Elsevier

American Heart Journal

Volume 176, June 2016, Pages 17-27
American Heart Journal

Clinical Investigation
Impact of an Atrial Fibrillation Decision Support Tool on thromboprophylaxis for atrial fibrillation

https://doi.org/10.1016/j.ahj.2016.02.009Get rights and content

Background

Appropriate thromboprophylaxis for patients with atrial fibrillation (AF) remains a national challenge.

Methods

We hypothesized that provision of decision support in the form of an Atrial Fibrillation Decision Support Tool (AFDST) would improve thromboprophylaxis for AF patients. We conducted a cluster randomized trial involving 15 primary care practices and 1,493 adults with nonvalvular AF in an integrated health care system between April 2014 and February 2015. Physicians in the intervention group received patient-level treatment recommendations made by the AFDST. Our primary outcome was the proportion of patients with antithrombotic therapy that was discordant from AFDST recommendation.

Results

Treatment was discordant in 42% of 801 patients in the intervention group. Physicians reviewed reports for 240 patients. Among these patients, thromboprophylaxis was discordant in 63%, decreasing to 59% 1 year later (P = .02). In nonstratified analyses, changes in discordant care were not significantly different between the intervention group and control groups. In multivariate regression models, assignment to the intervention group resulted in a nonsignificant trend toward decreased discordance (P = .29), and being a patient of a resident physician (P = .02) and a higher HAS-BLED score predicted decreased discordance (P = .03), whereas female gender (P = .01) and a higher CHADSVASc score (P = .10) predicted increased discordance.

Conclusions

Among patients whose physicians reviewed recommendations of the decision support tool discordant therapy decreased significantly over 1 year. However, in nonstratified analyses, the intervention did not result in significant improvements in discordant antithrombotic therapy.

Section snippets

Methods

We used our health system's clinical data store to identify 9,270 patients with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of AF (427.31) or atrial flutter (427.32) who did not have diagnoses of mitral valve disease (394.x), aortic valve disease (395.x), heart valve transplant (V42.2), or heart valve replacement (V42.3) in their active problem list. The data pull to form our inception cohort was performed in February of 2014. Because our

Results

Characteristics of patients and practices in each of the arms of the study are described in Table I. Results are only reported for patients who were part of the inception cohort formed in 2014. The 84 patients who died over the year were censored from these numbers. For the most part, patients in both groups were demographically comparable, and a similar proportion were receiving OAT. There were a slightly higher proportion of faculty members and a lower proportion of residents in the control

Discussion

A randomized controlled trial examining the impact of implementing the AFDST demonstrated no significant improvement in discordant antithrombotic therapy compared with a group of control practices that did not receive the tool. However, discordant therapy decreased significantly over a 1-year period of time for patients whose physicians actually reviewed the reports and recommendations of the decision support tool. This suggests that the AFDST can have a beneficial impact on clinical care if it

Conclusions

A randomized controlled trial examining the impact of implementing an AFDST found that among patients whose physicians actually reviewed the reports and recommendations of the decision support tool, discordant therapy decreased significantly over a 1-year period. However, in nonstratified analyses, the intervention did not result in significant improvements in discordant antithrombotic therapy. These findings suggest the next steps we must take to decrease barriers to the convenient and more

Author contributions

M.H.E., G.Y.H.L., R.E.W., F.L.F., D.K., C.A., A.L., A.C., and J.K. participated in the conception and design of the project; M.S., L.A., N.W., B.S., J.K., P.B., R.I., D.H., and B.M.H. were responsible for acquisition of data; M.H.E., A.L., and L.A. were responsible for data analysis and interpretation; M.H.E. drafted the original article; M.H.E., G.Y.H.L., R.E.W., S.B., M.S., N.W., B.K., M.L.F., D.K., P.B., R.I., D.H., B.M.H., C.A., A.L., L.A., D.S., A.C., and J.K. contributed to critical

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    Funding sources: Support for this study came from the Pfizer Educational Group, Bristol-Myers Squibb/Pfizer Education Consortium, and National Institutes of Health/National Center for Advancing Translational Sciences (Grant 8 UL1 TR000077-05). The funding sources had no role in study design, data collection, data analysis, data interpretation, or writing of the manuscript. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

    RCT No. NCT02524977.

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