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Naccarelli GV, Ruzieh M, Wolbrette DL, Sendra-Ferrer M, van Harskamp J, Bentz B, Caputo G, McConkey N, Mills K, Wasemiller S, Plamenac J, Leslie D, Glasser FD, Abendroth TW. Oral Anticoagulation Use in High-Risk Patients Is Improved by Elimination of False-Positive and Inactive Atrial Fibrillation Cases. Am J Med 2021; 134:e366-e373. [PMID: 33359273 DOI: 10.1016/j.amjmed.2020.11.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/04/2020] [Accepted: 11/10/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Multiple registries have reported that >40% of high-risk atrial fibrillation patients are not taking oral anticoagulants. The purpose of our study was to determine the presence or absence of active atrial fibrillation and CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 y, Diabetes mellitus, prior Stroke [or transient ischemic attack or thromboembolism], Vascular disease, Age 65-74 y, Sex category) risk factors to accurately identify high-risk atrial fibrillation (CHA2DS2-VASc ≥2) patients requiring oral anticoagulants and the magnitude of the anticoagulant treatment gap. METHODS We retrospectively adjudicated 6514 patients with atrial fibrillation documented by at least one of: billing diagnosis, electronic medical record encounter diagnosis, electronic medical record problem list, or electrocardiogram interpretation. RESULTS After review, 4555/6514 (69.9%) had active atrial fibrillation, while 1201 had no documented history of atrial fibrillation and 758 had a history of atrial fibrillation that was no longer active. After removing the 1201 patients without a confirmed atrial fibrillation diagnosis, oral anticoagulant use in high-risk patients increased to 71.1% (P < .0001 compared with 62.9% at baseline). Oral anticoagulant use increased to 79.7% when the 758 inactive atrial fibrillation patients were also eliminated from the analysis (P < .0001 compared with baseline). In the active high-risk atrial fibrillation group, there was no significant difference in the use of oral anticoagulants between men (80.7%) and women (78.8%) with a CHA2DS2-VASc ≥2, or in women with a CHA2DS2-VASc ≥3 (79.9%). CONCLUSIONS Current registries and health system health records with unadjudicated diagnoses over-report the number of high-risk atrial fibrillation patients not taking oral anticoagulants. Expert adjudication identifies a smaller treatment gap than previously described.
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Affiliation(s)
- Gerald V Naccarelli
- Penn State University Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pa.
| | | | - Deborah L Wolbrette
- Penn State University Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pa
| | - Mauricio Sendra-Ferrer
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia
| | | | - Barbara Bentz
- Penn State University Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pa
| | - Gregory Caputo
- Division of Internal Medicine, Penn State University College of Medicine, Hershey, Pa
| | - Nathan McConkey
- Penn State University Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pa
| | - Kevin Mills
- Penn State University Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pa
| | | | - Jovan Plamenac
- Penn State University Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pa
| | - Douglas Leslie
- Department of Public Health Sciences, Penn State University College of Medicine, Hershey, Pa
| | - Frendy D Glasser
- Penn State University Center for Quality Innovation, Hershey, Pa
| | - Thomas W Abendroth
- Penn State University Center for Quality Innovation, Hershey, Pa; Penn State University College of Medicine, Penn State Health, The Milton S. Hershey Medical Center, Hershey, Pa
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Davies M, Kristunas CA, Huddlestone L, Alshreef A, Bodicoat D, Dixon S, Eborall H, Glab A, Hudson N, Khunti K, Martin G, Northern A, Patterson M, Pritchard R, Schreder S, Stribling B, Turner J, Gray LJ. Increasing uptake of structured self-management education programmes for type 2 diabetes in a primary care setting: a feasibility study. Pilot Feasibility Stud 2020; 6:71. [PMID: 32477589 PMCID: PMC7243310 DOI: 10.1186/s40814-020-00606-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 04/22/2020] [Indexed: 01/16/2023] Open
Abstract
Background Structured self-management education (SSME) for people with type 2 diabetes mellitus (T2DM) improves biomedical and psychological outcomes, whilst being cost-effective. Yet uptake in the UK remains low. An ‘Embedding Package’ addressing barriers and enablers to uptake at patient, health care professional and organisational levels has been developed. The aim of this study was to test the feasibility of conducting a subsequent randomised controlled trial (RCT) to evaluate the Embedding Package in primary care, using a mixed methods approach. Methods A concurrent mixed methods approach was adopted. Six general practices in the UK were recruited and received the intervention (the Embedding Package). Pseudonymised demographic, biomedical and SSME data were extracted from primary care medical records for patients recorded as having a diagnosis of T2DM. Descriptive statistics assessed quantitative data completeness and accuracy. Quantitative data were supplemented and validated by a patient questionnaire, for which two recruitment methods were trialled. Where consent was