account for clustering at the clinical level. Discussion Stroke prevention therapy using anticoagulation in patients with AF is known to reduce strokes by two thirds or more in clinical trials, but most studies indicate under-use of this treatment in real-world practice. If the toolkit successfully improves care for patients with AF, stakeholders will be engaged to facilitate broader application to maximize the potential to improve patient outcomes. The intervention toolkit tested in this project could also provide a model to improve quality of care for other chronic cardiovascular conditions managed in primary care. Trial registration ClinicalTrials.gov (NCT01927445). Registered August 14, 2014 at https://clinicaltrials.gov/. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0523-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Theresa M Lee
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.
| | - Noah M Ivers
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.,Department of Family and Community Medicine, Women's College Hospital, 77 Grenville St, Toronto, ON, M5S 1B3, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Sacha Bhatia
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.,Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville St, Toronto, ON, M5S 1B2, Canada.,Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Debra A Butt
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Department of Family and Community Medicine, The Scarborough Hospital, 3030 Lawrence Avenue East, Suite 414, Scarborough, ON, M1P 2V5, Canada
| | - Paul Dorian
- Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division of Cardiology, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada
| | - Liisa Jaakkimainen
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Sunnybrook Academic Family Health Team, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Kori Leblanc
- Centre for Innovation in Complex Care, University Health Network, 200 Elizabeth Street Rm 13 N 1382, Toronto, ON, M5G 2C4, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON, M5S 3M2, Canada
| | - Dan Legge
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Dante Morra
- Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Centre for Innovation in Complex Care, University Health Network, 200 Elizabeth Street Rm 13 N 1382, Toronto, ON, M5G 2C4, Canada.,Institute for Better Health, Trillium Health Partners, 2200 Eglinton Avenue West, Mississauga, ON, L5M 2N1, Canada
| | - Alissia Valentinis
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Taddle Creek Family Health Team, 790 Bay St #522, Toronto, ON, M5G 1N8, Canada
| | - Laura Wing
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Jacqueline Young
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Karen Tu
- Institute for Clinical Evaluation Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Toronto Western Hospital Family Health Team, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
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Zeng-Treitler Q, Gibson B, Hill B, Butler J, Christensen C, Redd D, Shao Y, Bray B. The effect of simulated narratives that leverage EMR data on shared decision-making: a pilot study. BMC Res Notes 2016; 9:359. [PMID: 27448407 PMCID: PMC4957847 DOI: 10.1186/s13104-016-2152-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 07/04/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Shared decision-making can improve patient satisfaction and outcomes. To participate in shared decision-making, patients need information about the potential risks and benefits of treatment options. Our team has developed a novel prototype tool for shared decision-making called hearts like mine (HLM) that leverages EHR data to provide personalized information to patients regarding potential outcomes of different treatments. These potential outcomes are presented through an Icon array and/or simulated narratives for each "person" in the display. In this pilot project we sought to determine whether the inclusion of simulated narratives in the display affects individuals' decision-making. Thirty subjects participated in this block-randomized study in which they used a version of HLM with simulated narratives and a version without (or in the opposite order) to make a hypothetical therapeutic decision. After each decision, participants completed a questionnaire that measured decisional confidence. We used Chi square tests to compare decisions across conditions and Mann-Whitney U tests to examine the effects of narratives on decisional confidence. Finally, we calculated the mean of subjects' post-experiment rating of whether narratives were helpful in their decision-making. RESULTS In this study, there was no effect of simulated narratives on treatment decisions (decision 1: Chi squared = 0, p = 1.0; decision 2: Chi squared = 0.574, p = 0.44) or Decisional confidence (decision 1, w = 105.5, p = 0.78; decision 2, w = 86.5, p = 0.28). Post-experiment, participants reported that narratives helped them to make decisions (mean = 3.3/4). CONCLUSIONS We found that simulated narratives had no measurable effect on decisional confidence or decisions and most participants felt that the narratives were helpful to them in making therapeutic decisions. The use of simulated stories holds promise for promoting shared decision-making while minimizing their potential biasing effect.
