Clinical value of a tool for managing oral anticoagulation in nonvalvular atrial fibrillation in primary health care. Randomized clinical trial

INTRODUCTION AND OBJECTIVES

The management of atrial fibrillation is complex and requires improvement at strategic points, such as in the control of patients treated with vitamin K antagonists. The aim of this study was to evaluate the impact on health outcomes of a nonvalvular atrial fibrillation decision support tool based on visualization of the time in therapeutic range in primary care.

METHODS

The present randomized clinical trial was conducted in 2018 with a 1-year follow-up in 325 primary care centers in Catalonia. In the intervention centers, the decision support tool was installed to control the time in therapeutic range of patients treated with vitamin K antagonists. The tool was not visualized in the control group. This clinical trial was registered with ClinicalTrials.gov (NCT03367325).

RESULTS

In total, 44 556 patients were studied. The intervention protected against admission for stroke (adjusted odds ratio [OR], 0.70; 95% confidence interval [95%CI], 0.55-0.88). The number needed to treat was 3502 (95%CI, 3305-3725) while the number of admissions for stroke avoided was 12.63 (95%CI, 11.88-13.38). The intervention also protected against mortality (adjusted OR, 0.78; 95%CI, 0.67-0.90), with a number needed to treat of 13 687 (95%CI, 10 789-18 714) and number of deaths avoided of 3.23 (95%CI, 2.36-4.10).

CONCLUSIONS

The decision support tool was associated with slight reductions in the numbers of admissions for ischemic stroke and mortality. Although the follow-up time was short and the effect of the intervention was small, the results are valuable and could improve implementation of the tool.

Early Detection of the Start of the Influenza Epidemic Using Surveillance Systems in Catalonia (PREVIGrip Study)

Sentinel physician networks are the method of influenza surveillance recommended by the World Health Organization. Weekly clinical diagnoses based on clinical history are a surveillance method that provides more immediate information. The objective of this study is to evaluate which influenza surveillance system is capable of the earliest detection of the start of the annual influenza epidemic. We carried out an ecological time-series study based on influenza data from the population of Catalonia from the 2010-2011 to the 2018-2019 seasons. Rates of clinical diagnoses and of confirmed cases in Catalonia were used to study the changes in trends in the different surveillance systems, the differences in area and time lag between the curves of the different surveillance systems using Joinpoint regression, Simpson's 1/3 method and cross-correlation, respectively. In general, changes in the trend of the curves were detected before the beginning of the epidemic in most seasons, using the rates for the complete seasons and the pre-epidemic rates. No time lag was observed between clinical diagnoses and the total confirmed cases. Therefore, clinical diagnoses in Primary Care could be a useful tool for early detection of the start of influenza epidemics in Catalonia.

Gender and Socioeconomic Inequality in the Prescription of Direct Oral Anticoagulants in Patients with Non-Valvular Atrial Fibrillation in Primary Care in Catalonia (Fantas-TIC Study)

Background: Evidence points to unequal access to direct oral anticoagulant (DOAC) therapy, to the detriment of the most socioeconomically disadvantaged patients in different geographic areas; however, few studies have focused on people with atrial fibrillation. This study aimed to assess gender-based and socioeconomic differences in the prescriptions of anticoagulants in people with non-valvular atrial fibrillation who attended Primary Care. Method: A cross-sectional study with real-world data from patients treated in Primary Care in Catalonia (Spain). Data were obtained from the SIDIAP database, covering 287 Primary Care centers in 2018. Results were presented as descriptive statistics and odds ratios estimated by multivariable logistic regression. Results: A total of 60,978 patients on anticoagulants for non-valvular atrial fibrillation were identified: 41,430 (68%) were taking vitamin K antagonists and 19,548 (32%), DOACs. Women had higher odds of treatment with DOAC (adjusted odds ratio [ORadj] 1.12), while lower DOAC prescription rates affected patients from Primary Care centers located in high-deprivation urban centers (ORadj 0.58) and rural areas (ORadj 0.34). Conclusions: DOAC prescription patterns differ by population. Women are more likely to receive it than men, while people living in rural areas and deprived urban areas are less likely to receive this therapy. Following clinical management guidelines could help to minimize the inequality.

Oral Anticoagulant Adequacy in Non-Valvular Atrial Fibrillation in Primary Care: A Cross-Sectional Study Using Real-World Data (Fantas-TIC Study)

Background: Oral anticoagulants (OAs) are the treatment to prevent stroke in atrial fibrillation (AF). Anticoagulant treatment choice in non-valvular atrial fibrillation (NVAF) must be individualized, taking current guidelines into account. Adequacy of anticoagulant therapy under the current criteria for NVAF in real-world primary care is presented. Methods: Cross-sectional study, with real-world data from patients treated in primary care (PC). Data were obtained from the System for the Improvement of Research in Primary Care (SIDIAP) database, covering 60,978 NVAF-anticoagulated patients from 287 PC centers in 2018. Results: In total, 41,430 (68%) were treated with vitamin K antagonists (VKAs) and 19,548 (32%) NVAF with direct-acting oral anticoagulants (DOACs). Inadequate prescription was estimated to be 36.0% and 67.6%, respectively. Most DOAC inadequacy (77.3%) was due to it being prescribed as a first-line anticoagulant when there was no history of thromboembolic events or intracranial hemorrhage (ICH). A total of 22.1% had missing estimated glomerular filtration rate (eGFR) values. Common causes of inadequate VKA prescription were poor control of time in therapeutic range (TTR) (98.8%) and ICH (2.2%). Conclusions: Poor adequacy to current criteria was observed, being inadequacy higher in DOACs than in VKAs. TTR and GFR should be routinely calculated in electronic health records (EHR) to facilitate decision-making and patient safety.

