Integrating Real-Time Clinical Information to Provide Estimates of Net Clinical Benefit of Antithrombotic Therapy for Patients With Atrial Fibrillation

Eckman, Mark H.; Wise, R.; Speer, B. Bryce; Sullivan, Megan; Walker, Nita; Lip, Gregory Y.H.; Kissela, Brett M.; Flaherty, Matthew L.; Kleindorfer, Dawn; Khan, Faisal; Kues, John R.; Baker, Pete; Ireton, Robert C.; Hoskins, Dave; Harnett, Brett; Aguilar, Carlos; Leonard, Anthony; Prakash, Rajan; Arduser, Lora; Costea, Alexandru

doi:10.1161/circoutcomes.114.001163

Cited by 27 publications

(23 citation statements)

References 29 publications

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“…SAS (SAS Institute, Inc., Cary, NC) data files were created as necessary for statistical analyses using unique coded participant identifiers. Further details are described elsewhere …”

Section: Methodsmentioning

confidence: 99%

“…The computational engine of the AFDST is an individual‐specific decision analytic model consisting of a 29‐state Markov simulation that projects quality‐adjusted life expectancy for each of three strategies (no antithrombotic therapy, aspirin, OAT (warfarin in the base case)) for each individual . The decision model uses information from the electronic health record to integrate individual‐specific risk factors for stroke and hemorrhage in its calculations . Decision model construction and analysis was performed using a standard computer program (Decision Maker, Boston, MA).…”

Section: Methodsmentioning

confidence: 99%

“…Decision model construction and analysis was performed using a standard computer program (Decision Maker, Boston, MA). Further details of the individual‐specific decision analytical model are described elsewhere . Although the decision analytical model used efficacy and bleeding risk data from warfarin for the oral anticoagulation strategy, the AFDST recommendation was for any oral anticoagulant if the warfarin strategy was better than no antithrombotic therapy or aspirin.…”

Section: Methodsmentioning

confidence: 99%

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Using an Atrial Fibrillation Decision Support Tool for Thromboprophylaxis in Atrial Fibrillation: Effect of Sex and Age

Eckman

Lip

Wise

et al. 2016

J American Geriatrics Society

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Objectives Among patients with atrial fibrillation (AF), female gender has been associated with an increased risk of stroke and a decreased likelihood of receiving oral anticoagulant therapy (OAT). The elderly are less likely to receive OAT due to concerns about falling and frailty. This study assessed the appropriateness of OAT among women and the elderly, looking for patterns of under-treatment or unnecessary treatment. Design Retrospective cohort study. Setting Primary care practices of an academic healthcare system. Participants 1,585 adults with non-valvular AF seen between March 2013 and February 2014. Intervention Treatment recommendations were made by an Atrial Fibrillation Decision Support Tool (AFDST) based on projections for quality-adjusted life expectancy calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage. Results Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and in 39% (338/860) of men (p = 0.02). While current treatment was discordant from recommended in 35% (89/258) of the elderly (age ≥ 85), and in 43% (575/1328) of patients < 85 years of age (p = 0.01) a large proportion of under-treated elderly patients were receiving aspirin as the sole antithrombotic agent. Conclusion Physicians should understand that female gender is a significant risk factor for AF-related stroke and incorporate this into decision-making about thromboprophylaxis. By treating older patients with aspirin instead of oral anticoagulant therapy we are exposing them to a significant risk of bleeding with little to no benefit relative to reduction of AF-related stroke risk.

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“…SAS (SAS Institute, Inc., Cary, NC) data files were created as necessary for statistical analyses using unique coded participant identifiers. Further details are described elsewhere …”

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Using an Atrial Fibrillation Decision Support Tool for Thromboprophylaxis in Atrial Fibrillation: Effect of Sex and Age

Eckman

Lip

Wise

et al. 2016

J American Geriatrics Society

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“…[20] Current research focus, in patients with FA, is oriented towards information integration on the risk for stroke and the risk for bleeding, in order to provide the net clinical benefit of oral anticoagulant therapy. [21] Efforts are also put on clinical trials results translation into clinical practice, by addressing the clinical context complexity of patients in real life setting taking this therapy. [22] Managing oral anticoagulant therapy, since so challenging, was the first area where CDS programs, aimed at improving clinicians' decision making, have been developed.…”