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Affiliation(s)
- Qing Zeng-Treitler
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Bryan Gibson
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Brent Hill
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA. .,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA.
| | - Jorie Butler
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Carrie Christensen
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Douglas Redd
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Yijun Shao
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Bruce Bray
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way #140, Salt Lake City, UT, 84108, USA.,Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
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Eckman MH, Lip GY, Wise RE, Speer B, Sullivan M, Walker N, Kissela B, Flaherty ML, Kleindorfer D, Baker P, Ireton R, Hoskins D, Harnett BM, Aguilar C, Leonard AC, Arduser L, Steen D, Costea A, Kues J. Impact of an Atrial Fibrillation Decision Support Tool on thromboprophylaxis for atrial fibrillation. Am Heart J 2016; 176:17-27. [PMID: 27264216 DOI: 10.1016/j.ahj.2016.02.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 02/15/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Appropriate thromboprophylaxis for patients with atrial fibrillation (AF) remains a national challenge. METHODS We hypothesized that provision of decision support in the form of an Atrial Fibrillation Decision Support Tool (AFDST) would improve thromboprophylaxis for AF patients. We conducted a cluster randomized trial involving 15 primary care practices and 1,493 adults with nonvalvular AF in an integrated health care system between April 2014 and February 2015. Physicians in the intervention group received patient-level treatment recommendations made by the AFDST. Our primary outcome was the proportion of patients with antithrombotic therapy that was discordant from AFDST recommendation. RESULTS Treatment was discordant in 42% of 801 patients in the intervention group. Physicians reviewed reports for 240 patients. Among these patients, thromboprophylaxis was discordant in 63%, decreasing to 59% 1 year later (P = .02). In nonstratified analyses, changes in discordant care were not significantly different between the intervention group and control groups. In multivariate regression models, assignment to the intervention group resulted in a nonsignificant trend toward decreased discordance (P = .29), and being a patient of a resident physician (P = .02) and a higher HAS-BLED score predicted decreased discordance (P = .03), whereas female gender (P = .01) and a higher CHADSVASc score (P = .10) predicted increased discordance. CONCLUSIONS Among patients whose physicians reviewed recommendations of the decision support tool discordant therapy decreased significantly over 1 year. However, in nonstratified analyses, the intervention did not result in significant improvements in discordant antithrombotic therapy.
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O'Brien EC, Kim S, Thomas L, Fonarow GC, Kowey PR, Mahaffey KW, Gersh BJ, Piccini JP, Peterson ED. Clinical Characteristics, Oral Anticoagulation Patterns, and Outcomes of Medicaid Patients With Atrial Fibrillation: Insights From the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF I) Registry. J Am Heart Assoc 2016; 5:JAHA.115.002721. [PMID: 27146448 PMCID: PMC4889165 DOI: 10.1161/jaha.115.002721] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Whereas insurance status has been previously associated with care patterns, little is currently known about the association between Medicaid insurance and the clinical characteristics, treatment, or outcomes of patients with atrial fibrillation (AF). Methods and Results We used data from adults with AF enrolled in the Outcomes Registry for Better Informed Treatment of AF (ORBIT‐AF), a national outpatient registry conducted at 176 community, multispecialty sites. The primary outcome of interest was the proportion of patients prescribed any oral anticoagulation (OAC; warfarin or novel oral anticoagulants [NOAC]). Secondary outcomes of interest included the proportion of patients prescribed NOACs (dabigatran or rivaroxaban); time in therapeutic range (TTR) for warfarin users, all‐cause mortality, stroke/systemic embolism, and major bleed. Of 10 133 patients, N=470 (4.6%) had Medicaid insurance. Medicaid patients were similarly likely to receive OAC at baseline (72.8% vs 76.3%; unadjusted P=0.079), but less likely to receive NOAC at baseline or follow‐up (12.1% vs 16.3%; unadjusted P=0.019). After risk adjustment, Medicaid status was associated with lower use of OAC at baseline among patients with high stroke risk (odds ratio [OR]=0.68; 95% CI=0.49, 0.94), but was not associated with OAC use overall (OR=0.82; 95% CI=0.61, 1.09). Among warfarin users, median TTR was lower among Medicaid patients (60% vs 68%; P<0.0001; adjusted TTR difference, −2.9; 95% CI=−5.7, −0.2; P=0.04). Use of an NOAC over 2 years of follow‐up was not statistically different by insurance. Compared with non‐Medicaid patients, Medicaid patients had higher unadjusted rates of mortality, stroke/systemic embolism, and major bleeding; however, these differences were attenuated following adjustment for clinical characteristics. Conclusions In a contemporary AF cohort, use of OAC overall and use of NOACs were not significantly lower among Medicaid patients relative to others. However, among warfarin users, Medicaid patients spent less time in therapeutic range compared with those with other forms of insurance.
