A cluster-randomized controlled trial of a computerized antithrombotic risk assessment tool to optimize stroke prevention in general practice: a study protocol

The Effect of a Clinical Decision Support System on Improving Adherence to Guideline in the Treatment of Atrial Fibrillation: An Interrupted Time Series Study

To evaluate the effect of a computerized Decision Support System (CDSS) on improving adherence to an anticoagulation guideline for the treatment of atrial fibrillation (AF). This study had an interrupted time series design. The adherence to the guideline was assessed at fortnightly (two weeks) intervals from January 2016 to January 2017, 6 months before and 6 months after intervention. Newly diagnosed patients with AF were included in the offices of ten cardiologists. Stroke and major bleeding risks were calculated by the CDSS which was implemented via a mobile application. Treatment recommendations based on the guideline were shown to cardiologists. The segmented regression model was used to evaluate the effect of CDSS on level and trend of guideline adherence for the treatment of AF. In our analysis, 373 patients were included. The trend of adherence to the anticoagulation guideline for the treatment of AF was stable in the pre-intervention phase. After the CDSS intervention, mean of the adherence to the guideline significantly increased from 48% to 65.5% (P-value < 0.0001). The trend of adherence to the guideline was stable in the post-intervention phase. Our results showed that the CDSS can improve adherence to the anticoagulation guideline for the treatment of AF. Registration ID: IRCT2016052528070N1.

Effects of Computerized Decision Support Systems on Management of Atrial Fibrillation: A Scoping Review

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.

Clinical pre-test of a computerised antithrombotic risk assessment tool for stroke prevention in atrial fibrillation patients: giving consideration to NOACs

RATIONALE, AIMS AND OBJECTIVES

The decision-making around antithrombotics in atrial fibrillation requires comprehensive risk versus benefit assessment. In view of the availability of novel oral anticoagulants (NOACs) including dabigatran, rivaroxaban and apixaban, a decision support tool designed to assist the selection of antithrombotics has been modified to consider both warfarin and NOACs. This study aims to pre-test this modified decision support tool.

METHODS

The decision support tool was modified to consider either warfarin or NOACs as first-line therapy and applied to data pertaining to a cohort of 393 patients in New South Wales.

RESULTS

Overall, 380 (96.7%) patients were eligible for oral anticoagulants. In the scenario of warfarin being recommended as first-line therapy, the Computerised Antithrombotic Risk Assessment Tool version 2.0 (caratv2.0) recommended warfarin for 360 (91.6%) patients, any NOAC for 5 (1.3%) patients, either rivaroxaban or apixaban for 6 (1.5%) patients and apixaban for 9 (2.2%) patients. In the scenario of NOACs as first-line therapy, caratv2.0 recommended any NOAC for 279 (70.9%) patients, either rivaroxaban or apixaban for 80 (20.4%) patients, apixaban for 9 (2.3%) patients and warfarin for 12 (3.1%) patients. Key reasons for caratv2.0 to recommend a change from warfarin (patients' current therapy) to NOACs included known warfarin allergy/adverse reaction, a history of intracranial bleeding, and previous gastrointestinal bleeding. Key predictors for caratv2.0 to consider that patients are more suitable for NOACs over warfarin were a diagnosis of other gastrointestinal diseases, more co-morbidities and high risk of falls.

CONCLUSIONS

According to this decision support tool, both warfarin and NOACs are viable treatment options in majority of the patients, but there is a scope for better rationalization of therapy.

Selecting antithrombotic therapy for stroke prevention in atrial fibrillation: Health professionals' feedback on a decision support tool

A Computerised Antithrombotic Risk Assessment Tool was developed for assisting the selection of antithrombotic therapy based on the risk versus benefit assessment. In view of the recent availability of the novel oral anticoagulants, this tool has been updated to CARATV2.0. To explore health professionals' perspectives on the tool, semi-structured interviews were conducted in seven pharmacists, seven specialists, six general practitioners and six nurses, who were involved in management of antithrombotic therapy for atrial fibrillation. Three overarching themes emerged: (1) CARATV2.0 provides comprehensive structured assessment of patients and could assist with the prescription and review of antithrombotic therapy, (2) subjective issues such as health professionals' and patients' preferences for a particular antithrombotic therapy may affect the usefulness of CARATV2.0 and (3) CARATV2.0 requires integration into existing systems and processes. The majority of health professionals surveyed would like to use CARATV2.0 in practice, believing it would improve antithrombotic use and might reduce stroke incidence.

The Impact of Novel Anticoagulants: Should All AF Patients Now Be Anticoagulated?

Atrial Fibrillation (AF) is accompanied by an increased risk for thromboembolic events in most affected patients. Current guidelines therefore recommend antithrombotic therapy with vitamin K antagonist (VKA) or non VKA oral anticoagulant (NOAC) in the majority of AF patients. Current AF treatment guidelines recommend that only patients younger than 65 years of age with lone AF, meaning without further concomitant risk factors for thromboembolic events should not be anticoagulated. NOACs, like the direct thrombin inhibitor dabigatran and the factor X inhibitors rivaroxaban, apixaban, and edoxaban have undergone large phase III clinical trials concerning treatment efficacy and bleeding risk in comparison to the VKA warfarin. In most cases, treatment with NOACs has been shown to decrease thromboembolic risk and/or decrease bleeding risk when compared with warfarin. Especially, as major hemorrhages like life threatening or intracranial bleeds are reduced, the question arises, if due to favourable adverse event ratios the indication for oral anticoagulation therapy should be broadened and all patients with diagnosed AF should be anticoagulated. This article gives a review on currently used thromboembolic and bleeding risk scores. Furthermore, the impact of NOAC therapy on stroke and bleeding risk is summarized, especially taking pharmacological interactions of NOAC therapy altering thromboembolic or bleeding risk into consideration. Differences of currently available guidelines are discussed. Finally, ongoing recent studies on treatment of low risk patients are debated.