given, the questionnaire and primary care data were linked and compared. The cost of the intervention was estimated. An integrated qualitative study comprising ethnography and stakeholder and patient interviews explored the process of implementation, sustainability of change and ‘fit’ of the intervention. Qualitative data were analysed using a thematic framework guided by the Normalisation Process Theory (NPT). Results Primary care data were extracted for 2877 patients. The primary outcome for the RCT, HbA1c, was over 90% complete. Questionnaires were received from 423 (14.7%) participants, with postal invitations yielding more participants than general practitioner (GP) prompts. Ninety-one percent of questionnaire participants consented to data linkage. The mean cost per patient for the Embedding Package was £8.94, over a median follow-up of 162.5 days. Removing the development cost, this reduces to £5.47 per patient. Adoption of ethnographic and interview methods in the collection of data was appropriate, and the use of NPT, whilst challenging, enhanced the understanding of the implementation process. The need to delay the collection of patient interview data to enable the intervention to inform patient care was highlighted. Conclusions It is feasible to collect data with reasonable completeness and accuracy for the subsequent RCT, although refinement to improve the quality of the data collected will be undertaken. Based on resource use data collected, it was feasible to produce cost estimates for each individual component of the Embedding Package. The methods chosen to generate, collect and analyse qualitative data were satisfactory, keeping participant burden low and providing insight into potential refinements of the Embedding Package and customisation of the methods for the RCT. Trial registration ISRCTN, ISRCTN21321635, Registered 07/07/2017—retrospectively registered.
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Affiliation(s)
- Melanie Davies
- 1Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Caroline A Kristunas
- 1Diabetes Research Centre, University of Leicester, Leicester, UK.,2Department of Health Sciences, University of Leicester, Leicester, UK
| | - Lisa Huddlestone
- 2Department of Health Sciences, University of Leicester, Leicester, UK
| | - Abualbishr Alshreef
- 3School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Simon Dixon
- 3School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Helen Eborall
- 2Department of Health Sciences, University of Leicester, Leicester, UK
| | - Agnieszka Glab
- 4Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nicky Hudson
- 5Centre for Reproduction Research, School of Applied Social Science, De Montfort University, Leicester, UK
| | - Kamlesh Khunti
- 1Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Graham Martin
- 6THIS Institute, University of Cambridge, Cambridge, UK
| | - Alison Northern
- 4Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Mike Patterson
- 4Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Rebecca Pritchard
- 4Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sally Schreder
- 4Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Bernie Stribling
- 4Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jessica Turner
- 5Centre for Reproduction Research, School of Applied Social Science, De Montfort University, Leicester, UK
| | - Laura J Gray
- 2Department of Health Sciences, University of Leicester, Leicester, UK
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3
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Davies MJ, Kristunas CA, Alshreef A, Dixon S, Eborall H, Glab A, Huddlestone L, Hudson N, Khunti K, Martin G, Northern A, Patterson M, Pritchard R, Schreder S, Stribling B, Turner J, Gray LJ. The impact of an intervention to increase uptake to structured self-management education for people with type 2 diabetes mellitus in primary care (the embedding package), compared to usual care, on glycaemic control: study protocol for a mixed methods study incorporating a wait-list cluster randomised controlled trial. BMC FAMILY PRACTICE 2019; 20:152. [PMID: 31699046 PMCID: PMC6839094 DOI: 10.1186/s12875-019-1038-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/17/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Approximately 425 million people globally have diabetes, with ~ 90% of these having Type 2 Diabetes Mellitus (T2DM). This is a condition that leads to a poor quality of life and increased risk of serious health complications. Structured self-management education (SSME) has been shown to be effective in improving glycaemic control and patient related outcome measures and to be cost-effective. However, despite the demonstrated benefits, attendance at SSME remains low. An intervention has been developed to embed SSME called the 'Embedding Package'. The intervention aims to address barriers and enhance enablers to uptake of SSME at patient, healthcare professional and organisational levels. It comprises a marketing strategy, user friendly and effective referral pathways, new roles to champion SSME and a toolkit of resources. METHODS A mixed methods study incorporating a wait-list cluster randomised trial and ethnographic study, including 66 UK general practices, will be conducted with two intervention start times (at 0 and 9 months), each followed by an active delivery phase. At 18 months, the intervention will