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Affiliation(s)
| | - Sunghee Kim
- Duke Clinical Research Institute, Durham, NC
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10
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Shewale AR, Johnson JT, Li C, Nelsen D, Martin BC. Net Clinical Benefits of Guidelines and Decision Tool Recommendations for Oral Anticoagulant Use among Patients with Atrial Fibrillation. J Stroke Cerebrovasc Dis 2015; 24:2845-53. [PMID: 26482369 DOI: 10.1016/j.jstrokecerebrovasdis.2015.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 08/16/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The 2012 American College of Chest Physicians' Evidence-Based Clinical Practice (CHEST), the 2012 European Society of Cardiology, and the 2014 American Heart Association guidelines and published decision tools by LaHaye and Casciano offer oral anticoagulant (OAC) recommendations for patients with atrial fibrillation (AF). The aim of our study was to compare the net clinical benefit (NCB) of OAC prescribing that was concordant with these decision aids. METHODS A cohort study of the 2001-2013 LifeLink claims data was used. NCB in concordance with each decision aid was defined as adverse events (thromboembolic and major bleed events) prevented per 10,000 person-years. Cox proportional hazard models were used to assess the relative risk of AF adverse events associated in concordance with each decision aid adjusted for potential confounders. FINDINGS The study included 15,129 patients with AF, contributing 33,512 person-years. The NCB of the CHEST guidelines was the highest (NCB = 30.07; 95% confidence interval [CI] = 28.66, 31.49) and the European Society of Cardiology guidelines the lowest (NCB = 7.38; 95% CI = 5.97, 8.80). Significant unadjusted decreases in the risk of AF adverse events associated with concordant OAC use/nonuse were found for the CHEST guidelines (hazard ratio [HR] = .825; 95% CI = .695, .979), Casciano tool (HR = .838; 95% CI = .706, .995), and LaHaye tool (HR = .841; 95% CI = .709, .999); however, none were significant after multivariate adjustment. CONCLUSION Concordant OAC use with any of the decision aids except for the aggressive LaHaye tool led to a positive NCB. The decision aids based on the CHA2DS2-VASc algorithm did not consistently improve the NCB compared to CHADS2-based aids. Recommending OAC use when CHA2DS2-VASc score = 1 resulted in a lower NCB when all other factors guiding recommendations were held constant.
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Affiliation(s)
- Anand R Shewale
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Jill T Johnson
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Chenghui Li
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR
| | - David Nelsen
- Department of Family Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Bradley C Martin
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR.
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11
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Steinhubl SR, Topol EJ. Moving From Digitalization to Digitization in Cardiovascular Care: Why Is it Important, and What Could it Mean for Patients and Providers? J Am Coll Cardiol 2015; 66:1489-96. [PMID: 26403346 PMCID: PMC4583658 DOI: 10.1016/j.jacc.2015.08.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/05/2015] [Accepted: 08/03/2015] [Indexed: 11/28/2022]
Abstract
So far, the digitization of health care is best exemplified by electronic medical records, which have been far from favorably or uniformly accepted. However, properly implemented digitization can enable better patient outcomes, improve convenience, potentially lower healthcare costs, and possibly lead to much greater physician satisfaction. Precision (also known as personalized or individualized) medicine is frequently discussed today, but, in reality, it is what physicians have attempted to do as best they could for millennia. But now we have new tools that can begin to give us a much more high-definition view of our patients; from affordable and rapid genetic testing to wearable sensors that track a wide range of important physiologic parameters continuously. Although seemingly counterintuitive, the digitization of health care can also markedly improve the physician-patient relationship, allowing more time for human interaction when care is bolstered by digital technologies that better individualize diagnostics and treatments.
