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Amin AM, Ghaly R, Abuelazm MT, Ibrahim AA, Tanashat M, Arnaout M, Altobaishat O, Elshahat A, Abdelazeem B, Balla S. 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. Thromb J 2024; 22:45. [PMID: 38807186 PMCID: PMC11134712 DOI: 10.1186/s12959-024-00614-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 05/11/2024] [Indexed: 05/30/2024] Open
Abstract
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.
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Affiliation(s)
| | - Ramy Ghaly
- Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | | | | | | | - Obieda Altobaishat
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, Morgantown, WV, USA
| | - Sudarshan Balla
- Department of Cardiology, West Virginia University, Morgantown, WV, USA
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Belenkov YN, Popova LV, Ilgisonis SI. [Management of patients with atrial fibrillation and minor bleeding during therapy with direct oral anti-coagulants]. KARDIOLOGIIA 2021; 61:72-81. [PMID: 35057724 DOI: 10.18087/cardio.2021.12.n1872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 10/10/2021] [Accepted: 10/29/2021] [Indexed: 06/14/2023]
Abstract
The recommended tactics for prevention of thromboembolic complications of atrial fibrillation (AF) is the oral anticoagulant (OAC) treatment. The drugs of choice for preventing stroke for most patients with AF, excluding some valvular defects, are direct OACs (DOACS). Regardless of the drug class, all anticoagulants, even at appropriate doses, increase the risk of bleeding. However, the development of minor bleedings is not an absolute indication for DOAC withdrawal. This review presents a tactics for management of patients with minor bleeding associated with the DOAC treatment.
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Affiliation(s)
- Yu N Belenkov
- I.M. Sechenov First Moscow State Medical University, Moscow
| | - L V Popova
- I.M. Sechenov First Moscow State Medical University, Moscow
| | - S I Ilgisonis
- I.M. Sechenov First Moscow State Medical University, Moscow
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Osasu YM, Cooper R, Mitchell C. Patients' and clinicians' perceptions of oral anticoagulants in atrial fibrillation: a systematic narrative review and meta-analysis. BMC FAMILY PRACTICE 2021; 22:254. [PMID: 34937557 PMCID: PMC8697449 DOI: 10.1186/s12875-021-01590-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 11/22/2021] [Indexed: 11/10/2022]
Abstract
Background Atrial fibrillation (AF) increases the risk of developing a stroke by 20%. AF related strokes are associated with greater morbidity. Historically, warfarin was the anticoagulant of choice for stroke prevention in patients with AF but lately patients are being switched or started on direct oral anticoagulants (DOACs). DOACs are promoted as safer alternatives to warfarin and it is expected that they will be associated with fewer challenges both for patients and healthcare professionals. This systematic narrative review aimed to explore perspectives of patients and professionals on medicines optimisation of oral anticoagulation with vitamin K antagonists and DOACs in atrial fibrillation. Methods Prospero registration CRD42018091591. Systematic searches undertaken of research studies (qualitative and quantitative), published February 2018 to November 2020 from several databases (Web of Science, Scopus, Medline Via Ovid, CINHAL via Ebsco, and PubMED via NCBI) following PRISMA methodology. Data were organised using Covidence software. Two reviewers independently assessed the quality of the included studies and synthesized the findings (thematic analysis approach). Results Thirty-four studies were included. Studies were critically appraised using established critical appraisal tools (Qualsyst) and a risk of bias was assigned. Clinicians considered old age and the associated complexities such as co-morbidities and the increased potential for bleeding as potential barriers to optimising anticoagulation. Whereas patients’ health and medication beliefs influenced adherence. Notably, structured patient support was important in enhancing safety and effective anticoagulation. For both patients and clinicians, confidence and experience of safe anticoagulation was influenced by the presence of co-morbidities, poor knowledge and understanding of AF and the purpose of anticoagulation. Conclusion Age, complex multimorbidity and polypharmacy influence prescribing, with DOACs being perceived to be safer than warfarin. This systematic narrative review suggests that interventions are needed to support patient self-management. There are residual anxieties associated with long term anticoagulation in the context of complexities. Trial registration Not applicable.
Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01590-x.
