Addressing Undertreatment of Atrial Fibrillation With Community Pharmacists

Abstract

Atrial fibrillation (AF) increases the likelihood of ischemic strokes, including those most likely to result in death or permanent disability. This combined with the growing number of patients living with AF highlights that stroke prevention in AF is a top priority. However, despite the availability of safe, very low-burden oral anticoagulants (OAC) and relatively widespread availability of left atrial appendage occlusion, a significant proportion of patients with AF at high risk for stroke do not receive any preventative therapy. 1 A study of over 1.2 million Medicare beneficiaries with AF at high risk for stroke 2 revealed that fewer than half were prescribed OAC. Older age, female sex, and Black race were factors associated with OAC nonuse. 2 The news was slightly better in the Veterans Health Administration (VHA), 3 where OAC nonuse increased from 52% to 65.1% of eligible patients with AF between 2014 and 2018. Patients from racial and ethnic minority groups were less likely to receive OAC than their White counterparts. 3 Untreated AF is also costly. The cost for untreated patients covered by Medicare who had AF and experienced an ischemic stroke in 2018 was nearly $2.5 billion with per person, averaging approximately 3.7 times higher than the average Medicare beneficiary. 4 Given all of this, it makes sense to pull out all of the stops and use novel approaches to address underuse of OAC in high-risk patients with AF. Such is the case with the randomized clinical trial in JAMA Network Open, in which Sandhu et al 5 took the novel approach of partnering with community pharmacies in Alberta, Canada, to identify untreated patients with AF at increased risk of stroke.After comprehensive training, community pharmacists with independent prescribing authority and electronic health record (EHR) access screened patients 65 years or older with a CHADS 2 (congestive heart failure, hypertension, age, diabetes, and stroke or transient ischemic attack) score of at least 2 for undertreated AF. Eligible patients had a history of either newly diagnosed or known AF with (1) no OAC, (2) inappropriate medication (ie, antiplatelet agent), or (3) suboptimal OAC dosing. Atrial fibrillation was confirmed either through documentation in the medical record or via a single-lead mobile electrocardiographic apparatus used in the community pharmacy. Those patients found to have actionable AF (either newly diagnosed or identified as undertreated) were randomized in a 1:1 fashion to early vs delayed intervention by the community pharmacist. The early intervention group received AF education, blood pressure assessment, and OAC prescription on the spot with a summary of the intervention faxed to the primary care physician (PCP). They were followed up at the 1-and 3-month marks at the community pharmacy. Those randomized to the control group (delayed intervention) received AF education and the PCP was notified of actionable AF with a medication list.If after 3 months OAC treatment had not been optimized by the PCP, the community pharmacist inte...