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Affiliation(s)
| | - Eric J Topol
- Scripps Translational Science Institute, La Jolla, California
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12
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Shewale A, Johnson J, Li C, Nelsen D, Martin B. Variation in Anticoagulant Recommendations by the Guidelines and Decision Tools among Patients with Atrial Fibrillation. Healthcare (Basel) 2015; 3:130-45. [PMID: 27417752 PMCID: PMC4934528 DOI: 10.3390/healthcare3010130] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 01/07/2015] [Accepted: 02/20/2015] [Indexed: 11/26/2022] Open
Abstract
Published atrial fibrillation (AF) guidelines and decision tools offer oral anticoagulant (OAC) recommendations; however, they consider stroke and bleeding risk differently. The aims of our study are: (i) to compare the variation in OAC recommendations by the 2012 American College of Chest Physicians guidelines, the 2012 European Society of Cardiology (ESC) guidelines, the 2014 American Heart Association (AHA) guidelines and two published decision tools by Casciano and LaHaye; (ii) to compare the concordance with actual OAC use in the overall study population and the population stratified by stroke/bleed risk. A cross-sectional study using the 2001–2013 Lifelink claims data was used to contrast the treatment recommendations by these decision aids. CHA2DS2-VASc and HAS-BLED algorithms were used to stratify 15,129 AF patients into nine stroke/bleed risk groups to study the variation in treatment recommendations and concordance with actual OAC use/non-use. The AHA guidelines which were set to recommend OAC when CHA2DS2-VASc = 1 recommended OAC most often (86.30%) and the LaHaye tool recommended OAC the least often (14.91%). OAC treatment recommendations varied considerably when stroke risk was moderate or high (CHA2DS2-VASc > 0). Actual OAC use/non-use was highly discordant (>40%) with all of the guidelines or decision tools reflecting substantial opportunities to improve AF OAC decisions.
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Affiliation(s)
- Anand Shewale
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Jill Johnson
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Chenghui Li
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - David Nelsen
- Department of Family Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Bradley Martin
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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13
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Hendriks JM, Crijns HJ, Vrijhoef HJ. Integrated Chronic Care Management For Patients With Atrial Fibrillation - A Rationale For Redesigning Atrial Fibrillation Care. J Atr Fibrillation 2015; 7:1177. [PMID: 27957148 DOI: 10.4022/jafib.1177] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/21/2015] [Accepted: 01/21/2015] [Indexed: 01/18/2023]
Abstract
Atrial Fibrillation (AF) is a highly prevalent heart rhythm disturbance, often associated with underlying (cardio)vascular disease. Due to this the management of AF is often complex and current practice calls for a more comprehensive, multifactorial and patient-centred approach. Therefore an Integrated Chronic Care approach in AF was developed and implemented in terms of a nurse-led specialized outpatient clinic for patients with AF. A randomised controlled trial comparing the nurse-led approach with usual care demonstrated superiority in terms of cardiovascular hospitalization and death as well as cost-effectiveness in terms of Quality Adjusted Life Years (QALYs) and life years, in favour of the nurse-led approach. Implementing such approach can be difficult since daily practice can be persistent. To highlight the importance of integrated care wherein the nurse fulfils a significant role, and to provide a guide in developing and continuing such approach, this paper presents the theoretical framework of the AF-Clinic based on the principles of the Taxonomy for Integrated Chronic Atrial Fibrillation Management.
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Affiliation(s)
- Jeroen Ml Hendriks
- Maastricht University Medical Centre, Maastricht, The Netherlands; Linköping University, Linköping, Sweden
| | - Harry Jgm Crijns
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hubertus Jm Vrijhoef
- Maastricht University Medical Centre, Maastricht, The Netherlands; Saw Swee Hock School of Public Health, National University of Singapore, Singapore; Scientific Center for Care and Welfare, Tilburg University, Tilburg, The Netherlands
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14
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Ghijben P, Lancsar E, Zavarsek S. Preferences for oral anticoagulants in atrial fibrillation: a best-best discrete choice experiment. PHARMACOECONOMICS 2014; 32:1115-27. [PMID: 25027944 DOI: 10.1007/s40273-014-0188-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is recognised as a growing clinical and public health problem in many countries, owing to disability and death from stroke associated with the condition, high hospitalisation costs and an increasing prevalence with ageing populations. Under-treatment with oral anticoagulants has been a significant challenge of treatment, historically related to patient concerns over the safety and convenience of warfarin, which until recently was the only oral anticoagulant available. OBJECTIVES The aim of this study is to examine: (1) patient preferences for attributes of warfarin and the new oral anticoagulants (dabigatran, rivaroxaban, apixaban) in AF; (2) which attributes are most important; and (3) whether current under-treatment is likely to improve with the new oral anticoagulants. METHODS This study was conducted in Melbourne, Australia, with members of the general public with or without AF aged ≥40 years, where those without AF proxy for newly-diagnosed patients. Participants completed a computerised best-best discrete choice experiment (and follow-up interview) as if they had AF with a moderate-to-high risk of stroke. Choice data were modelled using mixed rank-ordered logit. Relative value was explored via estimation of marginal rates of substitution with predicted probability analysis used to simulate potential uptake of oral anticoagulants. RESULTS Seventy-six participants were recruited and completed the study. Efficacy (stroke risk) was more important than safety (bleed risk, antidote), which were both considerably more important than convenience factors (blood tests, dose frequency, drug or food interactions). Cost was also important. Predicted use of the new oral anticoagulants (and under-treatment of AF) using simulation, given moderate-to-high risk of stroke, is 25 % (52 %), 54 % (29 %) and 70 % (21 %) assuming a market price of AUD$120/month, AUD$30/month (subsidised price) and AUD$30/month with an antidote, respectively. CONCLUSIONS Based on the study sample and the modelled attributes, the overall profiles of the new oral anticoagulants were preferred to warfarin as their cost decreased. Public subsidisation and the development of antidotes (such as vitamin K for warfarin) for the new oral anticoagulants may have a positive effect on the under-treatment of AF.
