SUPPORT‐AF: Piloting a Multi‐Faceted, Electronic Medical Record‐Based Intervention to Improve Prescription of Anticoagulation

Abstract

BackgroundOnly 50% of eligible atrial fibrillation (AF) patients receive anticoagulation (AC). Feasibility and effectiveness of electronic medical record (EMR)–based interventions to profile and raise provider AC percentage is poorly understood. The SUPPORT‐AF (Supporting Use of AC Through Provider Profiling of Oral AC Therapy for AF) study aims to improve rates of adherence to AC guidelines by developing and delivering supportive tools based on the EMR to providers treating patients with AF.Methods and ResultsWe emailed cardiologists and community‐based primary care providers affiliated with our institution reports of their AC percentage relative to peers. We also sent an electronic medical record–based message to these providers the day before an appointment with an atrial fibrillation patient who was eligible but not receiving AC. The electronic medical record message asked the provider to discuss AC with the patient if he or she deemed it appropriate. To assess feasibility, we tracked provider review of our correspondence. We also tracked the change in AC for intervention providers relative to alternate primary care providers not receiving our intervention. We identified 3786, 1054, and 566 patients cared for by 49 cardiology providers, 90 community‐based primary care providers, and 88 control providers, respectively. At baseline, the percentage of AC was 71.3%, 63.5%, and 58.3% for these 3 respective groups. Intervention providers reviewed our e‐mails and electronic medical record messages 45% and 96% of the time, respectively. For providers responding, patient refusal was the most common reason for patients not being on AC (21%) followed by high bleeding risk (19%). At follow‐up 10 weeks later, change in AC was no different for either cardiology or community‐based primary care providers relative to controls (0.2% lower and 0.01% higher, respectively).ConclusionsOur intervention profiling AC was feasible, but not sufficient to increase AC in our population.

Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial

“…Expert decisional support may have greater traction in the current post-DOAC era as DOACs may be an "easier sell" if GPs are more pre-disposed to using these drugs over warfarin. However, our results are consistent with several randomised and non-randomised evaluations of implementation strategies for reducing stroke risk in AF which mainly report null findings or small differences in the uptake of anticoagulants in the pre and post-DOAC era [32,[36][37][38][39]. Taken together, these findings indicate that shifting prescribing practice remains challenging.…”

“…In contrast, another recent study found no effect of an intervention using email notifications reporting patient-specific stroke risk and guideline recommendations for antithrombotic treatment [36]. Evidence from other randomised and non-randomised trials suggests simply having access to support tools, such as risk calculators, electronically generated feedback reports and automated prompts in anticipation of patient visits does not impact prescribing rates [37][38][39]. Taken together, findings from this and our own research imply that interventions delivered outside the context of the consultation are ineffective, yet providing opportunities for GPs to engage patients in discussions during real-time decision making may drive changes in prescribing behaviour.…”

Usability and Perceived Usefulness of the AFib 2gether Mobile App in a Clinical Setting: Single-Arm Intervention Study

“…Specifically, we worked with an experienced EHR analyst who interrogated the Clarity database associated with Epic Systems EHR to identify demographic information. Through the use of ICD codes that we previously validated, the analyst was also able to identify the presence of comorbid conditions [ 3 , 16 ]. From chart reviews, we also captured the reason why a patient was not on AC.…”

Results of decision support system implementation for prescribing anticoagulants to patients with atrial fibrillation in hospital

“…Оральные антикоагулянты (АК) эффективно снижают риск ишемического инсульта у пациентов с ФП [4], однако недостаточный охват антикоагулянтной терапией (АКТ) [1], назначение субтерапевтических доз АК [2,3] и неудовлетворительная приверженность АКТ [4] могут ослабить профилактический эффект. По разным данным, 25-50% пациентов с ФП, нуждающихся в АК, не получают терапию [5,6]. Чаще всего это связано с пожилым возрастом пациента, высоким риском кровотечения (из-за онкологических заболеваний, высокого риска падений и т.д.…”