Section: Cds Program For a Long-term Oral Anticoagulant Therapy Survementioning

confidence: 99%

A methodology pathway to develop a Computer Drug Safety program in Primary health care setting based on clinical audit

Trtica

Guljaš

Šabanović

2015

JHA

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Objective: Medications management is an area in Primary health care (PHC) and General Practice (GP) setting where decision making is very important. Computer Decision Support program have been developed to help primary physicians in their decisions and have proved effective in improving the process of care and promising in economic issues. Methods: In order to create a Computer Drug Safety (CDS) program for managing oral anticoagulant therapy for use in PHC and GP setting with developed Information Technology (IT) System and established electronic Health Records (eHRs), we used clinical audit (a real-life practice analysis) as the methodology framework. We assumed that this method would enable a proposed CDS program to cope with clinical complexity of GP patients taking oral anticoagulants and also suggest this method as the operative framework for Quality of Care (QC) improvement and practice research. Results: By using clinical audit, we were able to identify the list of elements necessary for building up a feasible CDS program for a long-term oral anticoagulant therapy surveillance, for use in PHC and GP setting. According to this list of elements, we were able to create a paper based concept (a schemata) for this program development. This CDS program would not be a simple drug-dose calculator, but a comprehensive software support system integrated within the existing IT work applications. Conclusions: The main benefits, expected from this proposed CDS program, include: learning from work experience, oral anticoagulant QC improvement, better patients compliance to long-term treatment with the drug warfarin, practice performance follow up and practice research.

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“…(7,8) Patient-level treatment recommendations are generated based upon projections for quality-adjusted life years (QALYs) calculated by a 29-state Markov decision analytic model. The previously described A trial F ibrillation D ecision S upport T ool ( AFDST) considered choices between OAT with warfarin, aspirin, or no antithrombotic therapy.…”

Section: Introductionmentioning

confidence: 99%

Atrial fibrillation decision support tool: Population perspective

Eckman

Costea

Attari

et al. 2017

American Heart Journal

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Background Appropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. The recent availability of direct oral anticoagulants (DOACs) with comparable efficacy and improved safety compared with warfarin alters the balance between risk factors for stroke and benefit of anticoagulation. Our objective was to examine the impact of DOACs as an alternative to warfarin on the net benefit of oral anticoagulant therapy (OAT) in a real-world population of AF patients. Methods Retrospective cohort study of patients with paroxysmal or persistent nonvalvular AF. We updated an Atrial Fibrillation Decision Support Tool (AFDST) to include DOACs as treatment options. The tool generates patient–specific recommendations based upon individual patient risk factor profiles for stroke and major bleeding, using quality-adjusted life years (QALYs) calculated for each treatment strategy by a decision analytic model. The setting included inpatient and ambulatory sites in an academic health center in the mid-western United States. Study involved 5,121 adults with nonvalvular AF seen for any ambulatory visit or inpatient hospitalization over the 1-year period (January through December 2016). Outcome measure was net clinical benefit in QALYs. Results When DOACs are a therapeutic option, the AFDST recommends OAT for 4,134 (81%) patients, and no antithrombotic therapy or aspirin for 489 (9%). A strong recommendation for OAT could not be made in 498 (10%) patients. When warfarin is the only option, OAT is recommended for 3,228 (63%) patients, and no antithrombotic therapy or aspirin for 973 (19%). A strong recommendation for OAT could not be made in 920 (18%) patients. In total, 1,508 QALYs could be gained were treatment changed to that recommended by the AFDST. Conclusions Availability of DOACs increases the proportion of patients for whom oral anticoagulation therapy is recommended in a real-world cohort of AF patients and increased projected QALYs by more than 1,500 when all patients are receiving thromboprophylaxis as recommended by the AFDST compared with current treatment.

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Integrating Real-Time Clinical Information to Provide Estimates of Net Clinical Benefit of Antithrombotic Therapy for Patients With Atrial Fibrillation

Cited by 27 publications

References 29 publications

Using an Atrial Fibrillation Decision Support Tool for Thromboprophylaxis in Atrial Fibrillation: Effect of Sex and Age

Using an Atrial Fibrillation Decision Support Tool for Thromboprophylaxis in Atrial Fibrillation: Effect of Sex and Age

A methodology pathway to develop a Computer Drug Safety program in Primary health care setting based on clinical audit

Atrial fibrillation decision support tool: Population perspective

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