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Affiliation(s)
- Peter Ghijben
- Centre for Health Economics, Monash University, Clayton, VIC, 3800, Australia,
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15
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Eckman MH, Wise RE, Speer B, Sullivan M, Walker N, Lip GY, Kissela B, Flaherty ML, Kleindorfer D, Khan F, Kues J, Baker P, Ireton R, Hoskins D, Harnett BM, Aguilar C, Leonard A, Prakash R, Arduser L, Costea A. Integrating Real-Time Clinical Information to Provide Estimates of Net Clinical Benefit of Antithrombotic Therapy for Patients With Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2014; 7:680-6. [DOI: 10.1161/circoutcomes.114.001163] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background—
Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke risk as calculated by either the CHADS
2
or the CHA
2
DS
2
VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision making about antithrombotic therapy.
Methods and Results—
This study is a retrospective cohort study of 1876 adults with nonvalvular atrial fibrillation or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for quality-adjusted life expectancy reported as quality-adjusted life-years were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy between current treatment and treatment recommended by an Atrial Fibrillation Decision Support Tool. Current treatment was discordant from treatment recommended by the Atrial Fibrillation Decision Support Tool in 931 patients. A clinically significant gain in quality-adjusted life expectancy (defined as ≥0.1 quality-adjusted life-years) was projected in 832 patients. Subgroups were examined. For example, oral anticoagulant therapy was recommended for 188 who currently were receiving no antithrombotic therapy. For the entire cohort, a total of 736 quality-adjusted life-years could be gained were treatment changed to that recommended by the Atrial Fibrillation Decision Support Tool.
Conclusions—
Use of a decision support tool that integrates patient-specific stroke and bleeding risk could result in significant gains in quality-adjusted life expectancy for a primary care population of patients with atrial fibrillation.
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Affiliation(s)
- Mark H. Eckman
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Ruth E. Wise
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Barbara Speer
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Megan Sullivan
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Nita Walker
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Gregory Y.H. Lip
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Brett Kissela
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Matthew L. Flaherty
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Dawn Kleindorfer
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Faisal Khan
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - John Kues
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Peter Baker
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Robert Ireton
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Dave Hoskins
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Brett M. Harnett
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Carlos Aguilar
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Anthony Leonard
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Rajan Prakash
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Lora Arduser
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Alexandru Costea
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
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16
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Lang K, Bozkaya D, Patel AA, Macomson B, Nelson W, Owens G, Mody S, Schein J, Menzin J. Anticoagulant use for the prevention of stroke in patients with atrial fibrillation: findings from a multi-payer analysis. BMC Health Serv Res 2014; 14:329. [PMID: 25069459 PMCID: PMC4126814 DOI: 10.1186/1472-6963-14-329] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 07/23/2014] [Indexed: 11/13/2022] Open
Abstract
