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

Academic Detailing Interventions and Evidence-Based Prescribing: A Systematic Review

Importance

Academic detailing (interactive educational outreach) is a widely used strategy to encourage evidence-based prescribing by clinicians.

Objective

To evaluate academic detailing programs targeted at improving prescribing behavior and describe program aspects associated with positive outcomes.

Evidence Review

A systematic search of MEDLINE from April 1, 2007, through December 31, 2022, was performed for randomized trials and nonrandomized studies of academic detailing interventions to improve prescribing. Academic detailing was defined as evidence-based medication education outreach delivered interactively to individuals or small groups of prescribers. Only studies that measured prescribing outcomes were included. Two investigators independently assessed studies for risk of bias using validated assessment tools. Among all studies rated as having low risk of bias and randomized trials rated as having moderate risk of bias, the absolute change in the proportion of patients using the targeted medications and the proportion of studies that led to significant changes in 1 or more prescribing outcome were determined. The data analysis was performed between January 25, 2022, and November 4, 2024.

Findings

The 118 studies identified varied by setting (eg, inpatient, outpatient) and academic detailing delivery (eg, individual vs groups of prescribers). The most common therapeutic targets were antibiotic overuse (32 studies [27%]), opioid prescribing (24 studies [20%]), and management of mental health conditions (16 studies [14%]) and cardiovascular disease (13 studies [11%]). Most studies (66 [56%]) combined academic detailing with other interventions (eg, audit and feedback, electronic health record reminders). Among 36 studies deemed to have the lowest risk of bias, 18 interventions (50%; 95% CI, 33%-67%) led to significant improvements in all prescribing outcomes, and 7 (19%; 95% CI, 8%-36%) led to significant improvements in 1 or more prescribing outcomes. The median absolute change in the proportion of patients using the targeted medication or medications was 4.0% (IQR, 0.3%-11.3%) in the intended direction.

Conclusions and Relevance

In this systematic review of academic detailing interventions addressing evidence-based prescribing, most interventions led to substantial changes in prescribing behavior, although the quality of evidence varied. These findings support the use of academic detailing to bring about more evidence-based prescribing in a variety of clinical settings.

Personalizing Quality Improvement: Addressing Anticoagulation Gaps in Atrial Fibrillation

INTRODUCTION

Risk of stroke is greater in patients with atrial fibrillation. Anticoagulation is effective at decreasing risk, yet 40-50% of eligible patients are not prescribed anticoagulation and seem to have a concerning gap in care quality. This quality improvement initiative implemented a pharmacist-led approach to identify, verify, and close apparent anticoagulation treatment gaps.

METHODS

We included adult primary care patients with diagnosis of atrial fibrillation; congestive heart failure, hypertension, age ≥75 years (doubled), diabetes, stroke/transient ischemic attack (doubled), vascular disease, age 65-74 years, and sex (female) (CHA2DS2-VASc) score of at least 2, and no current anticoagulant use. We identified patients using claims and electronic health record data and evaluated explanations through chart review and provider contact. A provider outreach protocol was developed and implemented to address opportunities for anticoagulation.

RESULTS

Of 242 patients with an apparent gap, 84% had a verified treatment gap. However, 86% of verified treatment gaps were explained through pharmacist chart review and outreach to providers, and they did not require further action. Explanations included spontaneous resolution of atrial fibrillation, patient declining treatment, completion of a procedure to correct atrial fibrillation or mitigate stroke risk, and high bleeding risk.

CONCLUSIONS

Relying solely on claims- and electronic health record-based algorithms may substantially overestimate gaps in care quality.

Clinical decision support systems to optimize adherence to anticoagulant guidelines in patients with atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Clinical decision support systems (CDSS) have been utilized as a low-cost intervention to improve healthcare process measures. Thus, we aim to estimate CDSS efficacy to optimize adherence to oral anticoagulant guidelines in eligible patients with atrial fibrillation (AF).

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) retrieved from PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through August 2023. We used RevMan V. 5.4 to pool dichotomous data using risk ratio (RR) with a 95% confidence interval (CI).

PROSPERO ID

CRD42023471806.