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Affiliation(s)
- Yeyenta Mina Osasu
- Academic Unit of Primary Medical Care, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, S5 7AU, UK.
| | | | - Caroline Mitchell
- Academic Unit of Primary Medical Care, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, S5 7AU, UK
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Diaz J, Koza E, Chaudhary D, Shahjouei S, Naved MMA, Malik MT, Li J, Adibuzzaman M, Griffin P, Abedi V, Zand R. Adherence to anticoagulant guideline for atrial fibrillation: A large care gap among stroke patients in a rural population. J Neurol Sci 2021; 424:117410. [PMID: 33770707 DOI: 10.1016/j.jns.2021.117410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/12/2021] [Accepted: 03/18/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to investigate the prevalence and factors associated with oral anticoagulant undertreatment of atrial fibrillation (AF) among a cohort of rural patients with stroke outcomes and examine how undertreatment may influence a patient's one-year survival after stroke. METHODS This retrospective cohort study examined ischemic stroke patients with pre-stroke AF diagnosis from September 2003 to May 2019 and divided them into proper treatment and undertreatment group. Analysis included chi-square test, variance analysis, Kruskal-Wallis test, logistic regression, Kaplan-Meier estimator, and Cox proportional-hazards model. RESULTS Out of 1062 ischemic stroke patients with a pre-stroke AF diagnosis, 1015 patients had a CHA2DS2-VASc score ≥2, and 532 (52.4%) of those were undertreated. Median time from AF diagnosis to index stroke was significantly lower among undertreated patients (1.9 years vs. 3.6 years, p < 0.001). Other thromboembolism, excluding stroke, TIA, and myocardial infarction (OR 0.41, p < 0.001), the number of encounters per year (OR 0.90, p < 0.001), and the median time between AF diagnosis and stroke event (OR 0.86, p < 0.001) were negatively associated with undertreatment. Kaplan-Meier estimator showed no statistical difference in the one-year survival probability between groups (log-rank test, p = 0.29), while the Cox-Hazard model showed that age (HR 1.05, p < 0.001) and history of congestive heart failure (HR 1.88, p < 0.001) increased the risk of mortality. CONCLUSIONS More than half of our rural stroke patients with a pre-index AF diagnosis were not on guideline-recommended treatment. The study highlights a large care gap and an opportunity to improve AF management.
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Affiliation(s)
- Johan Diaz
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Durgesh Chaudhary
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | - Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | | | - Muhammad Taimur Malik
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA
| | - Mohammad Adibuzzaman
- Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Paul Griffin
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA, USA
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA; Biocomplexity Institute, Virginia Tech, Blacksburg, VA, USA
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA.
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O'Brien EC, Holmes DN, Thomas LE, Fonarow GC, Allen LA, Gersh BJ, Kowey PR, Singer DE, Ezekowitz MD, Naccarelli GV, Ansell JE, Chan PS, Mahaffey KW, Go AS, Freeman JV, Reiffel JA, Peterson ED, Piccini JP, Hylek EM. Prognostic Significance of Nuisance Bleeding in Anticoagulated Patients With Atrial Fibrillation. Circulation 2019; 138:889-897. [PMID: 29678813 DOI: 10.1161/circulationaha.117.031354] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Bleeding is commonly cited as a reason for stopping oral anticoagulants (OACs). Whether minor bleeding events (nuisance bleeding, NB) in patients with atrial fibrillation on OACs are associated with OAC discontinuation, major bleeding, and stroke/systemic embolism (SSE) is unknown. METHODS Within the ORBIT-AF prospective, outpatient registry (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation), we identified 6771 patients ≥18 years of age at 172 sites with atrial fibrillation and eligible follow-up visits. NB was ascertained from the medical record and was defined as minor bleeding that did not require medical attention (eg, bruising, hemorrhoidal bleeding). We used multivariable pooled logistic regression modeling to evaluate the associations between NB and major bleeding and SSE in the 180 days after documentation of NB. Our unit of analysis was the patient visit, occurring at ≈6-month intervals for a median of 1.5 years following enrollment. Changes in anticoagulation treatment satisfaction after NB were examined descriptively in a subset of patients. RESULTS The median age of the overall population was 75.0 (interquartile range, 67.0-81.0); 90.0% were white and 42.5% were female. Among 6771 patients (18 560 visits), n=1357 (20.0%) had documented NB, for an incidence rate of 14.8 events per 100 person-years. Over 96.4% of patients remained on OAC therapy after the NB event. Overall, 287 (4.3%) patients experienced major bleeding and 64 (0.96%) had a SSE event during follow-up. NB was not associated with a significant increased risk of major bleeding over 6 months in models adjusting for the ATRIA bleeding score (Anticoagulation and Risk Factors in Atrial Fibrillation) (odds ratio, 1.04; 95% confidence interval, 0.68-1.60; P=0.86). NB was also not associated with increased SSE risk over 6 months in models adjusting for the CHA2DS2-VASc risk score (odds ratio, 1.24; 95% confidence interval, 0.53-2.91; P=0.62). CONCLUSIONS NB is common among patients with atrial fibrillation on OACs. However, NB was not associated with a higher risk of major bleeding or SSE over the next 6 months, suggesting its occurrence should not lead to changes in anticoagulation treatment strategies in OAC-treated patients. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01165710.
