Optimizing Stroke Prevention in Patients With Atrial Fibrillation: A Cluster-Randomized Controlled Trial of a Computerized Antithrombotic Risk Assessment Tool in Australian General Practice, 2012-2013.

Beata V Bajorek,Ines Krass,Sarah N Hilmer,Parker J Magin

doi:10.5888/pcd13.160078

Abstract

IntroductionClinicians have expressed a need for tools to assist in selecting treatments for stroke prevention in patients with atrial fibrillation. The objective of this study was to evaluate the impact of a computerized antithrombotic risk assessment tool (CARAT) on general practitioners’ prescribing of antithrombotics for patients with atrial fibrillation.MethodsA prospective, cluster-randomized controlled trial was conducted in 4 regions (in rural and urban settings) of general practice in New South Wales, Australia (January 2012–June 2013). General practitioner practices were assigned to an intervention arm (CARAT) or control arm (usual care). Antithrombotic therapy prescribing was assessed before and after application of CARAT.ResultsOverall, the antithrombotic therapies for 393 patients were reviewed by 48 general practitioners; we found no significant baseline differences in use of antithrombotics between the control arm and intervention arm. Compared with control patients, intervention patients (n = 206) were 3.1 times more likely to be recommended warfarin therapy (over any other treatment option; P < .001) and 2.8 times more likely to be recommended any anticoagulant (in preference to antiplatelet; P = .02). General practitioners agreed with most (75.2%) CARAT recommendations; CARAT recommended that 75 (36.4%) patients change therapy. After application of CARAT, the proportion of patients receiving any antithrombotic therapy was unchanged from baseline (99.0%); however, anticoagulant use increased slightly (from 89.3% to 92.2%), and antiplatelet use decreased (from 9.7% to 6.8%).ConclusionTools such as CARAT can assist clinicians in selecting antithrombotic therapies, particularly in upgrading patients from antiplatelets to anticoagulants. However, the introduction of novel oral anticoagulants has complicated the decision-making process, and tools must evolve to weigh the risks and benefits of these new therapy options.

Highlights

Clinicians have expressed a need for tools to assist in selecting treatments for stroke prevention in patients with atrial fibrillation
Overall, the antithrombotic therapies for 393 patients were reviewed by 48 general practitioners; we found no significant baseline differences in use of antithrombotics between the control arm and intervention arm
After application of computerized antithrombotic risk assessment tool (CARAT), the proportion of patients receiving any antithrombotic therapy was unchanged from baseline (99.0%); anticoagulant use increased slightly, and antiplatelet use decreased

Summary

Introduction

Clinicians have expressed a need for tools to assist in selecting treatments for stroke prevention in patients with atrial fibrillation. A greater range of factors must be considered in weighing the risks and benefits of treatment, and this expanded range translates to a more complex decision-making process, which further contributes to the suboptimal use of antithrombotic therapy [8,9]. This complexity adds to the burden of care in the general practice setting, where general practitioners (GPs) are principally responsible for decision making and day-to-day management [10,11]. Simple scoring tools are available for GPs to assess the risks and benefits of treatment, for stroke risk assessment [13], but tools to guide selection of treatment for patients are lacking [10,11]

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