cease to be actively delivered and a 12 month observational follow-up phase will begin. The intervention, the Embedding Package, aims to increase SSME uptake and subsequent improvements in health outcomes, through a clear marketing strategy, user friendly and effective referral pathways, a local clinical champion and an 'Embedder' and a toolkit of resources for patients, healthcare professionals and other key stakeholders. The primary aim is, through increasing uptake to and attendance at SSME, to reduce HbA1c in people with T2DM compared with usual care. Secondary objectives include: assessing whether there is an increase in referral to and uptake of SSME and improvements in biomedical and psychosocial outcomes; an assessment of the sustainability of the Embedding Package; contextualising the process of implementation, sustainability of change and the 'fit' of the Embedding Package; and an assessment of the cost-effectiveness of the Embedding Package. DISCUSSION This study will assess the effectiveness, cost-effectiveness and sustainability of the Embedding Package, an intervention which aims to improve biomedical and psychosocial outcomes of people with T2DM, through increased referral to and uptake of SSME. TRIAL REGISTRATION International Standard Randomised Controlled Trials Number ISRCTN23474120. Assigned 05/04/2018. The study was prospectively registered. On submission of this manuscript practice recruitment is complete, participant recruitment is ongoing and expected to be completed by the end of 2019.
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Affiliation(s)
- Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK.,Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Caroline A Kristunas
- Diabetes Research Centre, University of Leicester, Leicester, UK.,Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, George Davies Centre , University Road, Leicester, LE1 7RH, UK
| | - Abualbishr Alshreef
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Simon Dixon
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Helen Eborall
- Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, George Davies Centre , University Road, Leicester, LE1 7RH, UK
| | - Agnieszka Glab
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Lisa Huddlestone
- Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, George Davies Centre , University Road, Leicester, LE1 7RH, UK
| | - Nicky Hudson
- Centre for Reproduction Research, School of Applied Social Science, De Montfort University, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK.,Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Graham Martin
- THIS Institute, University of Cambridge, Cambridge, UK
| | - Alison Northern
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Mike Patterson
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Rebecca Pritchard
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sally Schreder
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Bernie Stribling
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jessica Turner
- Centre for Reproduction Research, School of Applied Social Science, De Montfort University, Leicester, UK
| | - Laura J Gray
- Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, George Davies Centre , University Road, Leicester, LE1 7RH, UK.
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Barriers to a software reminder system for risk assessment of stroke in atrial fibrillation: a process evaluation of a cluster randomised trial in general practice. Br J Gen Pract 2018; 68:e844-e851. [PMID: 30397015 DOI: 10.3399/bjgp18x699809] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/29/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Oral anticoagulants reduce the risk of stroke in patients with atrial fibrillation (AF), but are underused. AURAS-AF (AUtomated Risk Assessment for Stroke in AF) is a software tool designed to identify eligible patients and promote discussions within consultations about initiating anticoagulants. AIM To investigate the implementation of the software in UK general practice. DESIGN AND SETTING Process evaluation involving 23 practices randomly allocated to use AURAS-AF during a cluster randomised trial. METHOD An initial invitation to discuss anticoagulation was followed by screen reminders appearing during consultations until a decision had been made. The reminders required responses, giving reasons for cases where an anticoagulant was not initiated. Qualitative interviews with clinicians and patients explored acceptability and usability. RESULTS In a sample of 476 patients eligible for the invitation letter, only 159 (33.4%) were considered suitable for invitation by their GPs. Reasons given were frequently based on frailty, and risk of falls or haemorrhage. Of those invited, 35 (22%) started an anticoagulant (7.4% of those originally identified). A total of 1695 main-screen reminders occurred in 940 patients. In 883 instances, the decision was taken not to initiate and a range of reasons offered. Interviews with 15 patients and seven clinicians indicated that the intervention was acceptable, though the issue of disruptive screen reminders was raised. CONCLUSION Automated risk assessment for stroke in atrial fibrillation and prompting during consultations are feasible and generally acceptable, but did not overcome concerns about frailty and risk of haemorrhage as barriers to anticoagulant uptake.
