Evidence behind quality of care measures for venous thromboembolism and atrial fibrillation

Outcomes of venous thromboembolism care: future directions

The complete picture of the outcomes of venous thromboembolism (VTE) care consists of conventional binary clinical outcomes (death, recurrent VTE, and bleeding), patient-centered outcomes, and society-level outcomes. Combined, these allow for the introduction of outcome-driven patient-centered health care. The emerging concept of valuing health care from such a holistic point of view, ie, value-based health care, holds a huge potential to revolutionize-and improve-the organization and evaluation of care. The ultimate goal of this approach was to achieve a high value for patients, ie, the best possible clinical outcomes at the right cost, providing a framework for evaluation and comparisons of different management strategies, patient pathways, or even complete health care delivery systems. To facilitate this, outcomes of care from a patient perspective, such as symptom burden, functional limitations, and quality of life, need to be routinely captured in clinical practice and trials, complementary to the conventional clinical outcomes, to fully capture the patients' values and needs. The aim of this review was to discuss the relevant outcomes of VTE care, explore value in VTE care from different perspectives, and propose future directions to inspire change. This is a call to action to shift the focus to outcomes that matter and make a larger difference in the lives of patients.

Quality gap in venous thromboembolism prophylaxis practices in inpatients: Assessment of prophylaxis practices in a University Hospital

BACKGROUND

Venous thromboembolism (VTE) is a prevalent complication of inpatient care, causing high burden of morbidity and mortality. Prophylaxis reduces the events; thus, these practices are promoted. We aimed to assess the VTE prophylaxis practices in the general internal medicine wards of a tertiary-care university hospital and utilize these data to propose quality improvement projects.

OBJECTIVE

Assess the pharmacological venous thromboembolism prophylaxis utilization by using the Padua Prediction Score and demonstrate the main determinants of inappropriate prophylaxis use.

METHODS

Electronic medical records were used to collect data cross-sectionally from 1 January 2019 to 30 June 2019. Padua Prediction Score was used to assess the appropriateness of VTE prophylaxis. Underlying health conditions, hospitalization causes, anti-platelets and use of glucocorticoids were also assessed as confounding factors.

RESULTS

A total of 295 patients were included. Higher proportion of patients who received VTE prophylaxis were obese and had higher rates of diabetes and coronary artery disease. Prophylaxis was more commonly utilized among patients who were elderly, obese, having an acute infection and/or rheumatologic disorder and prolonged bed rest (P ≤ 0.001, P = 0.01, P = 0.22 and P ≤ 0.001, respectively). Thirty-five patients (11.8%) received VTE prophylaxis, despite 89 patients (30.2%) were high-risk patients. In the high-risk group (n = 89), 27 patients (30.3%) received appropriate pharmacological prophylaxis, while 8 patients (3.9%) received VTE prophylaxis in the low-risk group (total n = 206). A considerable percentage of the high-risk population (69.6%) did not receive VTE prophylaxis.

DISCUSSION

Underuse constitutes a major challenge in our hospital but differing from other institutions, overuse is not a significant issue. Further studies are needed whether VTE prophylaxis improvement implementations uniformly increase appropriate VTE use.

Development of Quality Indicators to Assess Oral Anticoagulant Management in Community Pharmacies for Patients with Atrial Fibrillation

BACKGROUND

Few studies have evaluated the quality of oral anticoagulant management by community pharmacists. There is no complete set of quality indicators available for this purpose.

OBJECTIVE

To develop a set of specific quality indicators to assess oral anticoagulant management by community pharmacists for patients with atrial fibrillation (AF).

METHODS

Quality indicators were developed in 3 phases. In phase 1, potential quality indicators were generated based on clinical guidelines and a literature review. In phase 2, a modified RAND appropriateness method involving 2 rounds was implemented with 9 experts, who judged the appropriateness of quality indicators generated in phase 1 based on the extent to which they were accurate, based on evidence, relevant, representative of best practices, and measurable in community pharmacies. Phase 3 consisted of a feasibility assessment in 5 community pharmacies on 2 patients each.

RESULTS

The final set included 38 quality indicators grouped into 6 categories: documentation (n = 29), risk assessment (n = 3), clinical control (n = 1), clinical follow-up (n = 15), choice of therapy (n = 11), and interaction management (n = 8). The quality indicators referred to process of care (n = 34), clinical outcomes (n = 2), or structure of care (n = 2). There were 24 quality indicators related to vitamin K antagonists (VKAs), and 17 were related to direct oral anticoagulants (DOACs). To assess quality indicators, a questionnaire was developed for completion by community pharmacists for each patient, which included 17 questions about VKA patients and 12 questions about DOAC patients.

CONCLUSIONS

A first set of quality indicators is now available to assess the quality of oral anticoagulant management by community pharmacists for patients with AF.