RESULTS

We included nine RCTs with a total of 25,573 patients. There was no significant difference, with the use of CDSS compared to routine care, in the number of patients prescribed anticoagulants (RR: 1.06, 95% CI [0.98, 1.14], P = 0.16), the number of patients prescribed antiplatelets (RR: 1.01 with 95% CI [0.97, 1.06], P = 0.59), all-cause mortality (RR: 1.19, 95% CI [0.31, 4.50], P = 0.80), major bleeding (RR: 0.84, 95% CI [0.21, 3.45], P = 0.81), and clinically relevant non-major bleeding (RR: 1.05, 95% CI [0.52, 2.16], P = 0.88). However, CDSS was significantly associated with reduced incidence of myocardial infarction (RR: 0.18, 95% CI [0.06, 0.54], P = 0.002) and cerebral or systemic embolic event (RR: 0.11, 95% CI [0.01, 0.83], P = 0.03).

CONCLUSION

We report no significant difference with the use of CDSS compared to routine care in anticoagulant or antiplatelet prescription in eligible patients with AF. CDSS was associated with a reduced incidence of myocardial infarction and cerebral or systemic embolic events.

Cluster-Randomized Trial Comparing Ambulatory Decision Support Tools to Improve Heart Failure Care

BACKGROUND

Mineralocorticoid receptor antagonists (MRAs) are underprescribed for patients with heart failure with reduced ejection fraction (HFrEF).

OBJECTIVES

This study sought to compare effectiveness of 2 automated, electronic health record-embedded tools vs usual care on MRA prescribing in eligible patients with HFrEF.

METHODS

BETTER CARE-HF (Building Electronic Tools to Enhance and Reinforce Cardiovascular Recommendations for Heart Failure) was a 3-arm, pragmatic, cluster-randomized trial comparing the effectiveness of an alert during individual patient encounters vs a message about multiple patients between encounters vs usual care on MRA prescribing. This study included adult patients with HFrEF, no active MRA prescription, no contraindication to MRAs, and an outpatient cardiologist in a large health system. Patients were cluster-randomized by cardiologist (60 per arm).

RESULTS

The study included 2,211 patients (alert: 755, message: 812, usual care [control]: 644), with average age 72.2 years, average ejection fraction 33%, who were predominantly male (71.4%) and White (68.9%). New MRA prescribing occurred in 29.6% of patients in the alert arm, 15.6% in the message arm, and 11.7% in the control arm. The alert more than doubled MRA prescribing compared to usual care (relative risk: 2.53; 95% CI: 1.77-3.62; P < 0.0001) and improved MRA prescribing compared to the message (relative risk: 1.67; 95% CI: 1.21-2.29; P = 0.002). The number of patients with alert needed to result in an additional MRA prescription was 5.6.

CONCLUSIONS

An automated, patient-specific, electronic health record-embedded alert increased MRA prescribing compared to both a message and usual care. These findings highlight the potential for electronic health record-embedded tools to substantially increase prescription of life-saving therapies for HFrEF. (Building Electronic Tools to Enhance and Reinforce Cardiovascular Recommendations-Heart Failure [BETTER CARE-HF]; NCT05275920).

Research Opportunities in Stroke Prevention for Atrial Fibrillation: A Report From a National Heart, Lung, and Blood Institute Virtual Workshop

Atrial fibrillation (AF) is one of the strongest risk factors for ischemic stroke, which is a leading cause of disability and death. Given the aging population, increasing prevalence of AF risk factors, and improved survival in those with cardiovascular disease, the number of individuals affected by AF will continue increasing over time. While multiple proven stroke prevention therapies exist, important questions remain about the optimal approach to stroke prevention at the population and individual patient levels. Our report summarizes the National Heart, Lung, and Blood Institute virtual workshop focused on identifying key research opportunities related to stroke prevention in AF. The workshop reviewed major knowledge gaps and identified targeted research opportunities to advance stroke prevention in AF in the following areas: (1) improving risk stratification tools for stroke and intracranial hemorrhage; (2) addressing challenges with oral anticoagulants; and (3) delineating the optimal roles of percutaneous left atrial appendage occlusion and surgical left atrial appendage closure/excision. This report aims to promote innovative, impactful research that will lead to more personalized, effective use of stroke prevention strategies in people with AF.

