Alok Kapoor1,2,3, Azraa Amroze1,3, Fatima Vakil4, Sybil Crawford2, Jacqueline Der5, Jomol Mathew2, Eric Alper1,2, Dinesh Yogaratnam6, Saud Javed2, Rasha Elhag1,2, Abraham Lin2, Siddhartha Narayanan2, Donna Bartlett6, Ahmed Nagy2, Bevin Kathleen Shagoury7, Michael A Fischer7, Kathleen M Mazor2,3, Jane S Saczynski2,5, Jeffrey M Ashburner8, Renato Lopes9, David D McManus1,2,3. 1. University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.). 2. University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.). 3. Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.). 4. Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH (F.V.). 5. Northeastern University, Boston, MA (J.D., J.S.S.). 6. Mass College of Pharmacy and Health Sciences, Worcester, MA (D.Y., D.B.). 7. The National Resource Center for Academic Detailing, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA (B.K.S., M.A.F.). 8. Division of General Internal Medicine, Massachusetts General Hospital, Boston (J.M.A.). 9. Duke Clinical Research Institute, Durham, NC (R.L.).
Abstract
BACKGROUND: Previous provider-directed electronic messaging interventions have not by themselves improved anticoagulation use in patients with atrial fibrillation. Direct engagement with providers using academic detailing coupled with electronic messaging may overcome the limitations of the prior interventions. METHODS AND RESULTS: We randomized outpatient providers affiliated with our health system in a 2.5:1 ratio to ourelectronic profiling/messaging combined with academic detailing intervention. In the intervention, we emailed providers monthly reports of their anticoagulation percentage relative to peers for atrial fibrillation patients with elevated stroke risk (CHA2DS2-VASc ≥2). We also sent electronic medical record-based messages shortly before an appointment with an anticoagulation-eligible but untreated atrial fibrillation patient. Providers had the option to send responses with explanations for prescribing decisions. We also offered to meet with intervention providers using an academic detailing approach developed based on knowledge gaps discussed in provider focus groups. To assess feasibility, we tracked provider review of our messages. To assess effectiveness, we measured the change in anticoagulation for patients of intervention providers relative to controls. We identified 85 intervention and 34 control providers taking care of 3591 and 1908 patients, respectively; 33 intervention providers participated in academic detailing. More than 80% of intervention providers read our emails, and 98% of the time a provider reviewed our in-basket messages. Replies to messages identified patient refusal as the most common reason for patients not being on anticoagulation (11.2%). For the group of patients not on anticoagulation at baseline assigned to an intervention versus control provider, the adjusted percent increase in the use of anticoagulation over 6 months was 5.2% versus 7.4%, respectively (P=0.21). CONCLUSIONS: Our electronic messaging and academic detailing intervention was feasible but did not increase anticoagulation use. Patient-directed interventions or provider interventions targeting patients declining anticoagulation may be necessary to raise the rate of anticoagulation. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03583008.
RCT Entities:
BACKGROUND: Previous provider-directed electronic messaging interventions have not by themselves improved anticoagulation use in patients with atrial fibrillation. Direct engagement with providers using academic detailing coupled with electronic messaging may overcome the limitations of the prior interventions. METHODS AND RESULTS: We randomized outpatient providers affiliated with our health system in a 2.5:1 ratio to our electronic profiling/messaging combined with academic detailing intervention. In the intervention, we emailed providers monthly reports of their anticoagulation percentage relative to peers for atrial fibrillationpatients with elevated stroke risk (CHA2DS2-VASc ≥2). We also sent electronic medical record-based messages shortly before an appointment with an anticoagulation-eligible but untreated atrial fibrillationpatient. Providers had the option to send responses with explanations for prescribing decisions. We also offered to meet with intervention providers using an academic detailing approach developed based on knowledge gaps discussed in provider focus groups. To assess feasibility, we tracked provider review of our messages. To assess effectiveness, we measured the change in anticoagulation for patients of intervention providers relative to controls. We identified 85 intervention and 34 control providers taking care of 3591 and 1908 patients, respectively; 33 intervention providers participated in academic detailing. More than 80% of intervention providers read our emails, and 98% of the time a provider reviewed our in-basket messages. Replies to messages identified patient refusal as the most common reason for patients not being on anticoagulation (11.2%). For the group of patients not on anticoagulation at baseline assigned to an intervention versus control provider, the adjusted percent increase in the use of anticoagulation over 6 months was 5.2% versus 7.4%, respectively (P=0.21). CONCLUSIONS: Our electronic messaging and academic detailing intervention was feasible but did not increase anticoagulation use. Patient-directed interventions or provider interventions targeting patients declining anticoagulation may be necessary to raise the rate of anticoagulation. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03583008.
Authors: Jay Patel; Hammad Sadiq; John Catanzaro; Sybil Crawford; Adam Wright; Gordon Manning; Jeroan Allison; Kathleen Mazor; David McManus; Alok Kapoor Journal: Cardiovasc Digit Health J Date: 2021-07-17
Authors: Jordy Mehawej; Jane Saczynski; Jerry H Gurwitz; Hawa O Abu; Benita A Bamgbade; Wei-Jia Wang; Tenes Paul; Katherine Trymbulak; Connor Saleeba; Zi-Yue Wang; Catarina I Kiefe; Robert J Goldberg; David D McManus Journal: J Geriatr Cardiol Date: 2020-08 Impact factor: 3.189