Improving stroke prevention therapy for patients with atrial fibrillation in primary care: protocol for a pragmatic, cluster-randomized trial

Patient- and Physician-Level Factors Associated With Adherence to C-CHANGE Recommendations in Primary Care Settings in Ontario

BACKGROUND

We previously found large variation among family physicians in adherence to the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE). We assessed the role of patient- and physician-level factors in the variation in adherence to recommendations for managing cardiovascular disease risk factors.

METHODS

We conducted a retrospective study using multilevel logistic regression analyses with the Electronic Medical Record Administrative data Linked Database (EMRALD) housed at ICES in Ontario. Five quality indicators based on C-CHANGE guidelines were modelled. Effects of clustering and between-group variation, patient-level (sociodemographics, comorbidities) and physician-level characteristics (demographic and practice information) were assessed to determine odds ratios of receiving C-CHANGE recommended care.

RESULTS

In all, 324 Ontario physicians practicing in 41 clinics who provided care to 227,999 adult patients were studied. We found significant variation in quality indicators, with 15% to 39% of the total variation attributable to nonpatient factors. The largest variation was in performing 2-hour plasma glucose testing in prediabetic patients. Patient-level factors most frequently associated with recommendation adherence included sex, age, and multi-comorbidities. Women were more likely than men to have their body mass index measured, and their blood pressure controlled, but less likely to receive antiplatelet medications and liver-enzyme testing if overweight or obese.

CONCLUSIONS

The majority of variations in adherence were attributable to patient attributes, but a substantial proportion of unexplained variation was due to differences among physicians and clinics. This finding may signal suboptimal processes or structures and warrant further investigation to improve the quality of primary care management of cardiovascular disease in Ontario.

eHealth Tools to Provide Structured Assistance for Atrial Fibrillation Screening, Management, and Guideline-Recommended Therapy in Metropolitan General Practice: The AF - SMART Study

Background

This eHealth implementation study aimed to evaluate strategies to promote opportunistic atrial fibrillation (AF) screening using electronic screening prompts and improve treatment using electronic decision support (EDS) software.

Methods and Results

An electronic screening prompt appeared whenever an eligible patient's (aged ≥65 years, no AF diagnosis) medical record was opened in participating general practices. General practitioners and practice nurses offered screening using a smartphone ECG, with validated AF algorithm. Guideline‐based EDS was provided to assist treatment decisions. Deidentified data were collected from practices using a data extraction tool. General practices (n=8) across Sydney, Australia, screened for a median of 6 months. A total of 1805 of 11 476 (16%) eligible patients who attended were screened (44% men, mean age 75.7 years). Screening identified 19 (1.1%) new cases of AF (mean age, 79 years; mean CHA₂DS₂‐VASc, 3.7; 53% men). General practitioners (n=30) performed 70% of all screenings (range 1–448 patients per general practitioner). The proportion of patients with AF who had CHA₂DS₂‐VASc ≥2 for men or ≥3 for women prescribed oral anticoagulants was higher for those diagnosed during the study: 15 of 18 (83%) for screen‐detected and 39 of 46 (85%) for clinically detected, compared with 933 of 1306 (71%) patients diagnosed before the study (P<0.001). The EDS was accessed 111 times for patients with AF and for 4 of 19 screen‐detected patients.

Conclusions

The eHealth tools showed promise. Adherence to guideline‐based oral anticoagulant prescription was significantly higher in patients diagnosed during the study period, although the EDS was only used in a minority. While the proportion of eligible patients screened and EDS use was relatively low, further refinements may improve uptake in clinical practice.

Clinical Trial Registration

URL: www.anzctr.org.au. Unique identifier: ACTRN12616000850471.

Measuring Cardiovascular Quality in Primary Care Using Canadian Cardiovascular Harmonization of National Guidelines Endeavour and Electronic Medical Record Data in Ontario

Background

This project uses electronic medical record (EMR) data to assess performance by family physicians (FPs) in the screening for, diagnosis, and management of cardiovascular disease (CVD) and risk factors against national harmonized guidelines by the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE).

Methods

A retrospective cohort study using the Electronic Medical Record Administrative Data Linked Database (EMRALD) was conducted. A set of quality indicators (QIs) were developed on the basis of the 2014 C-CHANGE guidelines. Twenty-three readily measurable QIs were used to measure performance in the screening for and management of CVD, and to identify gaps in performance.

Results

Our study population consisted of 324 Ontario FPs and 284,959 patients. We assessed 23 of the 74 recommendations. There was variance in rates of adherence to QIs related to screening rates for CVD. Highest adherence to C-CHANGE guidelines was related to laboratory testing for patients with hypertension and prescription of antihypertensive therapies (≥ 91.4%). Lowest adherence to the guidelines was seen in administration of oral glucose tolerance tests for assessing prediabetic patients (4.4%).