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Affiliation(s)
- Emily C O'Brien
- Duke Clinical Research Institute, Durham, NC (E.C.O., D.N.H., L.E.T., E.D.P., J.P.P.)
| | - DaJuanicia N Holmes
- Duke Clinical Research Institute, Durham, NC (E.C.O., D.N.H., L.E.T., E.D.P., J.P.P.)
| | - Laine E Thomas
- Duke Clinical Research Institute, Durham, NC (E.C.O., D.N.H., L.E.T., E.D.P., J.P.P.)
| | | | - Larry A Allen
- University of Colorado Denver School of Medicine (L.A.A.)
| | | | - Peter R Kowey
- Jefferson Medical College, Wynnewood, PA (P.R.K., M.D.E.)
| | - Daniel E Singer
- Harvard Medical School and Massachusetts General Hospital, Boston (D.E.S.)
| | | | | | - Jack E Ansell
- Hofstra North Shore/LIJ School of Medicine, Hempstead, NY (J.E.A.)
| | - Paul S Chan
- University of Missouri-Kansas City School of Medicine (P.S.C.)
| | | | - Alan S Go
- Kaiser Permanente, Oakland, CA (A.S.G.)
| | | | - James A Reiffel
- Columbia University, Division of Cardiology, New York, NY (J.A.R.)
| | - Eric D Peterson
- Duke Clinical Research Institute, Durham, NC (E.C.O., D.N.H., L.E.T., E.D.P., J.P.P.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, NC (E.C.O., D.N.H., L.E.T., E.D.P., J.P.P.)
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Optimizing Anticoagulation in Older Patients with Nonvalvular Atrial Fibrillation. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0599-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Incidence, predictive factors, management, and survival impact of atrial fibrillation in non-Hodgkin lymphoma. Ann Hematol 2018; 97:1633-1640. [PMID: 29728734 DOI: 10.1007/s00277-018-3346-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/23/2018] [Indexed: 01/01/2023]
Abstract
Atrial fibrillation (AF) and cancer are common disorders in the general population but there are few studies in patients with both diseases. More specifically, there are scarce data on AF in patients with non-Hodgkin lymphoma (NHL). We assessed the incidence, predictive factors, management, and survival impact of AF in a cohort of patients with NHL from a single institution between 2002 and 2016 (n = 747). Twenty-three patients were diagnosed with AF before and 40 after the diagnosis of NHL (of the later, 16 were secondary to an extracardiac comorbidity and 24 unrelated to any triggering event [primary AF]). The 5-year cumulative incidence of new-onset AF was 4% (95% confidence interval [CI] 3-6%). Age and hypertension were the only predictive factors for the development of AF. Management of AF was heterogeneous, primarily with anti-vitamin K agents but also antiplatelet therapy in a significant proportion of patients. Among the 63 patients, there were six episodes of ischemic stroke/transient ischemic attack and four venous thromboembolic events, with four major bleeding episodes. Overall survival (OS) was inferior in patients with AF (HR 0.1, 95% CI 0.01-0.7, p = 0.02), largely due to secondary AF. We conclude that the incidence of new-onset AF in NHL patients seemed somewhat higher than in the general population, although with similar predictive factors. The management was heterogeneous, and the risk of ischemic and hemorrhagic events did not seem higher than in cancer-free patients. Survival was particularly poor for patients with secondary AF.