DISCLOSURES

This research was supported by the Réseau Québécois de recherche sur le médicament (RQRM); the Blueprint for Pharmacy in collaboration with Pfizer Canada; and the Cercle du Doyen of the Faculty of Pharmacy, University of Montreal. The study sponsors were not involved in the study design, data collection, data interpretation, the writing of the article, or the decision to submit the report for publication. Chartrand received a scholarship from the Fonds de Recherche du Québec en Santé (FRQ-S), the Réseau Québécois de recherche sur l'usage des médicaments with Pfizer, and the Faculty of Pharmacy, University of Montreal. Guénette holds a Junior-1 Clinician Researcher Award from the FRQ-S in partnership with the Société québécoise d'hypertension artérielle. Williamson holds a Junior-1 Career Award from the FRQ-S. Côté reported being a medical speaker for Bayer, Boehringer Ingelheim Canada, and Pfizer Canada. The other authors reported no conflicts of interest. Study concept and design were contributed by Lalonde, Chartrand, and Martin. Chartrand, Martin, and Lalonde collected the data, along with Brouillette, Côté, Huot, Landry, Martineau, Perreault, Williamson, and White-Guay. Data interpretation was performed by Chartrand, Gagnon, and Lalonde, along with Guénette and Martin. The manuscript was primarily written by Chartrand, along with Guénette and Lalonde, and revised by Chartrand, Guénette, and Lalonde, along with the other authors. A portion of this study's results was presented at the 4th RQRM Annual Meeting on September 22-23, 2014, in Orford, Quebec, Canada, in the form of an abstract, which was published in the Journal of Population Therapeutics and Clinical Pharmacology, 2014;21(2):e312.

A Call for Appropriate Evidence and Outcomes-Based Use and Measurement of Anticoagulation for Atrial Fibrillation: Moving the Population Towards Improved Health Via Multiple Stakeholders

A multidimensional approach involving consideration of available resources, individual patient characteristics, patient preferences, and cost of treatment is often required to optimize clinical decision making in the management of atrial fibrillation (AF). In order to bring together varying perspectives on effective tactics and to formulate innovative strategies to improve the management of AF, a think tank consortium of advisors was assembled from across the spectrum of health care stakeholders. Focus groups were conducted and facilitated by a moderator and a notetaker. Participants were asked to comment on preliminary data for the increased prevalence of AF, patterns of treatment, impact of adherence with anticoagulants on clinical and economic outcomes, and opportunities for optimizing treatment.Several recommendations to reach short- and long-term goals in improving AF management emerged from the focus group discussions. These recommendations specifically targeted 3 stakeholder groups--patients/caregivers, physicians, and payers--and addressed the need for better understanding of determinants of undertreatment and nonadherence for those on anticoagulation therapy. Recommendations included the use of real-world data studies to understand regional and demographic patterns of treatment and outcomes, the development of an enhanced national quality standard for anticoagulation, and engaging patients in shared decision making to optimize satisfaction with treatment. Actionable strategies were presented to address gaps related to anticoagulation management. Balancing new anticoagulants' higher prescription costs and safety concerns with their superior effectiveness and convenience of administration for at-risk individuals would require a concerted effort involving patients and their caregivers, physicians, and payers.

Increasing the quantity and quality of searching for current best evidence to answer clinical questions: protocol and intervention design of the MacPLUS FS Factorial Randomized Controlled Trials

BACKGROUND & AIMS

Finding current best evidence for clinical decisions remains challenging. With 3,000 new studies published every day, no single evidence-based resource provides all answers or is sufficiently updated. McMaster Premium LiteratUre Service--Federated Search (MacPLUS FS) addresses this issue by looking in multiple high quality resources simultaneously and displaying results in a one-page pyramid with the most clinically useful at the top. Yet, additional logistical and educational barriers need to be addressed to enhance point-of-care evidence retrieval. This trial seeks to test three innovative interventions, among clinicians registered to MacPLUS FS, to increase the quantity and quality of searching for current best evidence to answer clinical questions.

METHODS & DESIGN

In a user-centered approach, we designed three interventions embedded in MacPLUS FS: (A) a web-based Clinical Question Recorder; (B) an Evidence Retrieval Coach composed of eight short educational videos; (C) an Audit, Feedback and Gamification approach to evidence retrieval, based on the allocation of 'badges' and 'reputation scores.' We will conduct a randomized factorial controlled trial among all the 904 eligible medical doctors currently registered to MacPLUS FS at the hospitals affiliated with McMaster University, Canada. Postgraduate trainees (n=429) and clinical faculty/staff (n=475) will be randomized to each of the three following interventions in a factorial design (AxBxC). Utilization will be continuously recorded through clinicians’ accounts that track logins and usage, down to the level of individual keystrokes. The primary outcome is the rate of searches per month per user during the six months of follow-up. Secondary outcomes, measured through the validated Impact Assessment Method questionnaire, include: utility of answers found (meeting clinicians’ information needs), use (application in practice), and perceived usefulness on patient outcomes.

DISCUSSION

Built on effective models for the point-of-care teaching, these interventions approach evidence retrieval as a clinical skill. If effective, they may offer the opportunity to enhance it for a large audience, at low cost, providing better access to relevant evidence across many top EBM resources in parallel.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT02038439.