Conclusions

FP EMR data can be used to measure adherence to one-third of the C-CHANGE recommendations. There are varying levels of adherence among the measurable C-CHANGE recommendations, and there is room for improvement in quality of primary care management of CVD in Ontario. There is potential to use EMR data to assess changes to CVD management in FP practice using guidelines if recommendations are quantifiable and measurable.

Neuroprotective Agents in the Intensive Care Unit: -Neuroprotective Agents in ICU

Neuroprotection or prevention of neuronal loss is a complicated molecular process that is mediated by various cellular pathways. Use of different pharmacological agents as neuroprotectants has been reported especially in the last decades. These neuroprotective agents act through inhibition of inflammatory processes and apoptosis, attenuation of oxidative stress and reduction of free radicals. Control of this injurious molecular process is essential to the reduction of neuronal injuries and is associated with improved functional outcomes and recovery of the patients admitted to the intensive care unit. This study reviews neuroprotective agents and their mechanisms of action against central nervous system damages.

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.

Changes in Use of Anticoagulation in Patients With Atrial Fibrillation Within a Primary Care Network Associated With the Introduction of Direct Oral Anticoagulants

Atrial fibrillation (AF) and the decision to anticoagulate is a common problem faced by primary care physicians. Oral anticoagulation (OAC) is underused, despite its clear benefits with regard to stroke prevention. We examined OAC usage between 2010 and 2015, following the introduction of direct oral anticoagulants (DOACs) and specifically assessed whether more patients were anticoagulated over time. The study cohort included adult patients aged 18 and older with AF cared for in an 18-practice primary care network between 2010 and 2015. AF status was assigned each calendar year using a validated electronic health record algorithm. We examined OAC usage over time in all patients with AF, and in patients at high risk of stroke (CHA₂DS₂-VASc ≥ 2). The proportion of the population with AF increased over time (2010: 4,920 patients [3.5%], 2015: 6,452 patients [4.0%]). There was no increase in the proportion of patients prescribed any OAC treatment from 2010 (57.0%) to 2015 (57.4%) (p = 0.41). Similarly, in patients at high risk of stroke, the proportion anticoagulated did not increase over time (2010: 61.1%, 2015: 61.7%, p = 0.51). Over the study period, DOAC usage increased from 0.31% of all patients with AF in 2010 to 18.3% in 2015 (p < 0.001). Patients prescribed DOACs were younger, with lower risk of stroke. In conclusion, this study showed an increasing proportion of patients with AF over time in a primary care network. The use of DOACs increased over time; however, the proportion of patients treated with OAC did not increase over time.

Improving Care for Patients With or at Risk for Chronic Kidney Disease Using Electronic Medical Record Interventions: A Pragmatic Cluster-Randomized Trial Protocol

BACKGROUND

Many patients with or at risk for chronic kidney disease (CKD) in the primary care setting are not receiving recommended care.

OBJECTIVE

The objective of this study is to determine whether a multifaceted, low-cost intervention compared with usual care improves the care of patients with or at risk for CKD in the primary care setting.

DESIGN

A pragmatic cluster-randomized trial, with an embedded qualitative process evaluation, will be conducted.

SETTING

The study population comes from the Electronic Medical Record Administrative data Linked Database®, which includes clinical data for more than 140 000 rostered adults cared for by 194 family physicians in 34 clinics across Ontario, Canada. The 34 primary care clinics will be randomized to the intervention or control group.

INTERVENTION

The intervention group will receive resources from the "CKD toolkit" to help improve care including practice audit and feedback, printed educational materials for physicians and patients, electronic decision support and reminders, and implementation support.

MEASUREMENTS

Patients with or at risk for CKD within participating clinics will be identified using laboratory data in the electronic medical records. Outcomes will be assessed after dissemination of the CKD tools and after 2 rounds of feedback on performance on quality indicators have been sent to the physicians using information from the electronic medical records. The primary outcome is the proportion of patients aged 50 to 80 years with nondialysis-dependent CKD who are on a statin. Secondary outcomes include process of care measures such as screening tests, CKD recognition, monitoring tests, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker prescriptions, blood pressure targets met, and nephrologist referral. Hierarchical analytic modeling will be performed to account for clustering. Semistructured interviews will be conducted with a random purposeful sample of physicians in the intervention group to understand why the intervention achieved the observed effects.

CONCLUSIONS

If our intervention improves care, then the CKD toolkit can be adapted and scaled for use in other primary care clinics which use electronic medical records.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02274298.

The role of magnesium sulfate in the intensive care unit

Magnesium (Mg) has been developed as a drug with various clinical uses. Mg is a key cation in physiological processes, and the homeostasis of this cation is crucial for the normal function of body organs. Magnesium sulfate (MgSO4) is a mineral pharmaceutical preparation of magnesium that is used as a neuroprotective agent. One rationale for the frequent use of MgSO4 in critical care is the high incidence of hypomagnesaemia in intensive care unit (ICU) patients. Correction of hypomagnesaemia along with the neuroprotective properties of MgSO4 has generated a wide application for MgSO4 in ICU.