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Adderley N, Ryan R, Marshall T. The role of contraindications in prescribing anticoagulants to patients with atrial fibrillation: a cross-sectional analysis of primary care data in the UK. Br J Gen Pract 2017; 67:e588-e597. [PMID: 28630059 PMCID: PMC5569738 DOI: 10.3399/bjgp17x691685] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 11/30/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Underuse of anticoagulants in atrial fibrillation (AF) is an international problem, which has often been attributed to the presence of contraindications to treatment. No studies have assessed the influence of contraindications on anticoagulant prescribing in the UK. AIM To determine the influence of contraindications on anticoagulant prescribing in patients with AF in the UK. DESIGN AND SETTING Cross-sectional analysis of primary care data from 645 general practices contributing to The Health Improvement Network, a large UK database of electronic primary care records. METHOD Twelve sequential cross-sectional analyses were carried out from 2004 to 2015. Patients with a diagnosis of AF aged ≥35 years and registered for at least 1 year were included. Outcome measure was prescription of anticoagulant medication. RESULTS Over the 12 study years, the proportion of eligible patients with AF with contraindications who were prescribed anticoagulants increased from 40.1% (95% confidence interval [CI] = 38.3 to 41.9) to 67.2% (95% CI = 65.6 to 68.8), and the proportion of those without contraindications prescribed anticoagulants increased from 42.1% (95% CI = 41.6 to 42.6) to 67.7% (95% CI = 67.2 to 68.1). In patients with a recent history of major bleeding or aneurysm, prescribing rates increased from 44.3% (95% CI = 42.2 to 46.5) and 34.8% (95% CI = 29.4 to 40.6) in 2004 to 71.7% (95% CI = 69.9 to 73.5) and 63.2% (95% CI = 58.3 to 67.8) in 2015, respectively, comparable with rates in patients without contraindications. CONCLUSION The presence or absence of recorded contraindications has little influence on the decision to prescribe anticoagulants for the prevention of stroke in patients with AF. The study analysis suggests that, nationally, 38 000 patients with AF with contraindications are treated with anticoagulants. This has implications for patient safety.
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Affiliation(s)
- Nicola Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - Ronan Ryan
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham
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Ceornodolea AD, Bal R, Severens JL. Epidemiology and Management of Atrial Fibrillation and Stroke: Review of Data from Four European Countries. Stroke Res Treat 2017; 2017:8593207. [PMID: 28634569 PMCID: PMC5467327 DOI: 10.1155/2017/8593207] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/13/2017] [Accepted: 04/20/2017] [Indexed: 12/15/2022] Open
Abstract
In Europe, 1-3% of the population suffers from atrial fibrillation (AF) and has increased stroke risk. By 2060 a doubling in number of cases and great burden in managing this medical condition are expected. This paper offers an overview of data on epidemiology and management of AF and stroke in four European countries as well as the interconnection between these dimensions. A search index was developed to access multiple scientific and "grey" literatures. Information was prioritised based on strength of evidence and date. Information on country reports was double-checked with national experts. The overall prevalence of AF is consistent across countries. France has the lowest stroke incidence and mortality, followed by Netherland and UK, while Romania has higher rates. GPs or medical specialists are responsible for AF treatment; exception are the special thrombosis services in the Netherlands. Prevention measurements are only present in UK through screening programs. Although international and national guidelines are available, undertreatment is present in all countries. Despite differences in healthcare systems and management of AF, epidemiology is comparable between three of the countries. Romania is an outlier, by being limited in data accessibility. This knowledge can contribute to improved AF care in Europe.