SUPPORT-AF IV: Supporting use of AC through provider prompting about oral anticoagulation therapy for AF clinical trial study protocol

Background

Six million Americans suffer from atrial fibrillation (AF), a heart rhythm abnormality that significantly increases the risk of stroke. AF is responsible for 15% of ischemic strokes, which lead to permanent disability in 60% of cases and death in up to 20%. Anticoagulation (AC) is the mainstay for stroke prevention in patients with AF. Despite guidelines recommending AC for patients, up to half of eligible patients are not on AC. Clinical decision support tools in the electronic health record (EHR) can help bridge the disparity in AC prescription for patients with AF.

Objective

To enhance and assess the effectiveness of our previous rule-based alert on AC initiation and persistence in a diverse patient population from UMass-Memorial Medical Center and University of Florida at Jacksonville.

Methods/Results

Using the EHR, we will track AC initiation and persistence. We will interview both patients and providers to determine a measure of satisfaction with AC management. We will track digital crumbs to better understand the alert’s mechanism of effect and further add enhancements. These enhancements will be used to refine the alert and aid in developing an implementation toolkit to facilitate use of the alert at other health systems.

Conclusion

If the number of AC starts, the likelihood of persisting on AC, and the frequency alert use are found to be higher among intervention vs control providers, we believe such findings will confirm our hypothesis on the effectiveness of our alert.

Usability and Perceived Usefulness of the AFib 2gether Mobile App in a Clinical Setting: Single-Arm Intervention Study

Background

Although the American Heart Association and other professional societies have recommended shared decision-making as a way for patients with atrial fibrillation (AF) or atrial flutter to make informed decisions about using anticoagulation (AC), the best method for facilitating shared decision-making remains uncertain.

Objective

The aim of this study is to assess the AFib 2gether mobile app for usability, perceived usefulness, and the extent and nature of shared decision-making that occurred for clinical encounters between patients with AF and their cardiology providers in which the app was used.

Methods

We identified patients visiting a cardiology provider between October 2019 and May 2020. We measured usability from patients and providers using the Mobile App Rating Scale. From the 8 items of the Mobile App Rating Scale, we reported the average score (out of 5) for domains of functionality, esthetics, and overall quality. We administered a 3-item questionnaire to patients relating to their perceived usefulness of the app and a separate 3-item questionnaire to providers to measure their perceived usefulness of the app. We performed a chart review to track the occurrence of AC within 6 months of the index visit. We also audio recorded a subset of the encounters to identify evidence of shared decision-making.

Results

We facilitated shared decision-making visits for 37 patients visiting 13 providers. In terms of usability, patients’ average ratings of functionality, esthetics, and overall quality were 4.51 (SD 0.61), 4.26 (SD 0.51), and 4.24 (SD 0.89), respectively. In terms of usefulness, 41% (15/37) of patients agreed that the app improved their knowledge regarding AC, and 62% (23/37) agreed that the app helped clarify to their provider their preferences regarding AC. Among providers, 79% (27/34) agreed that the app helped clarify their patients’ preferences, 82% (28/34) agreed that the app saved them time, and 59% (20/34) agreed that the app helped their patients make decisions about AC. In addition, 32% (12/37) of patients started AC after their shared decision-making visits. We audio recorded 25 encounters. Of these, 84% (21/25) included the mention of AC for AF, 44% (11/25) included the discussion of multiple options for AC, 72% (18/25) included a provider recommendation for AC, and 48% (12/25) included the evidence of patient involvement in the discussion.

Conclusions

Patients and providers rated the app with high usability and perceived usefulness. Moreover, one-third of the patients began AC, and approximately 50% (12/25) of the encounters showed evidence of patient involvement in decision-making. In the future, we plan to study the effect of the app on a larger sample and with a controlled study design.

