Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O’CAFÉ trial)

Vinson, David R.; Rauchwerger, Adina S.; Karadi, Chandu A; Shan, Judy; Warton, E. Margaret; Zhang, Jennifer; Ballard, Dustin; Mark, Dustin G.; Hofmann, Erik R.; Cotton, Dale M.; Durant, Edward; Lin, James S.; Sax, Dana R.; Poth, Luke S; Gamboa, Stephen H; Ghiya, Meena; Kene, Mamata V.; Ganapathy, Anuradha; Whiteley, P. M.; Bouvet, Sean C.; Babakhanian, Leon; Kwok, Edward W; Solomon, Matthew D.; Go, Alan S.; Reed, Mary

doi:10.1186/s13063-023-07230-2

Cited by 6 publications

(1 citation statement)

References 133 publications

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“…Early-career physicians may find CDS clinical content and recommendations more useful than other physicians, might be more willing to use risk prediction tools, and may identify fewer barriers to implementation. Physicians in our study had previous access to other CDS tools to assist in decision-making for other common ED presentations (eg, atrial fibrillation, pulmonary embolism) which may influence their perspectives . Physicians from EDs with no previous exposure to CDS may report more and/or differing barriers to CDS use due to nonfamiliarity with health care technology.…”

Section: Discussionmentioning

confidence: 99%

Physicians’ Perceptions of Clinical Decision Support to Treat Patients With Heart Failure in the ED

Casey,

Reed,

LeMaster

et al. 2023

JAMA Netw Open

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ImportanceClinical decision support (CDS) could help emergency department (ED) physicians treat patients with heart failure (HF) by estimating risk, collating relevant history, and assisting with medication prescribing if physicians’ perspectives inform its design and implementation.ObjectiveTo evaluate CDS usability and workflow integration in the hands of ED physician end users who use it in clinical practice.Design, Setting, and ParticipantsThis mixed-methods qualitative study administered semistructured interviews to ED physicians from 2 community EDs of Kaiser Permanente Northern California in 2023. The interview guide, based on the Usability Heuristics for User Interface Design and the Sociotechnical Environment models, yielded themes used to construct an electronic survey instrument sent to all ED physicians.Main Outcomes and MeasuresMain outcomes were physicians’ perceptions of using CDS to complement clinical decision-making, usability, and integration into ED clinical workflow.ResultsSeven key informant physicians (5 [71.4%] female, median [IQR] 15.0 [9.5-15.0] years in practice) were interviewed and survey responses from 51 physicians (23 [45.1%] female, median [IQR] 14.0 [9.5-17.0] years in practice) were received from EDs piloting the CDS intervention. Response rate was 67.1% (51 of 76). Physicians suggested changes to CDS accessibility, functionality, and workflow integration. Most agreed that CDS would improve patient care and fewer than half of physicians expressed hesitation about their capacity to consistently comply with its recommendations, citing workload concerns. Physicians preferred a passive prompt that encouraged, but did not mandate, interaction with the CDS.Conclusions and RelevanceIn this qualitative study of physicians who were using a novel CDS intervention to assist with ED management of patients with acute HF, several opportunities were identified to improve usability as well as several key barriers and facilitators to CDS implementation.

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Section: Discussionmentioning

confidence: 99%

Physicians’ Perceptions of Clinical Decision Support to Treat Patients With Heart Failure in the ED

Casey,

Reed,

LeMaster

et al. 2023

JAMA Netw Open

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Decision Support Intervention and Anticoagulation for Emergency Department Atrial Fibrillation

Vinson,

Warton,

Durant

et al. 2024

JAMA Netw Open

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ImportanceOral anticoagulation for adults with atrial fibrillation or atrial flutter (AFF) who are at elevated stroke risk reduces the incidence of ischemic stroke but remains underused. Efforts to increase anticoagulation initiation on emergency department (ED) discharge have yielded conflicting results.ObjectiveTo evaluate the effectiveness of a multipronged intervention supporting anticoagulation initiation for eligible adult ED patients.Design, Setting, and ParticipantsThe Clinical Decision Support to Optimize Care of Patients With Atrial Fibrillation or Flutter in the Emergency Department (O’CAFÉ) pragmatic, stepped-wedge cluster randomized clinical trial was conducted from July 1, 2021, through April 30, 2023, at 13 community medical centers (in 9 clusters) of an integrated health system in Northern California. The study included adult ED patients with primary AFF eligible for anticoagulation initiation when discharged home. Clusters were randomly assigned to staggered dates for 1-way crossover from the control phase (usual care) to the intervention phase.InterventionPhysician education, facility-specific audit and feedback, and access to decision support, which identified eligible patients and recommended shared decision-making, anticoagulation initiation (if suitable), and timely follow-up.Main Outcomes and MeasuresThe main outcome was a composite of anticoagulation on discharge or within 30 days. A primary intention-to-treat analysis (decision support access regardless of use) and a secondary per-protocol analysis (decision support use) were performed. Multivariable analyses adjusted for intervention and exposure months with random effects, accounting for clustering by facility and patient.ResultsA total of 3388 eligible patients with atrial fibrillation were discharged home: 2185 (64.5%) were receiving pre-ED arrival anticoagulation and 1203 (35.5%) were eligible for anticoagulation. Among the 1203 patients with an initiation-eligible encounter, the median age was 74.0 (IQR, 68.0-82.0) years and approximately half (618 [51.4%]) were men. Among the 387 patients with an initiation-eligible control encounter, 244 (63.0%) received anticoagulation (190 [49.0%] at discharge and 54 [14.0%] within 30 days). Among the 816 patients with an initiation-eligible intervention encounter, 558 (68.4%) received anticoagulation (428 [52.5%] on discharge and 130 [15.9%] within 30 days). There was no statistically significant change in initiation of anticoagulation associated with the intervention (adjusted odds ratio, 1.33 [95% CI, 0.75-2.35]; P = .13). Decision support was used for 217 eligible case patients (26.6%) (per protocol) and was associated with a statistically significant change in anticoagulation initiation when compared with 599 patients for whom decision support was not used (164 [75.6%] vs 394 [65.8%]; P = .008).Conclusions and RelevanceIn this trial, a multipronged intervention to facilitate thromboprophylaxis among eligible ED patients with AFF did not significantly increase anticoagulation initiation. Opportunities exist to further improve stroke prevention among ED patients with primary AFF.Trial RegistrationClinicalTrials.gov Identifier: NCT05009225

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Atrial fibrillation triggered by cold drinks: increasing clinician and patient awareness

Vinson¹,

Campbell

Qiao

2023

Baylor University Medical Center Proceedings

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Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O’CAFÉ trial)

Cited by 6 publications

References 133 publications

Physicians’ Perceptions of Clinical Decision Support to Treat Patients With Heart Failure in the ED

Physicians’ Perceptions of Clinical Decision Support to Treat Patients With Heart Failure in the ED

Decision Support Intervention and Anticoagulation for Emergency Department Atrial Fibrillation

Atrial fibrillation triggered by cold drinks: increasing clinician and patient awareness

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