Decision Support Intervention and Anticoagulation for Emergency Department Atrial Fibrillation: The O'CAFE Stepped-Wedge Cluster Randomized Clinical Trial

被引：2

作者：

Vinson, David R. ^{[1
,2
,3
]}

Warton, E. Margaret ^{[2
]}

Durant, Edward J. ^{[1
,4
]}

Mark, Dustin G. ^{[1
,2
,5
]}

Ballard, Dustin W. ^{[1
,2
,6
]}

Hofmann, Erik R. ^{[1
,7
]}

Sax, Dana R. ^{[1
,2
,5
]}

Kene, Mamata V. ^{[1
,8
]}

Lin, James S. ^{[1
,9
]}

Poth, Luke S. ^{[1
,10
]}

Ghiya, Meena S. ^{[1
,10
]}

Ganapathy, Anuradha ^{[1
,11
]}

Whiteley, Patrick M. ^{[1
,11
]}

Bouvet, Sean C. ^{[1
,12
]}

Rauchwerger, Adina S. ^{[2
]}

Zhang, Jennifer Y. ^{[2
,13
]}

Shan, Judy ^{[2
,14
]}

Dilena, Daniel D. ^{[2
]}

Kea, Bory ^{[15
]}

Pai, Ashok P. ^{[1
,16
]}

Loyles, Jodi B. ^{[17
]}

Solomon, Matthew D. ^{[1
,2
,18
]}

Go, Alan S. ^{[1
,2
,19
]}

Reed, Mary E. ^{[2
]}

机构：

[1] Permanente Med Grp Inc, Oakland, CA USA

[2] Kaiser Permanente Northern Calif, Div Res, Oakland, CA USA

[3] Kaiser Permanente Roseville Med Ctr, Dept Emergency Med, 1600 Eureka Rd, Roseville, CA 95661 USA

[4] Kaiser Permanente Modesto Med Ctr, Dept Emergency Med, Modesto, CA USA

[5] Kaiser Permanente Oakland Med Ctr, Dept Emergency Med, Oakland, CA USA

[6] Kaiser Permanente San Rafael Med Ctr, Dept Emergency Med, San Rafael, CA USA

[7] Kaiser Permanente South Sacramento Med Ctr, Dept Emergency Med, Sacramento, CA USA

[8] Kaiser Permanente San Leandro Med Ctr, Dept Emergency Med, San Leandro, CA USA

[9] Kaiser Permanente St Clara Med Ctr, Dept Emergency Med, Santa Clara, CA USA

[10] Kaiser Permanente South San Francisco Creek Med Ct, Dept Emergency Med, San Francisco, CA USA

[11] Kaiser Permanente San Jose Med Ctr, Dept Emergency Med, San Jose, CA USA

[12] Kaiser Permanente San Francisco Med Ctr, Dept Emergency Med, San Francisco, CA USA

[13] Harvard TH Chan Sch Publ Hlth, Boston, MA USA

[14] Univ Calif San Francisco, Sch Med, San Francisco, CA USA

[15] Oregon Hlth & Sci Univ, Ctr Policy & Emergency Med, Dept Emergency Med, Portland, OR USA

[16] Oakland Med Ctr, Dept Hematol & Oncol, Oakland, CA USA

[17] Kaiser Permanente Northern Calif Reg Pharm, Oakland, CA USA

[18] Oakland Med Ctr, Dept Cardiol, Oakland, CA USA

[19] Univ Calif San Francisco, Dept Epidemiol Biostat & Med, San Francisco, CA USA

来源：

JAMA NETWORK OPEN | 2024年 / 7卷 / 11期

关键词：

ORAL ANTICOAGULATION; RISK; FLUTTER; STROKE; CARE; SCORE;

D O I：

10.1001/jamanetworkopen.2024.43097

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

Importance Oral anticoagulation for adults with atrial fibrillation or atrial flutter (AFF) who are at elevated stroke risk reduces the incidence of ischemic stroke but remains underused. Efforts to increase anticoagulation initiation on emergency department (ED) discharge have yielded conflicting results. Objective To evaluate the effectiveness of a multipronged intervention supporting anticoagulation initiation for eligible adult ED patients. Design, Setting, and Participants The Clinical Decision Support to Optimize Care of Patients With Atrial Fibrillation or Flutter in the Emergency Department (O'CAF & Eacute;) pragmatic, stepped-wedge cluster randomized clinical trial was conducted from July 1, 2021, through April 30, 2023, at 13 community medical centers (in 9 clusters) of an integrated health system in Northern California. The study included adult ED patients with primary AFF eligible for anticoagulation initiation when discharged home. Clusters were randomly assigned to staggered dates for 1-way crossover from the control phase (usual care) to the intervention phase. Intervention Physician education, facility-specific audit and feedback, and access to decision support, which identified eligible patients and recommended shared decision-making, anticoagulation initiation (if suitable), and timely follow-up. Main Outcomes and Measures The main outcome was a composite of anticoagulation on discharge or within 30 days. A primary intention-to-treat analysis (decision support access regardless of use) and a secondary per-protocol analysis (decision support use) were performed. Multivariable analyses adjusted for intervention and exposure months with random effects, accounting for clustering by facility and patient. Results A total of 3388 eligible patients with atrial fibrillation were discharged home: 2185 (64.5%) were receiving pre-ED arrival anticoagulation and 1203 (35.5%) were eligible for anticoagulation. Among the 1203 patients with an initiation-eligible encounter, the median age was 74.0 (IQR, 68.0-82.0) years and approximately half (618 [51.4%]) were men. Among the 387 patients with an initiation-eligible control encounter, 244 (63.0%) received anticoagulation (190 [49.0%] at discharge and 54 [14.0%] within 30 days). Among the 816 patients with an initiation-eligible intervention encounter, 558 (68.4%) received anticoagulation (428 [52.5%] on discharge and 130 [15.9%] within 30 days). There was no statistically significant change in initiation of anticoagulation associated with the intervention (adjusted odds ratio, 1.33 [95% CI, 0.75-2.35]; P = .13). Decision support was used for 217 eligible case patients (26.6%) (per protocol) and was associated with a statistically significant change in anticoagulation initiation when compared with 599 patients for whom decision support was not used (164 [75.6%] vs 394 [65.8%]; P = .008). Conclusions and Relevance In this trial, a multipronged intervention to facilitate thromboprophylaxis among eligible ED patients with AFF did not significantly increase anticoagulation initiation. Opportunities exist to further improve stroke prevention among ED patients with primary AFF.

引用

页数：13

共 43 条

[1] Identifying barriers and facilitators to successful implementation of computerized clinical decision support systems in hospitals: a NASSS framework-informed scoping review [J].