Background Oral anticoagulation is recommended for stroke prevention in intermediate/high stroke risk atrial fibrillation (AF) patients. The objective of this study was to demonstrate the usefulness of analytic software tools for descriptive analyses of disease management in atrial AF; a secondary objective is to demonstrate patterns of potential anticoagulant undertreatment in AF. Methods Retrospective data analyses were performed using the Anticoagulant Quality Improvement Analyzer (AQuIA), a software tool designed to analyze health plan data. Two-year data from five databases were analyzed: IMS LifeLink (IMS), MarketScan Commercial (MarketScanCommercial), MarketScan Medicare Supplemental (MarketScanMedicare), Clinformatics™ DataMart, a product of OptumInsight Life Sciences (Optum), and a Medicaid Database (Medicaid). Included patients were ≥ 18 years old with a new or existing diagnosis of AF. The first observed AF diagnosis constituted the index date, with patient outcomes assessed over a one year period. Key study measures included stroke risk level, anticoagulant use, and frequency of International Normalized Ratio (INR) monitoring. Results High stroke risk (CHADS2 ≥ 2 points) was estimated in 54% (IMS), 22% (MarketScanCommercial), 64% (MarketscanMedicare), 42% (Optum) and 62% (Medicaid) of the total eligible population. Overall, 35%, 29%, 38%, 39% and 16% of all AF patients received an anticoagulant medication in IMS, MarketScanCommercial, MarketScanMedicare, Optum and Medicaid, respectively. Among patients at high risk for stroke, 19% to 51% received any anticoagulant. Conclusions The AQuIA provided a consistent platform for analysis across multiple AF populations with varying baseline characteristics. Analyzer results show that many high-risk AF patients in selected commercial, Medicare-eligible, and Medicaid populations do not receive appropriate thromboprophylaxis, as recommended by treatment guidelines.
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Lopes LC, Spencer FA, Neumann I, Ventresca M, Ebrahim S, Zhou Q, Bhatnagar N, Schulman S, Eikelboom J, Guyatt G. Systematic review of observational studies assessing bleeding risk in patients with atrial fibrillation not using anticoagulants. PLoS One 2014; 9:e88131. [PMID: 24523876 PMCID: PMC3921139 DOI: 10.1371/journal.pone.0088131] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 01/03/2014] [Indexed: 12/01/2022] Open
Abstract
Background Patients with atrial fibrillation considering use of anticoagulants must balance stroke reduction against bleeding risk. Knowledge of bleeding risk without the use of anticoagulants may help inform this decision. Purpose To determine the rate of major bleeding reported in observational studies of atrial fibrillation patients not receiving Vitamin K antagonists (VKA). Data Sources We searched MEDLINE, EMBASE and CINAHL to October 2011 and examined reference lists of eligible studies and related reviews. Study Selection All longitudinal cohort studies that included over 100 adult patients with atrial fibrillation not receiving VKA. Data Extraction Teams of two reviewers independently and in duplicate adjudicated eligibility, assessed risk of bias and abstracted study characteristics and outcomes. Data Synthesis Twenty-one eligible studies included 96,448 patients. Major bleeding rates varied widely, from 0 to 4.69 events per 100 patient-years. The pooled estimate in 13 studies with 78839 patients was 1.59 with a 99% confidence interval of 1.10 to 2.3 and median 1.42 (interquartile range 0.62–2.70). Pooled estimates for fatal bleeding and non-fatal bleeding from 4 studies that reported these outcomes were, respectively, 0.40 (0.34 to 0.46) and 1.18 (0.30 to 4.56) per 100 patient-years. In 9 randomized controlled trials (RCTs) the median rate of major bleeding in patients not receiving either anticoagulant or antiplatelet therapy was 0.6 (interquartile 0.2 to 0.90), and in 12 RCTs the median rate of major bleeding in patients receiving a single antiplatelet agent was 0.75 (interquartile 0.4 to 1.4). Conclusion Results suggest that patients with atrial fibrillation not receiving VKA enrolled in observational studies represent a population on average at higher risk of bleeding.