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Affiliation(s)
- Andreea D. Ceornodolea
- eMbrace Institute, Amsterdam, Netherlands
- Institute of Health Policy & Management, Erasmus University Rotterdam, Postbus 1738, 3000 DR Rotterdam, Netherlands
| | - Roland Bal
- Institute of Health Policy & Management, Erasmus University Rotterdam, Postbus 1738, 3000 DR Rotterdam, Netherlands
| | - Johan L. Severens
- Institute of Health Policy & Management, Erasmus University Rotterdam, Postbus 1738, 3000 DR Rotterdam, Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, Netherlands
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Arts DL, Abu-Hanna A, Medlock SK, van Weert HCPM. Effectiveness and usage of a decision support system to improve stroke prevention in general practice: A cluster randomized controlled trial. PLoS One 2017; 12:e0170974. [PMID: 28245247 PMCID: PMC5330455 DOI: 10.1371/journal.pone.0170974] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 12/20/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Adherence to guidelines pertaining to stroke prevention in patients with atrial fibrillation is poor. Decision support systems have shown promise in increasing guideline adherence. AIMS To improve guideline adherence with a non-obtrusive clinical decision support system integrated in the workflow. Secondly, we seek to capture reasons for guideline non-adherence. DESIGN AND SETTING A cluster randomized controlled trial in Dutch general practices. METHOD A decision support system was developed that implemented properties positively associated with effectiveness: real-time, non-interruptive and based on data from electronic health records. Recommendations were based on the Dutch general practitioners guideline for atrial fibrillation that uses the CHA2DS2-VAsc for stroke risk stratification. Usage data and responses to the recommendations were logged. Effectiveness was measured as adherence to the guideline. We used a chi square to test for group differences and a mixed effects model to correct for clustering and baseline adherence. RESULTS Our analyses included 781 patients. Usage of the system was low (5%) and declined over time. In total, 76 notifications received a response: 58% dismissal and 42% acceptance. At the end of the study, both groups had improved, by 8% and 5% respectively. There was no statistically significant difference between groups (Control: 50%, Intervention: 55% P = 0.23). Clustered analysis revealed similar results. Only one usable reasons for non-adherence was captured. CONCLUSION Our study could not demonstrate the effectiveness of a decision support system in general practice, which was likely due to lack of use. Our findings should be used to develop next generation decision support systems that are effective in the challenging setting of general practice.
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Affiliation(s)
- Derk L. Arts
- Academic Medical Centre, Department of General Practice Amsterdam, The Netherlands
- Academic Medical Centre, Department of Medical Informatics, Amsterdam, The Netherlands
| | - Ameen Abu-Hanna
- Academic Medical Centre, Department of Medical Informatics, Amsterdam, The Netherlands
| | - Stephanie K. Medlock
- Academic Medical Centre, Department of Medical Informatics, Amsterdam, The Netherlands
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Wehbe RM, Yadlapati A. Underuse of Oral Anticoagulants for Nonvalvular Atrial Fibrillation: Past, Present, and Future. Tex Heart Inst J 2016; 43:287-90. [PMID: 27547134 DOI: 10.14503/thij-16-5785] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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12
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Discrepancy between guidelines for stroke prevention in atrial fibrillation and practice patterns in primary care. The nationwide French AFIGP survey. Arch Cardiovasc Dis 2015; 108:544-53. [DOI: 10.1016/j.acvd.2015.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/17/2015] [Accepted: 05/12/2015] [Indexed: 11/21/2022]
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13
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Aronis KN, Thigpen JL, Tripodis Y, Dillon C, Forster K, Henault L, Quinn EK, Berger PB, Limdi NA, Hylek EM. Paroxysmal atrial fibrillation and the hazards of under-treatment. Int J Cardiol 2015; 202:214-20. [PMID: 26397414 DOI: 10.1016/j.ijcard.2015.09.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/23/2015] [Accepted: 09/06/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Oral anticoagulants are highly efficacious for the prevention of stroke in atrial fibrillation, and are the preferred treatment by current guidelines. The purpose of our study was to assess the utilization of antithrombotic drugs in atrial fibrillation patients at the time of ischemic stroke and the factors associated with their use. METHODS We enrolled 759 consecutive patients admitted with ischemic stroke at Boston Medical Center, Geisinger Health System, and the University of Alabama. To be eligible, patients had to have electrocardiographically-confirmed atrial fibrillation at the time of admission or within 6 months of the index stroke. All stroke events and electrocardiograms were validated by study physicians. Patients with newly diagnosed atrial fibrillation were not eligible. RESULTS The mean age was 78 years, 43% were male, 19% black, and the mean CHADS2 score is 3.0. Atrial fibrillation was paroxysmal in 31%. At presentation, 181 (24%) patients were taking warfarin only, 96 (13%) both warfarin and aspirin, 294 (39%) aspirin alone, and 189 (25%) no antithrombotic therapy. The mean international normalized ratio was 1.6. Among patients with paroxysmal atrial fibrillation, one in five was taking warfarin. Although increasing stroke risk was associated with a greater likelihood of warfarin use, only 39% of highest risk CHADS2 3-6 were taking warfarin at the time of stroke. CONCLUSIONS Among high-risk individuals with atrial fibrillation, only 37% were taking warfarin at the time of stroke. Paroxysmal atrial fibrillation was associated with the highest risk of not receiving warfarin.