Trial Registration

ClinicalTrials.gov NCT04118270; https://clinicaltrials.gov/ct2/show/NCT04118270

International Registered Report Identifier (IRRID)

RR2-21986

Geriatric Conditions Are Associated With Decreased Anticoagulation Use in Long-Term Care Residents With Atrial Fibrillation

Background

Anticoagulation is the mainstay for stroke prevention in patients with atrial fibrillation, but concerns about bleeding inhibit its use in residents of long‐term care facilities. Risk‐profiling algorithms using comorbid disease information (eg, CHADS₂ and ATRIA [Anticoagulation and Risk Factors in Atrial Fibrillation]) have been available for years. In the long‐term care setting, however, providers and residents may place more value on geriatric conditions such as mobility impairment, activities of daily living dependency, cognitive impairment, low body mass index, weight loss, and fall history.

Methods and Results

Using a retrospective cohort design, we measured the association between geriatric conditions and anticoagulation use and type. After merging nursing home assessments containing information about geriatric conditions (Minimum Data Set 2015) with Medicare Part A 2014 to 2015 claims and prescription claims (Medicare Part D) 2015 to 2016, we identified 228 741 residents with atrial fibrillation and elevated stroke risk (CHA₂DS₂‐VASc score ≥2) for our main analysis. Recent fall, activities of daily living dependency, moderate and severe cognitive impairment, low body mass index, and unintentional weight loss were all associated with lower anticoagulation use even after adjustment for multiple predictors of stroke and bleeding (odds ratios ranging from 0.51 to 0.91). Residents with recent fall, low body mass index, and unintentional weight loss were more likely to be using a direct oral anticoagulant, although the magnitude of this effect was smaller.

Conclusions

Geriatric conditions were associated with lower anticoagulation use. Preventing stroke in these residents with potential for further physical and cognitive impairment would appear to be of paramount significance, although the net benefit of anticoagulation in these individuals warrants further research.

The information needs of patients with atrial fibrillation: A scoping review

AIMS AND OBJECTIVES

To identify the atrial fibrillation (AF)-specific information needs of patients with AF.

BACKGROUND

Patients' understanding of AF is pertinent to optimising treatment and outcomes, thus highlighting the need for effective patient education. The information required to deliver effective AF-specific patient education is less examined.

METHODS

Guided by Arksey and O'Malley's framework, a scoping review was conducted for studies reporting the AF-specific information needs of patients with AF. Systematic searches were conducted across six databases (Medline, PubMed, CINAHL, Scopus, PsycINFO and ProQuest). All analyses were narrated in prose and outlined in tables. The PRISMA-ScR checklist was used to report this review.

RESULTS

The systematic search yielded 3816 articles, of which 22 were included. Three major themes emerged from the thematic analysis. Each theme was supported by three subthemes. First, in 'Understanding AF', patients reported the need for 'Easy-to-understand information', information on the 'Screening and diagnosis' of AF and 'Trajectory of disease and its associated risks'. Second, in 'Treating AF', patients required information on the 'Role of anticoagulation', 'Existing or novel therapeutic options' and 'Monitoring effectiveness of treatment'. Lastly, in 'Living with AF', patients needed education in 'Symptom management', 'Secondary prevention of risks' and 'Recognition of emergency situations'.

CONCLUSIONS

This review has identified the key AF-specific information needs of patients with AF. Being cognisant of the information needs of patients with AF, healthcare providers may become more effective in developing person-centred patient education interventions.

RELEVANCE TO CLINICAL PRACTICE

Delivering relevant patient education is an important cornerstone for atrial fibrillation care. Nurses by convention play a professional role in patient education. It may be facilitative for nurses to refer to the review findings when developing and implementing patient education interventions. Being in the midst of an ongoing pandemic, patient education strategies may require the use of telecommunication technologies.