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Sheibani R, Sheibani M, Heidari-Bakavoli A, Abu-Hanna A, Eslami S. The Effect of a Clinical Decision Support System on Improving Adherence to Guideline in the Treatment of Atrial Fibrillation: An Interrupted Time Series Study. J Med Syst 2017; 42:26. [PMID: 29273997 DOI: 10.1007/s10916-017-0881-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/13/2017] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Reza Sheibani
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Computer Engineering, Mashhad Branch, Islamic Azad University, Mashhad, Iran
| | - Mehdi Sheibani
- Cardiovascular Research Center, 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.
- Pharmaceutical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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6
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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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Karlsson LO, Nilsson S, Charitakis E, Bång M, Johansson G, Nilsson L, Janzon M. Clinical decision support for stroke prevention in atrial fibrillation (CDS-AF): Rationale and design of a cluster randomized trial in the primary care setting. Am Heart J 2017; 187:45-52. [PMID: 28454807 DOI: 10.1016/j.ahj.2017.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 02/08/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with substantial morbidity, in particular stroke. Despite good evidence for the reduction of stroke risk with anticoagulant therapy, there remains a significant undertreatment. The main aim of the current study is to investigate whether a clinical decision support tool for stroke prevention (CDS) integrated in the electronic health record can improve adherence to guidelines for stroke prevention in patients with AF. METHODS We will conduct a cluster randomized trial where 43 primary care clinics in the county of Östergötland, Sweden (population 444,347), will be randomized to be part of the CDS intervention or serve as controls. The CDS will alert responsible physicians of patients with AF and increased risk for thromboembolism according to the CHA2DS2VASc (Congestive heart failure, Hypertension, Age ≥ 74 years, Diabetes mellitus, previous Stroke/TIA/thromboembolism, Vascular disease, Age 65-74 years, Sex category (i.e. female sex)) algorithm without anticoagulant therapy. The primary end point will be adherence to guidelines after 1 year. CONCLUSION The present study will investigate whether a clinical decision support system integrated in an electronic health record can increase adherence to guidelines regarding anticoagulant therapy in patients with AF.
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Holt TA, Dalton A, Marshall T, Fay M, Qureshi N, Kirkpatrick S, Hislop J, Lasserson D, Kearley K, Mollison J, Yu LM, Hobbs FDR, Fitzmaurice D. Automated Software System to Promote Anticoagulation and Reduce Stroke Risk: Cluster-Randomized Controlled Trial. Stroke 2017; 48:787-790. [PMID: 28119433 DOI: 10.1161/strokeaha.116.015468] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 10/31/2016] [Accepted: 11/08/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Oral anticoagulants (OAC) substantially reduce risk of stroke in atrial fibrillation, but uptake is suboptimal. Electronic health records enable automated identification of people at risk but not receiving treatment. We investigated the effectiveness of a software tool (AURAS-AF [Automated Risk Assessment for Stroke in Atrial Fibrillation]) designed to identify such individuals during routine care through a cluster-randomized trial. METHODS Screen reminders appeared each time the electronic health records of an eligible patient was accessed until a decision had been taken over OAC treatment. Where OAC was not started, clinicians were prompted to indicate a reason. Control practices continued usual care. The primary outcome was the proportion of eligible individuals receiving OAC at 6 months. Secondary outcomes included rates of cardiovascular events and reports of adverse effects of the software on clinical decision-making. RESULTS Forty-seven practices were randomized. The mean proportion-prescribed OAC at 6 months was 66.3% (SD=9.3) in the intervention arm and 63.9% (9.5) in the control arm (adjusted difference 1.21% [95% confidence interval -0.72 to 3.13]). Incidence of recorded transient ischemic attack was higher in the intervention practices (median 10.0 versus 2.3 per 1000 patients with atrial fibrillation; P=0.027), but at 12 months, we found a lower incidence of both all cause stroke (P=0.06) and hemorrhage (P=0.054). No adverse effects of the software were reported. CONCLUSIONS No significant change in OAC prescribing occurred. A greater rate of diagnosis of transient ischemic attack (possibly because of improved detection or overdiagnosis) was associated with a reduction (of borderline significance) in stroke and hemorrhage over 12 months. CLINICAL TRIAL REGISTRATION URL: http://www.isrctn.com. Unique Identifier: ISRCTN55722437.