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Affiliation(s)
- Luciane Cruz Lopes
- Pharmaceutical Sciences Postgraduate Course, University of Sorocaba, Sao Paulo, Brazil
- * E-mail:
| | - Frederick A. Spencer
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Ignacio Neumann
- Internal Medicine Department, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Matthew Ventresca
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Shanil Ebrahim
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Stanford Prevention Research Center, Stanford University, Stanford, California, United States of America
| | - Qi Zhou
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Neera Bhatnagar
- Health Sciences Library McMaster University, Hamilton, Ontario, Canada
| | - Sam Schulman
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John Eikelboom
- Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Arts DL, Visscher S, Opstelten W, Korevaar JC, Abu-Hanna A, van Weert HCPM. Frequency and risk factors for under- and over-treatment in stroke prevention for patients with non-valvular atrial fibrillation in general practice. PLoS One 2013; 8:e67806. [PMID: 23861809 PMCID: PMC3702536 DOI: 10.1371/journal.pone.0067806] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 05/22/2013] [Indexed: 12/02/2022] Open
Abstract
Objective To determine adequacy of antithrombotic treatment in patients with non-valvular atrial fibrillation. To determine risk factors for under- and over-treatment. Design Retrospective, cross-sectional study of electronic health records from 36 general practitioners in 2008. Setting General practice in the Netherlands. Subjects Primary care physicians (n = 36) and patients (n = 981) aged 65 years and over. Main Outcome Measures Rates of adequate, under and over-treatment, risk factors for under and over-treatment. Results Of the 981 included patients with a mean of age 78, 18% received no antithrombotic treatment (under-treatment), 13% received antiplatelet drugs and 69% received oral anticoagulation (OAC). Further, 43% of the included patients were treated adequately, 26% were under-treated, and 31% were over-treated. Patients with a previous ischaemic stroke were at high risk for under-treatment (OR 2.4, CI 1.6–3.5), whereas those with contraindications for OAC were at high risk for over-treatment (OR 37.0, CI 18.1–79.9). Age over 75 (OR 0.2, CI: 0.1–0.3]), diabetes (OR 0.1, CI: 0.1–0.3), heart failure (OR 0.2, CI: 0.1–0.3), hypertension (OR 0.1, CI: 0.1–0.2) and previous ischaemic stroke (OR 0.04, CI: 0.02–0.11) protected against over-treatment. Conclusions In general practice, CHADS2-criteria are being used, but the antithrombotic treatment of patients with atrial fibrillation frequently deviates from guidelines on this topic. Patients with previous stroke are at high risk of not being prescribed OAC. Contraindications for OAC, however, seem to be frequently overlooked.
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Affiliation(s)
- Derk L Arts
- Department of General Practice, Academic Medical Centre, Amsterdam, The Netherlands.
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Wess ML, Saleem JJ, Tsevat J, Luckhaupt SE, Johnston JA, Wise RE, Kopke JE, Eckman MH. Usability of an atrial fibrillation anticoagulation decision-support tool. J Prim Care Community Health 2013; 2:100-6. [PMID: 23804743 DOI: 10.1177/2150131910387608] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION In individuals with nonvalvular atrial fibrillation, anticoagulant therapy with warfarin reduces the rate of thromboembolic events but increases the risk of bleeding. Treatment decisions frequently are inconsistent with guidelines. A new web-based atrial fibrillation decision-support tool (AF-DST) provides patient-specific information on the risk-benefit tradeoff of anticoagulation. METHODS The authors performed a pilot usability testing study of the AF-DST with 4 medical house officers and 4 attending physicians by simulating 9 outpatient clinical encounters involving tradeoffs between risks and benefits of anticoagulation. They recorded positive and negative critical incidents in the simulations and assessed satisfaction with use of the AF-DST by the Computer System Usability Questionnaire (CSUQ; score range on each item: 1 = strongly disagree to 7 = strongly agree). RESULTS Users found the AF-DST to be helpful and had high CSUQ scores (mean item score, 6.3). Usability testing identified 6 positive and 14 negative critical incidents. Participants felt that the AF-DST guided them toward the correct decision. Nevertheless, they desired more information on the "black box" calculations and ignored alerts. Training level appeared to affect how the AF-DST was used, in particular, how users interacted with the AF-DST. CONCLUSIONS Overall satisfaction with the AF-DST was high and the tool effectively communicated recommendations and uncertainty. Usability testing identified design issues and potential errors caused by decision-support tool use; these gaps should be addressed prior to clinical implementation.
