Development and validation of a Screening Tool to Evaluate and Warrant Anticoagulation Treatment prior to Discharge in inpatients with Atrial Fibrillation (STEWARxD-AF).

OBJECTIVE: Anticoagulation is highly effective for stroke prevention in atrial fibrillation (AF), reducing the risk by about 64%. Despite overwhelming evidence in support of anticoagulation, up to 40% of AF patients remain untreated. We aimed to develop and validate STEWARxD-AF: a Screening Tool to Evaluate and Warrant Anticoagulation Treatment prior to Discharge in Atrial Fibrillation. MATERIALS AND METHODS: STEWARxD-AF was developed by integrating information extracted from the electronic health record (EHR). A stepwise decision process was applied, based on AF diagnosis, estimated CHA2DS2-VASc-score and anticoagulant use. A priority score was assigned accordingly, ranging from 0 (no risk) to 5 (highest risk of undertreatment). A cross-sectional study was performed to assess the accuracy of STEWARxD-AF. Criterion and tool validity were ascertained by determining sensitivity and specificity, compared to a manual check of the EHR in an inpatient sample (n = 800). Consistency regarding the priority score was determined by estimating Cohen's kappa. RESULTS: A tool to screen for un(der)treated AF was developed and embedded into the EHR. Sensitivity and specificity for AF diagnosis were 98.4% and 87.6%, respectively. Overall sensitivity and specificity for identification of a CHA2DS2-VASc-score ≥ 2 was 97.7% and 72.7%. Sensitivity and specificity to determine the presence of anticoagulant treatment was at least 87.8% and 97.1% There was good agreement for the priority score (κ 0.74 (unweighted); 0.66 (weighted)). CONCLUSIONS: STEWARxD-AF was able to identify untreated AF inpatients reliably and with a high sensitivity. Nearly no patients were missed. We will now implement this AF-screening tool in clinical practice to improve the use of anticoagulation and reduce the risk of stroke.

Impact of Check of Medication Appropriateness (CMA) in optimizing analgesic prescribing: An interrupted time series analysis.

BACKGROUND: Pain therapy in inpatients is regularly suboptimal and might be improved by clinical pharmacy services. In our hospital, we have implemented a software-supported 'Check of Medication Appropriateness' (CMA), which is a centralized pharmacist-led service consisting of a clinical rule-based screening for potentially inappropriate prescriptions (PIPs), and a subsequent medication review by pharmacists. We aimed to investigate the impact of the CMA on pain-related prescribing. METHODS: A quasi-experimental study was performed in a large teaching hospital, using an interrupted time series design. Pre-implementation, patients were exposed to standard of care. Afterwards, a pain-focused CMA comprising 12 specific clinical rules pertaining to analgesic prescribing were implemented in the post-implementation period. A regression model was used to assess the impact of the intervention on the number of pain-related residual PIPs between both periods. The total number of recommendations and acceptance rate was recorded for the post-implementation period. RESULTS: At baseline, a median number of 13.1 (range: 9.5-15.8) residual PIPs per day was observed. After the CMA intervention, the number was reduced to 2.2 (range: 0-9.5) per day. Clinical rules showed an immediate relative reduction of 66% (p < .0001) in pain-related residual PIPs. A significant decreasing time trend was observed during the post-implementation period. Post-implementation, 1683 recommendations were given over 1 year with an acceptance rate of 74.3%. CONCLUSIONS: We proved that the CMA approach reduced the number of pain-related residual PIPs. More pharmacist involvement and the use of clinical rules during hospital stay should be further promoted to optimize appropriate prescribing of analgesics. SIGNIFICANCE: Prescribing of analgesics should be improved in inpatients to optimize pain control and to reduce iatrogenic harm. The Check of Medication Appropriateness (CMA) approach, comprising a clinical rule-based screening for patients at risk and a targeted medication review by pharmacists, reduced the number of pain-related potentially inappropriate prescriptions in a highly significant and sustained manner. This study presents the opportunities of a centralized clinical pharmacy service to help clinicians to further improve analgesic prescribing.

Development and feasibility of a telemonitoring tool with full integration in the electronic medical record: a proof of concept study for patients with inflammatory bowel disease in remission on biological therapy.

Objectives: Telemonitoring can be implemented to enhance disease monitoring and ultimately reduce the number of outpatient visits and associated costs. We developed an in house IBD mobile app and established a proof of concept study to demonstrate the effectiveness and accuracy of the telemonitoring tool for monitoring of disease activity.Methods: An IBD mobile app was designed through close collaboration between the Information Technology and Gastroenterology department of University Hospitals of Leuven. The study was proposed to all patients in remission under stable biological therapy visiting the outpatient clinic. During one-year follow-up, patients completed weekly and monthly questionnaires on their mobile device or on a website. Entered data were directly sent to the electronic medical record. Predefined red flags or alerts, generated by the answers to the questionnaires, were monitored daily.Results: The pilot study in 45 patients demonstrated accurate monitoring of disease activity with fast intervention during flares. During the 12-months follow-up period, an alert for disease activity was generated for 9 different patients out of 1296 completions of the questionnaire. Symptoms resolved spontaneously in 8 patients. One patient reported consecutive PRO-2 increase, endoscopy confirmed an IBD flare and therapy was switched. For the remaining 36 included patients, no alerts indicating disease activity increase were reported. Median compliance to all weekly and monthly questionnaires during 1 year was 52% (IQR: 24-91).Conclusions: We developed the mynexuzhealth IBD app with full integration in the electronic medical record. The app enabled continuous remote monitoring and showed accurate detection of flares.