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Computerized clinical decision support to improve stroke prevention therapy in primary care management of atrial
Jafna Cox1, Laura Hamilton2, Lehana Thabane3
1Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.
Insights
Computerized clinical decision support (CDS) improved guideline-based oral anticoagulant therapy prescribing for atrial fibrillation (AF) patients in primary care. The tool optimized OAC use, enhancing patient care processes over 12 months.
Area of Science:
- Cardiology
- Health Informatics
- Primary Care Medicine
Background:
- Guidelines recommend antithrombotic therapy for atrial fibrillation (AF) but under-prescribing remains a challenge.
- Computerized clinical decision support (CDS) systems offer a potential solution to improve guideline adherence.
- This study investigated the impact of CDS on oral anticoagulant (OAC) prescribing in primary care AF patients.
Purpose of the Study:
- To evaluate the effectiveness of a CDS tool in promoting guideline-based antithrombotic therapy for AF patients.
- To assess whether CDS can overcome persistent under-prescribing of OACs in primary care settings.
- To determine the impact of CDS on the clinical process of care for AF patients.
Main Methods:
- A cluster randomized trial comparing CDS with usual care (UC) in primary care practices.
- Participants were followed for 12 months, with the CDS tool providing risk scores and OAC recommendations.
- Included 203 primary care providers and 1,145 eligible AF patients.
Main Results:
- At baseline, a high proportion of patients (68.7% UC, 74.9% CDS) received guideline-based OAC therapy.
- After 12 months, significantly more patients in the CDS group were managed according to guidelines (84.0% vs. 77.1% UC).
- The relative risk for guideline adherence in the CDS group was 1.08 (95% CI, 1.01-1.15; P=.024).
Conclusions:
- CDS effectively optimized OAC prescribing for AF patients in primary care, even with high baseline rates.
- The findings suggest that CDS tools can significantly improve the clinical process of care for AF patients.
- Implementing CDS is a viable strategy to enhance guideline adherence in managing AF patients.
Background:
Despite guidelines supporting antithrombotic therapy use in atrial fibrillation (AF), under-prescribing persists. We assessed whether computerized clinical decision support (CDS) would enable guideline-based antithrombotic therapy for AF patients in primary care.
Methods:
This cluster randomized trial of CDS versus usual care (UC) recruited participants from primary care practices across Nova Scotia, following them for 12 months. The CDS tool calculated bleeding and stroke risk scores and provided recommendations for using oral anticoagulants (OAC) per Canadian guidelines.
Results:
From June 14, 2014 to December 15, 2016, 203 primary care providers (99 UC, 104 CDS) with access to high-speed Internet were recruited, enrolling 1,145 eligible patients (543 UC, 590 CDS) assigned to the same treatment arm as their provider. Patient mean age was 72.3 years; most were male (350, 64.5% UC, 351, 59.5% CDS) and from a rural area (298, 54.9% UC, 315, 53.4% CDS). At baseline, a higher than anticipated proportion of patients were receiving guideline-based OAC therapy (373, 68.7% UC, 442, 74.9% CDS; relative risk [RR] 0.97 (95% confidence interval [CI], 0.87-1.07; P = .511)). At 12 months, prescription data were available for 538 usual care and 570 CDS patients, and significantly more CDS patients were managed according to guidelines (415, 77.1% UC, 479, 84.0% CDS; RR 1.08 (95% CI, 1.01-1.15; P = .024)).
Conclusion:
Notwithstanding high baseline rates, primary care provider access to the CDS over 12 months further optimized the prescribing of OAC therapy per national guidelines to AF patients potentially eligible to receive it. This suggests that CDS can be effective in improving clinical process of care.
Trial Registration:
Clinical Trials NCT01927367. https://clinicaltrials.gov/ct2/show/NCT01927367?term=NCT01927367&draw=2&rank=1.
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