scholarly journals Screening for Atrial Fibrillation in Older Adults at Primary Care Visits: the VITAL-AF Randomized Controlled Trial

2021 ◽  
Author(s):  
Steven Lubitz ◽  
Steven J. Atlas ◽  
Jeffrey M. Ashburner ◽  
Ana Lipsanopoulos ◽  
Leila Borowsky ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Usual Care ◽  
Controlled Trial ◽  
Oral Anticoagulants ◽  
Care Practice ◽  
Control Group ◽  
Newly Diagnosed ◽  
One Year ◽  
And Control

Background: Undiagnosed atrial fibrillation (AF) may cause preventable strokes. Guidelines differ regarding AF screening recommendations. We tested whether point-of-care screening with a handheld single lead electrocardiogram (ECG) at primary care practice visits increases diagnoses of AF. Methods: We randomized 16 primary care clinics 1:1 to AF screening using a handheld single-lead ECG (AliveCor KardiaMobile) during vital sign assessments, or usual care. Patients included were aged ≥ 65 years. Screening results were provided to primary care clinicians at the encounter. All confirmatory diagnostic testing and treatment decisions were made by the primary care clinician. New AF diagnoses over one-year follow-up were ascertained electronically and manually adjudicated. Proportions and incidence rates were calculated. Effect heterogeneity was assessed. Results: Of 30,715 patients without prevalent AF (n=15,393 screening [91% screened], n=15,322 control), 1.72% of individuals in the screening group had new AF diagnosed at one year versus 1.59% in the control group (risk difference [RD] 0.13%, 95% confidence interval [CI] -0.16,0.42, P=0.38). New AF diagnoses in the screening and control groups differed by age with the greatest effect observed for those aged ≥ 85 years (5.56% versus 3.76%, respectively, RD 1.80%, 95% CI 0.18,3.30). The difference in newly diagnosed AF between the screening period and the prior year was marginally greater in the screening versus control group (0.32% versus -0.12%, RD 0.43%, 95% CI -0.01,0.84). The proportion of individuals with newly diagnosed AF who were initiated on oral anticoagulants was similar in the screening (n=194, 73.5%) and control (n=172, 70.8%) arms (RD 2.7%, 95% CI -5.5,10.4). Conclusions: Screening for AF using a single-lead ECG at primary care visits was not associated with a significant increase in new AF diagnoses among individuals aged 65 years or older compared to usual care. However, screening may be associated with an increased likelihood of diagnosing AF among individuals aged 85 years or older and warrants further evaluation.

scholarly journals Opportunistic screening versus usual care for diagnosing atrial fibrillation in general practice: a cluster randomised controlled trial

2020 ◽  
Vol 70 (695) ◽  
pp. e427-e433 ◽  
Author(s):  
Femke Kaasenbrood ◽  
Monika Hollander ◽  
Steven HM de Bruijn ◽  
Carlijn PE Dolmans ◽  
Robert G Tieleman ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Randomised Controlled Trial ◽  
Usual Care ◽  
Controlled Trial ◽  
Chronic Obstructive ◽  
Screening Methods ◽  
Opportunistic Screening ◽  
Newly Diagnosed ◽  
Randomised Controlled

BackgroundAtrial fibrillation (AF) increases the risk of stroke, heart failure, and all-cause mortality. AF may be asymptomatic and therefore remain undiagnosed. Devices such as single-lead electrocardiographs (ECGs) may help GPs to diagnose AF.AimTo investigate the yield of opportunistic screening for AF in usual primary care using a single-lead ECG device.Design and settingA clustered, randomised controlled trial among patients aged ≥65 years with no recorded AF status in the Netherlands from October 2014 to March 2016.MethodFifteen intervention general practices used a single-lead ECG device at their discretion and 16 control practices offered usual care. The follow-up period was 1 year, and the primary outcome was the proportion of newly diagnosed cases of AF.ResultsIn total, 17 107 older people with no recorded AF status were eligible to participate in the study. In the intervention arm, 10.7% of eligible patients (n = 919) were screened over the duration of the study year. The rate of newly diagnosed AF was similar in the intervention and control practices (1.43% versus 1.37%, P = 0.73). Screened patients were more likely to have comorbidities, such as hypertension (60.0% versus 48.7%), type 2 diabetes (24.3% versus 18.6%), and chronic obstructive pulmonary disease (11.3% versus 7.4%), than eligible patients not screened in the intervention arm. Among patients with newly diagnosed AF in intervention practices, 27% were detected by screening, 23% by usual primary care, and 50% by a medical specialist or after stroke/transient ischaemic attack.ConclusionOpportunistic screening with a single-lead ECG at the discretion of the GP did not result in a higher yield of newly detected cases of AF in patients aged ≥65 years in the community than usual care. For higher participation rates in future studies, more rigorous screening methods are needed.

