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The Canadian Community Utilization of Stroke Prevention Study in Atrial Fibrillation in the Emergency Department
Ratika Parkash1, Kirk Magee1, Mark McMullen1
1QEII Health Sciences Center, Halifax, Nova Scotia, Canada.
Insights
A new tool kit for emergency physicians significantly increased oral anticoagulation prescriptions for atrial fibrillation patients in the emergency department. Follow-up in an atrial fibrillation clinic showed a trend toward higher long-term use.
Area of Science:
- Cardiology
- Emergency Medicine
- Public Health
Background:
- Prescribing oral anticoagulation (OAC) for atrial fibrillation (AF) patients in the emergency department (ED) remains a significant care gap.
- This study addresses the need to improve OAC initiation for eligible AF patients presenting to the ED.
Purpose of the Study:
- To evaluate the effectiveness of an intervention toolkit for emergency physicians, including an OAC prescription tool and AF clinic follow-up, in increasing OAC prescription rates at ED discharge.
- To compare the impact of the toolkit alone versus the toolkit combined with AF clinic follow-up.
Main Methods:
- A before-after study conducted in 5 Canadian EDs across 3 cities.
- Involved three 1-year phases: retrospective baseline (Phase 1), prospective with OAC prescription tool and patient education (Phase 2), and prospective with tool, education, AF educational session, and AF clinic follow-up (Phase 3).
- Primary outcome was the rate of new OAC prescriptions at ED discharge for eligible, OAC-naive AF patients.
Main Results:
- A total of 631 patients were included; mean age was 69 years, with 47.4% women and 69.6% having a CHADS2 score ≥ 1.
- New OAC prescription rates increased from 15.8% (Phase 1) to 54.1% (Phase 2) and 47.2% (Phase 3).
- Multivariable analysis showed an 8.03-fold increased odds of OAC prescription in Phase 3 versus Phase 1. No significant difference in 6-month OAC use between Phase 2 and 3, but a trend towards higher use in Phase 3 (79.4% vs 71.6%). Major bleeding rates were low (0-1%) across all phases.
Conclusions:
- An OAC prescription tool for emergency physicians effectively increases OAC initiation in the ED for AF patients.
- AF clinic follow-up, while showing a trend towards higher 6-month OAC use, did not significantly enhance the initial prescription rate compared to the tool alone.
- The intervention demonstrates a successful strategy to address the OAC prescribing gap in the ED setting.
Study Objective:
Lack of oral anticoagulation prescription in the emergency department (ED) has been identified as a care gap in atrial fibrillation patients. This study seeks to determine whether the use of a tool kit for emergency physicians with a follow-up community-based atrial fibrillation clinic resulted in greater oral anticoagulation prescription at ED discharge than usual care.
Methods:
This was a before-after study in 5 Canadian EDs in 3 cities. Patients who presented to the ED with atrial fibrillation were eligible for inclusion. The before phase (1) was retrospective; 2 after phases (2 and 3) were prospective: phase 2 used an oral anticoagulation prescription tool for emergency physicians and patient education materials, whereas phase 3 used the same prescription tool, patient materials, atrial fibrillation educational session, and follow-up in an atrial fibrillation clinic. Each phase was 1 year long. The primary outcome was the rate of new oral anticoagulation prescription at ED discharge for patients who were oral anticoagulation eligible and not receiving oral anticoagulation at presentation.
Results:
A total of 631 patients were included. Mean age was 69 years (SD 14 years), 47.4% were women, and 69.6% of patients had a CHADS2 score greater than or equal to 1. The rate of new oral anticoagulation prescription in phase 1 was 15.8% compared with 54.1% and 47.2%, in phases 2 and 3, respectively. After multivariable adjustment, the odds ratio for new oral anticoagulation prescription was 8.03 (95% confidence interval 3.52 to 18.29) for phase 3 versus 1. The 6-month rate of oral anticoagulation use was numerically but not significantly higher in phase 3 compared with phase 2 (71.6% versus 79.4%; adjusted odds ratio 2.30; 95% confidence interval 0.89 to 5.96). The rate of major bleeding at 6 months was 0%, 0.8%, and 1% in phases 1, 2, and 3, respectively.
Conclusion:
An oral anticoagulation prescription tool was associated with an increase in new oral anticoagulation prescription in the ED, irrespective of whether an atrial fibrillation clinic follow-up was scheduled. The use of an atrial fibrillation clinic was associated with a trend to a higher rate of oral anticoagulation at 6-month follow-up.
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