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Published on: February 26, 2013
Improving guideline-based anticoagulation in atrial fibrillation: A systematic literature review of prospective
Zachary A Sporn1, Adam N Berman2, Danielle Daly3
1Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
Insights
Interventions like patient education and electronic decision support can effectively reduce the gap in prescribing anticoagulation for atrial fibrillation (AF) patients, lowering stroke risk. These strategies improve appropriate anticoagulation rates in clinical practice.
Area of Science:
- Cardiology
- Public Health
- Health Services Research
Background:
- Atrial fibrillation (AF) guidelines recommend anticoagulation to prevent ischemic stroke.
- A significant gap exists between AF patients indicated for anticoagulation and those actually receiving it.
- Addressing this anticoagulation gap is crucial for improving patient outcomes.
Purpose of the Study:
- To evaluate the effectiveness of population-based interventions designed to close the anticoagulation gap in AF patients.
- To identify specific intervention types that successfully increase anticoagulation prescribing rates.
Main Methods:
- A systematic literature review of prospective individually randomized and cluster randomized trials was performed.
- Searches were conducted across four major electronic databases: PubMed, Google Scholar, Web of Science, and Medline.
- Twenty trials were included after screening 1474 studies.
Main Results:
- Forty-five percent of the reviewed trials successfully reduced the AF anticoagulation gap.
- Effective interventions included electronic risk assessment/decision support (6 trials), patient education (2 trials), and provider education (1 trial).
- Interventions focusing on patient education, provider education, and electronic decision support increased appropriate anticoagulation prescribing by 8.3%, 4.9%, and 2.0%, respectively.
Conclusions:
- Interventions to improve anticoagulation prescribing in AF are effective but show outcome heterogeneity.
- Patient education, provider education, and electronic risk assessment/decision support were the most impactful intervention strategies.
- Targeted interventions can significantly enhance appropriate anticoagulation rates in AF patients, thereby reducing stroke risk.
Background:
Guidelines for anticoagulation in patients with atrial fibrillation (AF) aim to decrease the risk of ischemic stroke. However, there is a gap in actual practice between patients who have an indication for anticoagulation and those who are actually prescribed anticoagulation.
Objective:
We sought to evaluate the efficacy of prior population-based interventions aimed at decreasing this AF anticoagulation gap.
Methods:
This study was prospectively registered in the International Prospective Register of Systematic Reviews database (CRD42021287875). A systematic literature review was conducted to obtain all prospective individually randomized and cluster randomized trials by searching 4 electronic databases: PubMed, Google Scholar, Web of Science, and Medline.
Results:
After a review of 1474 studies, 20 trials were included in this systematic literature review. Forty-five percent were effective in decreasing the AF anticoagulation gap. Trial interventions that improved anticoagulation prescribing included 6 trials of electronic risk assessment or decision support, 1 trial of provider education, 2 trials of new protocol or pathway, and 2 trials of patient education. Six of 15 ambulatory trials, 2 of 4 inpatient trials, and 1 trial that spanned inpatient and outpatient settings improved anticoagulation prescribing rates. Interventions focused on patient education, provider education, and electronic risk assessment or decision support increased absolute appropriate anticoagulation prescribing by 8.3%, 4.9%, and 2.0%, respectively.
Conclusion:
Interventions aimed at improving anticoagulation prescribing patterns in AF can be effective, although there is heterogeneity in outcomes across intervention type. The most effective interventions appeared to target patient education, provider education, and electronic risk assessment or decision support.
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