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Affiliation(s)
- Konstantinos N Aronis
- Department of Medicine, Boston Medical Center, Boston University, 801 Massachusetts Avenue, Crosstown 2, Boston, MA 02118 USA.
| | - Jonathan L Thigpen
- Department of Pharmacy, Notre Dame of Maryland University, Baltimore, MD, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Chrisly Dillon
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristen Forster
- Department of Cardiology, Geisinger Health System, Danville, PA, USA
| | - Lori Henault
- Department of Medicine, Boston Medical Center, Boston University, 801 Massachusetts Avenue, Crosstown 2, Boston, MA 02118 USA
| | - Emily Kate Quinn
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Peter B Berger
- Department of Cardiology, Geisinger Health System, Danville, PA, USA
| | - Nita A Limdi
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Elaine M Hylek
- Department of Medicine, Boston Medical Center, Boston University, 801 Massachusetts Avenue, Crosstown 2, Boston, MA 02118 USA
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Sabouret P, Depret-Bixio L, Cotte FE, Marie P, Bedira N, Blin P. Sex differences in stroke prevention in atrial fibrillation in French primary care. Results of the AFIGP (Atrial Fibrillation In General Practice) database. Clin Res Cardiol 2014; 103:887-93. [PMID: 24830515 DOI: 10.1007/s00392-014-0726-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Most of the French patients diagnosed with atrial fibrillation (AF) are managed by general practitioners (GPs). The objective was to evaluate stroke prevention in AF patients ahead of the arrival of the non vitamin K oral anticoagulant in France. METHODS A cross-sectional study using a French GPs database of all patients with a diagnosis of AF consulting their GP between July-2010 and June-2011. Multivariate analyses were used to identify determinants of prevention prescription. RESULTS Among 15,623 AF patients, 42.5 % were ≥75 years and 40.5 % women, 59.2 % had hypertension, 17.2 % diabetes, 11.4 % heart failure, 4.9 % stroke history. CHADS2 score was ≥1 for 83.1 % and ≥2 for 50.9 % of patients (CHA2DS2-VASc score ≥1 for 93.7 % and ≥2 for 82.3 %). Antithrombotic therapies were vitamin K antagonists (VKA) for 50.7 % of patients, followed by aspirin for 19.9 %, clopidogrel ± aspirin for 4.3 % and none for 25.1 %. For patients with CHADS2 scores ≥1, 73.3 % received an antithrombotic and for those with CHADS2 scores ≥2, 54.9 % were treated by a VKA. An age-stratified multivariate analysis showed that women had an odds ratio to be treated with VKA compared to 0.83 (95 % CI: 0.72-0.95) and 0.66 (95 % CI: 0.59-0.74) when aged <75 years and ≥75 years, respectively. CONCLUSIONS Most AF patients followed by French GPs required stroke prevention according to European guidelines, but many of them did not receive the recommended antithrombotic treatment. Women over 75 were a third less likely to be treated with recommended anticoagulants than men of similar age.
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Affiliation(s)
- Pierre Sabouret
- Department of Cardiology, Pitié Salpétrière Hospital, Heart Institute, Pierre and Marie Curie University, Paris, France,
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