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Affiliation(s)
- Tim A Holt
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.).
| | - Andrew Dalton
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.)
| | - Tom Marshall
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.)
| | - Matthew Fay
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.)
| | - Nadeem Qureshi
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.)
| | - Susan Kirkpatrick
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.)
| | - Jenny Hislop
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.)
| | - Daniel Lasserson
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.)
| | - Karen Kearley
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.)
| | - Jill Mollison
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.)
| | - Ly-Mee Yu
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.)
| | - F D Richard Hobbs
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.)
| | - David Fitzmaurice
- From the Nuffield Department of Primary Care Health Sciences, Oxford University, United Kingdom (T.A.H., S.K., J.H., D.L., K.K., J.M., L.-M.Y., F.D.R.H.); Postgraduate School of Public Health, Health Education West Midlands, Birmingham, United Kingdom (A.D.); Primary Care Clinical Sciences, Birmingham University, United Kingdom (T.M., D.F.); Westcliffe Medical Centre, Shipley, United Kingdom (M.F.); and School of Medicine, University of Nottingham, United Kingdom (N.Q.)
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Cook DA, Enders F, Caraballo PJ, Nishimura RA, Lloyd FJ. An automated clinical alert system for newly-diagnosed atrial fibrillation. PLoS One 2015; 10:e0122153. [PMID: 25849969 PMCID: PMC4388495 DOI: 10.1371/journal.pone.0122153] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 02/13/2015] [Indexed: 11/18/2022] Open
Abstract
Objective Clinical decision support systems that notify providers of abnormal test results have produced mixed results. We sought to develop, implement, and evaluate the impact of a computer-based clinical alert system intended to improve atrial fibrillation stroke prophylaxis, and identify reasons providers do not implement a guideline-concordant response. Materials and Methods We conducted a cohort study with historical controls among patients at a tertiary care hospital. We developed a decision rule to identify newly-diagnosed atrial fibrillation, automatically notify providers, and direct them to online evidence-based management guidelines. We tracked all notifications from December 2009 to February 2010 (notification period) and applied the same decision rule to all patients from December 2008 to February 2009 (control period). Primary outcomes were accuracy of notification (confirmed through chart review) and prescription of warfarin within 30 days. Results During the notification period 604 notifications were triggered, of which 268 (44%) were confirmed as newly-diagnosed atrial fibrillation. The notifications not confirmed as newly-diagnosed involved patients with no recent electrocardiogram at our institution. Thirty-four of 125 high-risk patients (27%) received warfarin in the notification period, compared with 34 of 94 (36%) in the control period (odds ratio, 0.66 [95% CI, 0.37–1.17]; p = 0.16). Common reasons to not prescribe warfarin (identified from chart review of 151 patients) included upcoming surgical procedure, choice to use aspirin, and discrepancy between clinical notes and the medication record. Conclusions An automated system to identify newly-diagnosed atrial fibrillation, notify providers, and encourage access to management guidelines did not change provider behaviors.
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Affiliation(s)
- David A. Cook
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States of America
- Mayo Clinic Online Learning, Mayo Clinic College of Medicine, Rochester, MN, United States of America
- * E-mail:
| | - Felicity Enders
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Pedro J. Caraballo
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Rick A. Nishimura
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Farrell J. Lloyd
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Division of Hospital Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States of America
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