Optimizing Stroke Prevention in Patients With Atrial Fibrillation: A Cluster-Randomized Controlled Trial of a Computerized Antithrombotic Risk Assessment Tool in Australian General Practice, 2012-2013

INTRODUCTION

Clinicians have expressed a need for tools to assist in selecting treatments for stroke prevention in patients with atrial fibrillation. The objective of this study was to evaluate the impact of a computerized antithrombotic risk assessment tool (CARAT) on general practitioners' prescribing of antithrombotics for patients with atrial fibrillation.

METHODS

A prospective, cluster-randomized controlled trial was conducted in 4 regions (in rural and urban settings) of general practice in New South Wales, Australia (January 2012-June 2013). General practitioner practices were assigned to an intervention arm (CARAT) or control arm (usual care). Antithrombotic therapy prescribing was assessed before and after application of CARAT.

RESULTS

Overall, the antithrombotic therapies for 393 patients were reviewed by 48 general practitioners; we found no significant baseline differences in use of antithrombotics between the control arm and intervention arm. Compared with control patients, intervention patients (n = 206) were 3.1 times more likely to be recommended warfarin therapy (over any other treatment option; P < .001) and 2.8 times more likely to be recommended any anticoagulant (in preference to antiplatelet; P = .02). General practitioners agreed with most (75.2%) CARAT recommendations; CARAT recommended that 75 (36.4%) patients change therapy. After application of CARAT, the proportion of patients receiving any antithrombotic therapy was unchanged from baseline (99.0%); however, anticoagulant use increased slightly (from 89.3% to 92.2%), and antiplatelet use decreased (from 9.7% to 6.8%).

CONCLUSION

Tools such as CARAT can assist clinicians in selecting antithrombotic therapies, particularly in upgrading patients from antiplatelets to anticoagulants. However, the introduction of novel oral anticoagulants has complicated the decision-making process, and tools must evolve to weigh the risks and benefits of these new therapy options.

Old age, high risk medication, polypharmacy: a 'trilogy' of risks in older patients with atrial fibrillation

Background:

The safety of pharmacotherapy in atrial fibrillation (AF) is compounded by a trilogy of risks old age, high-risk medications (e.g., antithrombotics, antiarrhythmics), polypharmacy due to multiple patient comorbidities. However, to date, scarce study has investigated the use of polypharmacy (including potentially inappropriate medication (PIM)) in AF patients, and how this may contribute to their overall risk of medication misadventure.

Objectives:

To review the extent of polypharmacy and PIM use in older patients (65 years or older) with AF.

Methods:

Information was extracted from a database characterising a cohort of older AF patients treated in general practice in New South Wales, Australia. Patient characteristics, number and types of drugs, the degree of PIM use were recorded. The predictors for the use of polypharmacy in older AF patients were identified.

Results:

Overall, 367 patients (mean age 77.8 years) were reviewed, among which 94.8% used 5 medications or more and over half used 10 medications or more. Cardiovascular agents were most commonly used (98.9%), followed by antithrombotics (90.7%). Among agents deemed PIMs, digoxin (30.2%) was the most frequently used, followed by benzodiazepines (19.6%), and sotalol (9.8%). AF patients using polypharmacy were more likely to have low bleeding risk (OR=10.97), representing those patients in whom high-risk antithrombotics are mostly indicated. Patients with major-polypharmacy (5-9 medications) are more likely to have obstructive pulmonary diseases (OR=2.32), upper gastrointestinal diseases (OR=2.02) and poor physical function (OR=1.04), but less likely to have cognitive impairment (OR=0.27).

Conclusion:

Polypharmacy affects oldest AF patients, comprising medications that are indicated for AF, yet regarded as PIMs. Patients with lower risk of bleeding, obstructive pulmonary diseases, upper gastrointestinal diseases and poor physical function are also at higher risk of using higher number of medications. This may lead to an increased risk for medication misadventure due to the concomitant use of polypharmacy and medications for AF.

Contemporary approaches to managing atrial fibrillation: A survey of Australian general practitioners

BACKGROUND

Recent attention to the management of atrial fibrillation (AF) and stroke prevention has emphasised the need to support the use of existing pharmacotherapy through available services and resources, in preference to using the new, more expensive, novel oral anticoagulants. In this regard, general practitioners (GPs) are at the core of care.

AIMS

To survey Australian GPs regarding their approach to managing AF, particularly in relation to stroke prevention therapy, and to identify the range of services to support patient care.

METHODS

A structured questionnaire, comprising quantitative and qualitative responses, was administered to participating GPs within four geographical regions of NSW (metropolitan, regional, rural areas).

RESULTS

Fifty GPs (mean age 53.74±9.94 years) participated. Most (98 per cent) GPs regarded themselves as primarily responsible for the management of AF, only referring patients to specialists when needed. However, only 10 per cent of GPs specialised in "heart/vascular health". Most (76 per cent) GPs offered point-of-care international normalised ratio (INR) testing, with 90 per cent also offering patient support via practice nurses and home visits. Overall, key determinants influencing GPs' initiation of antithrombotic therapy were: "stroke risk"/"CHADS2 score", followed by "patients' adherence/compliance". GPs focused more on medication safety considerations and the day-to-day management of therapy than on the risk of bleeding.

CONCLUSION

Australian GPs are actively engaged in managing AF, and appear to be well resourced. Importantly, there is a greater focus on the benefits of therapy during decision-making, rather than on the risks. However, medication safety considerations affecting routine management of therapy remain key concerns, with patients' adherence to therapy a major determinant in decision-making.