Electronic physician notifications to improve guideline-based anticoagulation in atrial fibrillation: a randomized controlled trial

Ashburner, Jeffrey M.; Atlas, Steven J.; Khurshid, Shaan; Weng, Lu‐Chen; Hulme, Olivia L.; Chang, Yuchiao; Singer, Daniel E.; Ellinor, Patrick T.; Lubitz, Steven A.

doi:10.1007/s11606-018-4612-6

Cited by 27 publications

(30 citation statements)

References 44 publications

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“…Expert decisional support may have greater traction in the current post-DOAC era as DOACs may be an "easier sell" if GPs are more pre-disposed to using these drugs over warfarin. However, our results are consistent with several randomised and non-randomised evaluations of implementation strategies for reducing stroke risk in AF which mainly report null findings or small differences in the uptake of anticoagulants in the pre and post-DOAC era [32,[36][37][38][39]. Taken together, these findings indicate that shifting prescribing practice remains challenging.…”

Section: Implications For Current Practicesupporting

confidence: 91%

“…A recent study reported a small (3%) but significant increase in anticoagulant prescribing attributable to a computerised decision support tool activated during interactions between physicians and patients [34], consistent with results from an earlier study employing a computerised risk assessment tool to guide real-time decision making [35]. In contrast, another recent study found no effect of an intervention using email notifications reporting patient-specific stroke risk and guideline recommendations for antithrombotic treatment [36]. Evidence from other randomised and non-randomised trials suggests simply having access to support tools, such as risk calculators, electronically generated feedback reports and automated prompts in anticipation of patient visits does not impact prescribing rates [37][38][39].…”

Section: Comparison With Other Studiessupporting

confidence: 64%

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Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial

et al. 2020

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Background: Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. Methods: We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. Results: One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86-1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). Conclusions: Specialist feedback in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. Trial registration: ANZCTRN12611000076976 Retrospectively registered.

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Section: Implications For Current Practicesupporting

confidence: 91%

Section: Comparison With Other Studiessupporting

confidence: 64%

Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial

et al. 2020

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“…The burden of atrial fibrillation (AF) is concentrated in older adults—80% of adults with AF are 65 years and older, many with comorbid conditions that affect functioning and quality of life 1,2 . Whereas clinical guidelines recommend clinicians focus primarily on ischemic stroke risk when considering anticoagulants for thromboprophylaxis, physicians report that geriatric syndromes are important when considering anticoagulants for older adults 3‐8 …”

Section: Introductionmentioning

confidence: 99%

Geriatric Syndromes and Atrial Fibrillation: Prevalence and Association with Anticoagulant Use in a National Cohort of Older Americans

Shah

Fang

Jeon

et al. 2020

J American Geriatrics Society

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BACKGROUND Although guidelines recommend focusing primarily on stroke risk to recommend anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls and disability) are important when considering anticoagulants. Little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use. METHODS We performed a cross‐sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older Americans. Participants were asked questions to assess domains of aging, including function, cognition, and medical conditions. We included participants 65 years and older with 2 years of continuous Medicare enrollment who met AF diagnosis criteria by claims codes. We examined five geriatric syndromes: one or more falls within the last 2 years, receiving help with activities of daily living (ADLs) or instrumental ADLs (IADL), experienced incontinence, and cognitive impairment. We determined the prevalence of geriatric syndromes and their association with anticoagulant use, adjusting for ischemic stroke risk (i.e., CHA2DS2‐VASc score [congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex]). RESULTS In this study of 779 participants with AF (median age = 80 years; median CHA2DS2‐VASc score = 4), 82% had one or more geriatric syndromes. Geriatric syndromes were common: 49% reported falls, 38% had ADL impairments, 42% had IADL impairments, 37% had cognitive impairments, and 43% reported incontinence. Overall, 65% reported anticoagulant use; guidelines recommend anticoagulant use for 97% of participants. Anticoagulant use rate decreased for each additional geriatric syndrome (average marginal effect = −3.7%; 95% confidence interval = −1.4% to −5.9%). Lower rates of anticoagulant use were reported in participants with ADL dependency, IADL dependency, and dementia. CONCLUSION Most older adults with AF had at least one geriatric syndrome, and geriatric syndromes were associated with reduced anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulant use in older adults.

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“…The use of reminders such as emails, faculty meetings, and webinars to increase provider adherence to clinical guidelines was previously shown to have variable results. In 2018, Ashburner et al 17 concluded that the email reminders with specific patient information and educational materials, including clinical guidelines, did not increase rates of appropriate anticoagulation prescribing for those at increased stroke risk. On the other hand, active engagement of physicians through “continuing medical education and multifaceted interventions were found to be the most effective methods for implementing guidelines into general practice.” 18 In this QI initiative, we actively engaged frontline providers throughout the process with ongoing education, ongoing reminders, and an MOC opportunity.…”

Section: Discussionmentioning

confidence: 99%

Promoting Judicious Primary Care Referral of Patients with Chest Pain to Cardiology: A Quality Improvement Initiative

et al. 2021

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Objective To decrease referrals to cardiology of patients ages 7 to 21 years with low-probability cardiac pathology who presented to primary care with chest pain by 50% within 24 months. Study Design A multidisciplinary team designed and implemented an initiative consisting of 1) a decision support tool (DST), 2) educational sessions, 3) routine feedback to improve use of referral criteria, and 4) patient family education. Four pediatric practices, comprising 34 pediatricians and 7 nurse practitioners, were included in this study. We tracked progress via statistical process control charts. Results A total of 421 patients ages 7 to 21 years presented with chest pain to their pediatrician. The utilization of the DST increased from baseline of 16% to 68%. Concurrently, the percentage of low-probability cardiology referrals in pediatric patients ages 7 to 21 years who presented with chest pain decreased from 17% to 5% after our interventions. At a median follow-up time of 0.9 years (interquartile range, 0.3–1.6 years), no patient had a life-threatening cardiac event. Conclusion Our health care improvement initiative to reduce low-probability cardiology referrals for children presenting to primary care practices with chest pain was feasible, effective, and safe.

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Electronic physician notifications to improve guideline-based anticoagulation in atrial fibrillation: a randomized controlled trial

Abstract: ClinicalTrials.gov identifier NCT02950285.

Cited by 27 publications

References 44 publications

Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial

Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial

Geriatric Syndromes and Atrial Fibrillation: Prevalence and Association with Anticoagulant Use in a National Cohort of Older Americans

Promoting Judicious Primary Care Referral of Patients with Chest Pain to Cardiology: A Quality Improvement Initiative

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