RT Journal Article
SR Electronic
T1 Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation
JF BMJ Quality & Safety
JO BMJ Qual Saf
FD BMJ Publishing Group Ltd
SP 835
OP 842
DO 10.1136/bmjqs-2019-009367
VO 28
IS 10
A1 Shirley V Wang
A1 James R Rogers
A1 Yinzhu Jin
A1 David DeiCicchi
A1 Sara Dejene
A1 Jean M Connors
A1 David W Bates
A1 Robert J Glynn
A1 Michael A Fischer
YR 2019
UL http://qualitysafety.bmj.com/content/28/10/835.abstract
AB Background Clinical guidelines recommend anticoagulation for patients with atrial fibrillation (AF) at high risk of stroke; however, studies report 40% of this population is not anticoagulated.Objective To evaluate a population health intervention to increase anticoagulation use in high-risk patients with AF.Methods We used machine learning algorithms to identify patients with AF from electronic health records at high risk of stroke (CHA2DS2-VASc risk score ≥2), and no anticoagulant prescriptions within 12 months. A clinical pharmacist in the anticoagulation service reviewed charts for algorithm-identified patients to assess appropriateness of initiating an anticoagulant. The pharmacist then contacted primary care providers of potentially undertreated patients and offered assistance with anticoagulation management. We used a stepped-wedge design, evaluating the proportion of potentially undertreated patients with AF started on anticoagulant therapy within 28 days for clinics randomised to intervention versus usual care.Results Of 1727 algorithm-identified high-risk patients with AF in clinics at the time of randomisation to intervention, 432 (25%) lacked evidence of anticoagulant prescriptions in the prior year. After pharmacist review, only 17% (75 of 432) of algorithm-identified patients were considered potentially undertreated at the time their clinic was randomised to intervention. Over a third (155 of 432) were excluded because they had a single prior AF episode (transient or provoked by serious illness); 36 (8%) had documented refusal of anticoagulation, the remainder had other reasons for exclusion. The intervention did not increase new anticoagulant prescriptions (intervention: 4.1% vs usual care: 4.0%, p=0.86).Conclusions Algorithms to identify underuse of anticoagulation among patients with AF in healthcare databases may not capture clinical subtleties or patient preferences and may overestimate the extent of undertreatment. Changing clinician behaviour remains challenging.