SUPPORT-AF III: supporting use of AC through provider prompting about oral anticoagulation therapy for AF

Only half of atrial fibrillation (AF) patients with elevated stroke risk receive anticoagulation (AC). Electronic health record (EHR) alerts have the potential to close the gap. We designed an outpatient EHR alert (linked to an order set for ordering AC, labs, and specialty referrals) that fired when cardiology and primary care providers (PCPs) saw AF patients not on AC. We assigned all untreated patients seen by cardiology providers and PCPs in the 8 months before and after the alert launch to pre- and post-launch intervention cohorts, respectively. Untreated AF patients seeing other types of providers became controls. We then compared the difference in AC starts between intervention and control patients post-launch to the same difference prelaunch (adjusting for covariates). We measured alert responsiveness as how often patients had at least one encounter with a provider, who interacted with the alert. The adjusted percentage of AC starts for the prelaunch cohort was 20% for intervention patients and 17% for controls (difference = 3%); post-launch, the percentage was 13% for both post-launch intervention and controls (difference = 0%). The difference in difference was - 3% (p value 0.63). For half of patients, at least one provider was responsive to our alert. Reasons for no AC commonly included relative contraindications (e.g. fall, gastrointestinal bleed). Our alert did not increase AC starts but responsiveness to it was high. Increasing AC starts will likely require education surrounding relative contraindications.

Mobile health technology-supported atrial fibrillation screening and integrated care: A report from the mAFA-II trial Long-term Extension Cohort

BACKGROUND

In the mobile Atrial Fibrillation App (mAFA)-II trial, the use of mobile health (mHealth) technology, incorporating AF screening and integrated management strategy, was associated with improved short-term clinical outcomes. The aim of this study was to report adherence/persistence and long term (≥1 year) clinical outcomes of the mAFA-II trial, with mHealth-supported optimised stroke prevention, symptom control and comorbidity management.

METHODS

We studied an adult population screened for AF, where identified patients could enter a structured program of holistic and integrated care based on the ABC (Atrial fibrillation Better Care) pathway using mHealth with a mAFA intervention. In this cluster randomised trial, comparing mHeath intervention to usual care, the primary composite outcome was 'stroke/thromboembolism, all-cause death and rehospitalization'.

RESULTS

The 1261 subjects (mean age 67.0 years, 38.0% female) who were followed up over one year (mean follow-up 687 (standard deviation, SD 191) days) in the intervention arm, had a lower risk of the composite outcome of 'ischaemic stroke/systemic thromboembolism, death, and rehospitalization' (hazard ratio, HR 0.18, 95% confidence interval, CI: 0.13-0.25, P < 0.001), compared to usual care (1212 subjects, mean age 70.1 years, 42.1% female). Of 842 patients using their smart devices for 'Better symptom management', 70.8% had good management adherence (monitoring time/follow-up since initial monitoring ≥ 70%), with the persistence of use of 91.7%.

CONCLUSION

Amongst AF patients with long term use (≥1 year) of mHealth technology for optimising stroke prevention, symptom control and comorbidity management, adherence/persistence was good and associated with a reduction in adverse clinical outcomes.

Assessing Anticoagulation Management and Shared Decision-Making Documentation From Providers Participating in the SUPPORT-AF II Study

BACKGROUND

A previously tested intervention featured educational outreach with modified academic detailing (AD) to increase anticoagulation use in patients with atrial fibrillation. Currently, this study compares providers receiving and not receiving AD in terms of inclusion of AD educational topics and shared decision-making elements in documentation.

METHODS

Physicians reviewed themes discussed with providers during AD and evaluated charts for evidence of shared decision-making. Frequencies of documentation of individual items for providers receiving AD versus non-AD providers were compared. To understand baseline documentation practices of AD providers, encounters of AD providers before their AD participation were randomly selected.

RESULTS

There were 113 eligible encounters in the four months after AD-36 from AD providers and 77 from non-AD providers. Thirty-five encounters were identified from AD providers before participating in the intervention. Providers infrequently documented many reviewed items (% documenting): anticoagulation mentioned (44%), multiple options for anticoagulation (5%), CHA2DS2-VASc score (11%), bleeding risk factors (2%). Compared with non-AD providers, AD providers had statistically significant higher percentages for the following items: mention of anticoagulation (64% versus 35%), stroke risk (11% versus 0%), anticoagulation benefits (8% versus 0%), and patient involvement (17% versus 0%). There was no improvement, however, for AD providers compared with baseline documentation percentages.

DISCUSSION

Providers infrequently documented important items in anticoagulation management and shared decision-making. AD participation did not improve documentation. Improving adoption of AD educational items may require more prolonged interaction with providers. Improving shared decision-making may require an intervention more focused on it and its documentation.