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Dutta R, Ryan JG, Hurley S, Wylie J. A targeted educational intervention increases oral anticoagulation rates in high-risk atrial fibrillation patients. Heart Rhythm O2 2024; 5:294-300. [PMID: 38840762 PMCID: PMC11148488 DOI: 10.1016/j.hroo.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Background Anticoagulation is the cornerstone of atrial fibrillation (AF) management for stroke prevention. Recently, we showed that oral anticoagulation (OAC) rates of AF patients in a large U.S. multispecialty health system are >80%. Objective The purpose of this study was to improve OAC rates in AF patients via an educational intervention targeted to primary care providers with low OAC rates. Methods Primary care clinicians were stratified by proportions of their AF patients at elevated stroke risk not taking anticoagulation medication. Clinicians with the lowest rates of anticoagulation were assigned to a target group receiving an educational program consisting of E-mail messaging summarizing anticoagulation guidelines. All other clinicians were assigned to a comparison group (CG). Data from a 6-month lead-in phase were compared with a 6-month follow-up period to determine whether the proportion of AF patients treated with OACs had changed. Results Of the 141 primary care clinicians with patients who met the inclusion criteria, 36 (25.53%) were assigned to the educational group (EG) and 105 (74.47%) to the CG. At baseline, there was a significant difference in percent of high-risk AF patients who were untreated in the EG (20.65%) compared to the high-risk patients who were untreated in the CG (13.64%; P = .001). After the educational intervention, high-risk AF patients without anticoagulation decreased in both EG (15.47%; P = .047) and CG (10.14%; P = .07), with greater absolute reduction in the EG (5.19% vs 3.50%). Conclusion A targeted education program was associated with increased anticoagulation rates for AF patients at high risk for stroke.
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Affiliation(s)
- Roop Dutta
- St. Elizabeth’s Medical Center, Boston, Massachusetts
| | | | - Sally Hurley
- St. Elizabeth’s Medical Center, Boston, Massachusetts
| | - John Wylie
- St. Elizabeth’s Medical Center, Boston, Massachusetts
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Piazza G, Hurwitz S, Campia U, Bikdeli B, Lou J, Khairani CD, Bejjani A, Snyder JE, Pfeferman M, Barns B, Rizzo S, Glezer A, Goldhaber SZ. Electronic alerts for ambulatory patients with atrial fibrillation not prescribed anticoagulation: A randomized, controlled trial (AF-ALERT2). Thromb Res 2023; 227:1-7. [PMID: 37182298 DOI: 10.1016/j.thromres.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Despite widely available risk stratification tools, safe and effective anticoagulants, and guideline recommendations, anticoagulation for stroke prevention in atrial fibrillation (AF) is under-prescribed in ambulatory patients. To assess the impact of alert-based computerized decision support (CDS) on anticoagulation prescription in ambulatory patients with AF and high-risk for stroke, we conducted this randomized controlled trial. METHODS Patients with AF and CHA2DS2-VASc score ≥ 2 who were not prescribed anticoagulation and had a clinic visit at Brigham and Women's Hospital were enrolled. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) versus control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription. RESULTS The CDS tool assigned 395 and 403 patients to the alert and control groups, respectively. Alert patients were more likely to be prescribed anticoagulation within 48 h of the clinic visit (15.4 % vs. 7.7 %, p < 0.001) and at 90 days (17.2 % vs. 9.9 %, p < 0.01). Direct oral anticoagulants were the predominantly prescribed form of anticoagulation. No significant differences were observed in stroke, TIA, or systemic embolic events (0 % vs. 0.8 %, p = 0.09), symptomatic VTE (0.5 % vs. 1 %, p = 0.43), all-cause mortality (2 % vs. 0.7 %, p = 0.12), or major adverse cardiovascular events (2.8 % vs. 2.5 %, p = 0.79) at 90 days. CONCLUSIONS An alert-based CDS strategy increased a primary efficacy outcome of anticoagulation in clinic patients with AF and high-risk for stroke who were not receiving anticoagulation at the time of the office visit. The study was likely underpowered to assess an impact on clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier- NCT02958943.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Shelley Hurwitz
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Umberto Campia
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Yale New Haven Hospital (YNHH), Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Junyang Lou
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Candrika D Khairani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antoine Bejjani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julia E Snyder