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Affiliation(s)
- Mark L Wess
- Division of General Internal Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Roskell NS, Samuel M, Noack H, Monz BU. Major bleeding in patients with atrial fibrillation receiving vitamin K antagonists: a systematic review of randomized and observational studies. Europace 2013; 15:787-97. [PMID: 23407628 PMCID: PMC3663334 DOI: 10.1093/europace/eut001] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIMS Clinical trials have shown that anticoagulation with vitamin K antagonists (VKAs), e.g. warfarin, decreases the risk of stroke in patients with atrial fibrillation (AF); however, increased bleeding risk is one of the safety concerns. The primary objective was to conduct a systematic review of the published literature, assessing the risk of major bleeding and mortality in patients with AF treated with VKAs. METHODS AND RESULTS Online searches of MEDLINE, EMBASE, BIOSIS, and the Cochrane Library were performed to a pre-specified protocol from 1960 to March 2012 for randomized controlled trials (RCTs) and from January 1990 to March 2012 for observational studies. A total of 47 studies (16 RCTs and 31 observational studies) were included. Cumulative follow-up was 61,563 patient-years for RCTs and 484 241 patient-years for observational studies. The overall median incidence of major bleeding was 2.1 per 100 patient-years (range, 0.9-3.4 per 100 patient-years) for RCTs and 2.0 per 100 patient-years (range, 0.2-7.6 per 100 patient-years) for observational studies. With study year as a proxy for changing management patterns, some evidence of bleeding rates and/or their reporting increasing over time was noted. Mortality rates from observational studies were inadequately reported to allow comparison with those from RCT data. CONCLUSION The median rate of major bleeding in observational studies and RCTs is similar. The larger heterogeneity in bleeding rates observed in a real-life setting could reflect a high variability in standard of care of patients on VKAs and/or methodological differences between observational studies and/or variability in data sources.
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Affiliation(s)
- Neil S Roskell
- RTI Health Solutions, 2nd Floor, The Pavilion, Towers Business Park, Wilmslow Road, Didsbury, Manchester M20 2LS, UK.
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Risk of bleeding with oral anticoagulants: an updated systematic review and performance analysis of clinical prediction rules. Ann Hematol 2011; 90:1191-200. [DOI: 10.1007/s00277-011-1267-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 05/24/2011] [Indexed: 11/25/2022]
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Goldstein JN, Greenberg SM. Should anticoagulation be resumed after intracerebral hemorrhage? Cleve Clin J Med 2011; 77:791-9. [PMID: 21048052 DOI: 10.3949/ccjm.77a.10018] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Intracerebral hemorrhage (ICH) is the most feared and the most deadly complication of oral anticoagulant therapy, eg, with warfarin (Coumadin). After such an event, clinicians wonder whether their patients should resume anticoagulant therapy. The authors review the management of anticoagulation during and after anticoagulation-associated ICH.
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Affiliation(s)
- Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA.
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Somme D, Corvol A, Lazarovici C, Lahjibi-Paulet H, Gisselbrecht M, Saint-Jean O. Clinical usefulness in geriatric patients of combining CHADS2 and HEMORR2HAGES scores to guide antithrombotic prophylaxis in atrial fibrillation. Aging Clin Exp Res 2010; 22:289-94. [PMID: 19996707 DOI: 10.1007/bf03337725] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Two scores exist to assess the benefits and risks of antithrombotic therapy in patients with atrial fibrillation: CHADS2 [for Congestive heart failure, Hypertension, Age over 75, Diabetes mellitus; and 2 points for a history of Stroke] and HEMORR2HAGES [for Hepatic or renal failure, Ethanol abuse, Malignancy, Older (age over 75), Reduced platelet count or function, 2 points for Rebleeding risk Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk (including neurodegenerative and psychiatric disorders) and history of Stroke]. The potential value of using both scores routinely was studied in order to guide the choice of antithrombotic therapy for geriatric patients. METHODS Retrospective calculation of CHADS2 and HEMORR2HAGES scores and discharge treatment were collected for all patients with atrial fibrillation during a six-month period. All files were analysed when there were differences between therapeutic choices and the results of analysis of combining the two scores. RESULTS 83 patients were identified. Their mean age was 89.2±4.9 years and 30% of them were on oral anticoagulants on discharge. Usual prescription habits of oral anticoagulants correlated strongly with each of the scores and with the difference between the two scores. The clinical usefulness of using the two scores seemed poor since they indicated that two-thirds of the patients had a similar risk of hemorrhagic and ischemic events. CONCLUSIONS Based on this preliminary study, the CHADS2 and HEMORR2HAGES scores are associated with the prescription of oral anticoagulants, but their routine use may not significantly change the choice of antithrombotic therapy for patients with atrial fibrillation.
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Affiliation(s)
- Dominique Somme
- Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Gériatrie, 75908 Paris Cedex 15, France.
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