Impact of Implementing a Dyslipidemia Management Guideline on Cholesterol Control for Secondary Prevention of Ischemic Heart Disease in Primary Care

Cardiovascular diseases (CVD) are the main cause of death worldwide. The control of CVD risk factors, such as dyslipidemia, reduces their mortality rate. Nonetheless, fewer than 50% of patients with ischemic heart disease (IHD) have good cholesterol control. Our objective is to assess whether the level of participation of general practitioners (GPs) in activities to implement a dyslipidemia management guideline, and the characteristics of the patient and physician are associated with cholesterol control in IHD patients. We undertook a quasi-experimental, uncontrolled, before-and-after study of 1151 patients. The intervention was carried out during 2010 and 2011, and consisted of a face-to-face training and online course phase (Phase 1), and another of face-to-face feedback (Phase 2). The main outcome variable was the low-density lipoprotein cholesterol (LDL-C) control, whereby values of <100 mg/dL (2.6 mmol/L) were set as a good level of control, according to the recommendations of the guidelines in force in 2009. After Phase 1, 6.7% more patients demonstrated good cholesterol control. With respect to patient characteristics, being female and being older were found to be risk factors of poor control. Being diabetic and having suffered a stroke were protective factors. Of the GPs' characteristics, being tutor in a teaching center for GP residents and having completed the online course were found to be protective factors. We concluded that cholesterol control in IHD patients was influenced by the type of training activity undertook by physicians during the implementation of the GPC, and patient and physician characteristics. We highlight that if we apply the recent targets of the European guideline, which establish a lower level of LDL-C control, the percentage of good control could be worse than the observed in this study.

Cost-effectiveness of direct oral anticoagulants versus vitamin K antagonist in atrial fibrillation: A study protocol using Real-World Data from Catalonia (FantasTIC Study)

BACKGROUND

Anticoagulant therapy is used for stroke prevention and proved to be effective and safe in the long term. The study aims to analyse the cost-effectiveness relationship of using of direct-acting oral anticoagulants vs vitamin K antagonists to prevent ischaemic stroke in patients with nonvalvular atrial fibrillation, including all the active ingredients marketed in Spain, prescribed for 2 years in the Primary Care service of the Institut Català de la Salut.

METHODS

Population-based cohort study, in which the cost of the 2 treatment groups will be evaluated. Direct costs (pharmacy, primary care, emergency and hospitalization) and indirect costs (lost productivity) will be included from a social perspective. Effectiveness (assessed as the occurrence of a health event, the 1 of primary interest being stroke) will be determined, with a 2-year time horizon and a 3% discount rate. The average cost of the 2 groups of drugs will be compared using a regression model to determine the factors with the greatest influence on determining costs. We will carry out a univariate ('one-way') deterministic sensitivity analysis.

DISCUSSION

We hope to provide relevant information about direct and indirect costs of oral anticoagulants, which, together with aspects of effectiveness and safety, could help shape the consensual decision-making of evaluating bodies.

A new clinical decision support tool for improving the adequacy of anticoagulant therapy and reducing the incidence of stroke in nonvalvular atrial fibrillation: A randomized clinical trial in primary care

INTRODUCTION

Atrial fibrillation (AF) is the most common cardiac arrhythmia and increases the risk of ischemic stroke 4 to 5-fold. The first choice of anticoagulant therapy (AT) is the vitamin K antagonist (VKA). Contraindication to VKA or poor control of the International Normalized Ratio leads to the administration of direct-acting oral anticoagulants. There is a trend toward inadequate AT in nonvalvular AF (NVAF) patients.

AIM

To evaluate the impact of the implementation of a decision support tool linked to the digital clinical history on the adequacy of AT, the incidence of complications, and the mortality in patients with NVAF in primary care centers (PCCs) of the Catalan Institute of Health (ICS).

METHODS AND ANALYSIS

Randomized clinical trial in 287 PCCs, formed by 2 groups (intervention and control).

POPULATION

patients controlled in PCCs, diagnosed with NVAF 1 year before the implementation of the decision support tool and with VKA treatment over a minimum of 1 year. A simple randomization method will be performed at a sector level. The decision support tool will be available for 1 year. The time in therapeutic range (TTR) will be available in the digital clinical history only to professionals of the intervention group. The information system for primary care research development database will be used for the data extraction. Statistical analysis will be done at 3 time points: before the implementation of the tool, at 1 year, and at 2 years after the beginning of the intervention. Multilevel (patient and professional levels) logistic regression models will be used to estimate the effect of the intervention.

ETHICS AND DISSEMINATION

This study protocol was approved by the Ethical Committee of Clinical Investigation of the Institut Universitari d'Investigació en Atenció Primària Jordi Gol (code P17/091). Articles will be published in scientific journals.

TRIAL REGISTRATION

Clinical-Trials.gov: NCT03367325.