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mariana Pfeferman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Briana Barns
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samantha Rizzo
- Georgetown University School of Medicine, Washington, DC, USA
| | - Alexandra Glezer
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Brown JS, Mendelsohn AB, Nam YH, Maro JC, Cocoros NM, Rodriguez-Watson C, Lockhart CM, Platt R, Ball R, Dal Pan GJ, Toh S. The US Food and Drug Administration Sentinel System: a national resource for a learning health system. J Am Med Inform Assoc 2022; 29:2191-2200. [PMID: 36094070 PMCID: PMC9667154 DOI: 10.1093/jamia/ocac153] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/18/2022] [Accepted: 08/18/2022] [Indexed: 07/23/2023] Open
Abstract
The US Food and Drug Administration (FDA) created the Sentinel System in response to a requirement in the FDA Amendments Act of 2007 that the agency establish a system for monitoring risks associated with drug and biologic products using data from disparate sources. The Sentinel System has completed hundreds of analyses, including many that have directly informed regulatory decisions. The Sentinel System also was designed to support a national infrastructure for a learning health system. Sentinel governance and guiding principles were designed to facilitate Sentinel's role as a national resource. The Sentinel System infrastructure now supports multiple non-FDA projects for stakeholders ranging from regulated industry to other federal agencies, international regulators, and academics. The Sentinel System is a working example of a learning health system that is expanding with the potential to create a global learning health system that can support medical product safety assessments and other research.
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Affiliation(s)
- Jeffrey S Brown
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron B Mendelsohn
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Young Hee Nam
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Judith C Maro
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Noelle M Cocoros
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Carla Rodriguez-Watson
- Reagan-Udall Foundation for the Food and Drug Administration, Washington, District of Columbia, USA
| | - Catherine M Lockhart
- Biologics and Biosimilars Collective Intelligence Consortium, Alexandria, Virginia, USA
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Ball
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gerald J Dal Pan
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sengwee Toh
- Corresponding Author: Sengwee Toh, ScD, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215, USA;
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Dutta R, Hurley S, Atkins D, Weinstein J, Wylie J. High rates of oral anticoagulation in atrial fibrillation patients observed in a large multi-specialty health system in the Northeast. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01395-7. [PMID: 36264386 DOI: 10.1007/s10840-022-01395-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 10/05/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Anticoagulation is a cornerstone in atrial fibrillation (AF) management for stroke prevention. Studies showed that oral anticoagulants (OAC), previously limited to warfarin, were underused. Recently, non-vitamin K oral anticoagulants (NOACs) have seen widespread adoption, but it has not been well studied whether there has been a subsequent increase in OAC usage in AF patients. METHODS We quantified OAC rates in AF patients in a large multispecialty health system in the Northeast United States. A total of 351,795 patients seen in the network over the preceding 18 months were reviewed. RESULTS Of these patients, 8727 (2.5%) carried a diagnosis of AF, and, of the 6933 patients with a CHA2DS2-VASc score of 2 or higher, 5576 (80.4%) had an OAC listed as an active medication or had received a left atrial appendage occlusion device. Of the 6605 patients treated with an OAC, 5308 (80.4%) were treated with a NOAC and 1295 (19.6%) were prescribed warfarin. A higher percentage of patients with CHA2DS2-VASc ≥ 2 who had seen a cardiologist were treated with an OAC vs. those who had not seen a cardiologist in the prior 18 months (83.95% vs. 67.43%, p < 0.01). CONCLUSIONS We show dramatically increased OAC usage among patients with AF and that NOACs comprise the large majority of OACs compared with previous studies. This suggests an association between widespread adoption of NOACs and increased oral anticoagulation rates. Future directions include assessing barriers to oral anticoagulation and developing interventions to reduce disparity in OAC use between clinics.
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Affiliation(s)
- Roop Dutta
- St. Elizabeth's Medical Center, Boston, MA, USA
| | | | | | | | - John Wylie
- St. Elizabeth's Medical Center, Boston, MA, USA.
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