RESUMO
Background: Despite benefits of oral anticoagulation (OAC), many individuals with diagnosed atrial fibrillation (AF) do not receive OAC. Objective: The purpose of this study was to assess whether cardiac rhythm assessment for AF impacted use of OAC in patients with previously diagnosed AF. Methods: VITAL-AF was a cluster randomized controlled trial conducted in 16 primary care practices assessing the efficacy of AF rhythm assessment with single-lead electrocardiogram in routine care. Patients 65 years and older were offered rhythm assessment at visits. In this secondary analysis, we evaluated rhythm assessment uptake and compared initiation and discontinuation of OAC in patients with previously diagnosed AF from intervention and control arms over 1 year. Results: The study included 4593 patients with previously diagnosed AF (2250 intervention; 2343 control). In the intervention arm, 2022 (89.9%) completed rhythm assessment (median 2 visits with rhythm assessment) and 40.1% had ≥1 "Possible AF" result. Initiation of OAC was similar in the intervention (17.7%) and control (19.1%) arms but was influenced by the rhythm assessment result: higher with a "Possible AF" (26.1%; adjusted odds ratio [aOR] 1.62; 95% confidence interval [CI] 1.04-2.51), and lower with a "Normal" result (9.9%; aOR 0.45; 95% CI 0.29-0.71) compared to control. OAC discontinuation was similar in the intervention (6.3%) and control (7.2%) arms, with lower discontinuation with a "Possible AF" result (3.8%; aOR 0.51; 95% CI 0.32-0.81). Conclusions: Including patients with previously diagnosed AF in a point-of-care rhythm assessment strategy did not increase overall OAC use compared to the control arm. However, the rhythm assessment result influenced both initiation and discontinuation of OAC.
RESUMO
BACKGROUND: Lack of timely medication intensification and inadequate medication safety monitoring are two prevalent and potentially modifiable barriers to effective and safe chronic care. Innovative applications of health information technology tools may help support chronic disease management. OBJECTIVE: To examine the clinical impact of a novel health IT tool designed to facilitate between-visit ordering and tracking of future laboratory testing. DESIGN AND PARTICIPANTS: Clinical trial randomized at the provider level (n = 44 primary care physicians); patient-level outcomes among 3,655 primary care patients prescribed 5,454 oral medicines for hyperlipidemia, diabetes, and/or hypertension management over a 12-month period. MAIN MEASURES: Time from prescription to corresponding follow-up laboratory testing; proportion of follow-up time that patients achieved corresponding risk factor control (A1c, LDL); adverse event laboratory monitoring 4 weeks after medicine prescription. KEY RESULTS: Patients whose physicians were allocated to the intervention (n = 1,143) had earlier LDL laboratory assessment compared to similar patients (n = 703) of control physicians [adjusted hazard ratio (aHR): 1.15 (1.01-1.32), p = 0.04]. Among patients with elevated LDL (486 intervention, 324 control), there was decreased time to LDL goal in the intervention group [aHR 1.26 (0.99-1.62)]. However, overall there were no significant differences between study arms in time spent at LDL or HbA1c goal. Follow-up safety monitoring (e.g., creatinine, potassium, or transaminases) was relatively infrequent (ranging from 7 % to 29 % at 4 weeks) and not statistically different between arms. Intervention physicians indicated that lack of reimbursement for non-visit-based care was a barrier to use of the tool. CONCLUSIONS: A health IT tool to support between-visit laboratory monitoring improved the LDL testing interval but not LDL or HbA1c control, and it did not alter safety monitoring. Adoption of innovative tools to support physicians in non-visit-based chronic disease management may be limited by current visit-based financial and productivity incentives.