scholarly journals An Effectiveness Trial of STEADI in an Outpatient, Primary Care Practice

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 774-774
Author(s):  
David Rein ◽  
Madeleine Hackney ◽  
Michele Dougherty ◽  
Camille Vaughan ◽  
Laurie Imhof ◽  
...  
Keyword(s):  
Primary Care ◽  
Medication Review ◽  
Primary Care Practice ◽  
Controlled Trial ◽  
Care Practice ◽  
Strength Assessment ◽  
Randomized Controlled ◽  
Study Team ◽  
One Year ◽  
The Impact

Abstract The STEADI Options trial uses a randomized, controlled-trial design to assess the effectiveness and cost-effectiveness of the STEADI Initiative . Beginning March, 2020, we will randomize 3,000 adults ≥ 65 years of age at risk for falls seen in an Emory Clinic primary care practice to: (1) full STEADI; (2) a STEADI-derived gait, balance, and strength assessment with physical therapy referrals; (3) a STEADI-derived medication review and management; or (4) usual care. This presentation will discuss decisions made by the study team to facilitate implementation of STEADI including electronically conducting screening prior to the date of encounter, the use of dedicated nursing staff to conduct assessments, implementation of strength, balance, orthostatic hypotension, and vision testing, methods to facilitate medication review, and communication of assessment information to providers. The results from this study will be used to estimate the impact of STEADI on falls, service utilization, and costs over one year.

scholarly journals Diabetes education in primary care: a randomized clinical trial

2016 ◽  
Vol 32 (5) ◽  
Author(s):  
Maria de Fatima Ferreira Grillo ◽  
Cristina Rolim Neumann ◽  
Suzana Fiore Scain ◽  
Raquel Farias Rozeno ◽  
Luis Beloli ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Primary Care ◽  
Type 2 Diabetes Mellitus ◽  
Diabetes Education ◽  
Insulin Dose ◽  
Control Group ◽  
One Year ◽  
And Control

Abstract: The aim of the study was to evaluate the effect of a structured group education program administered by a primary care nurse in patients with type 2 diabetes mellitus. The sample included 137 patients with type 2 diabetes mellitus, randomized into two groups: intervention (5-week educational course and reinforcements every 4 months for one year) and control (with no structured diabetes mellitus education) with an evaluation of metabolic control, weight, blood pressure, distress scores, and knowledge on diabetes. There were no differences between the two groups in HbA1c at 4, 8, or 12 months when compared to baseline values. An increase in HbA1c was observed in the control group after adjusting for baseline HbA1c and insulin dose (p = 0.044 between groups). Knowledge scores and diabetes-related distress improved after the intervention. A structured educational program administered to type 2 diabetes mellitus patients seen at a primary care unit improved the knowledge and distress associated with the disease. The results also suggest the prevention of an increase in HbA1c.

scholarly journals Opportunistic screening versus usual care for detection of atrial fibrillation in primary care: cluster randomised controlled trial

BMJ ◽  
2020 ◽  
pp. m3208
Author(s):  
Steven B Uittenbogaart ◽  
Nicole Verbiest-van Gurp ◽  
Wim A M Lucassen ◽  
Bjorn Winkens ◽  
Mark Nielen ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Usual Care ◽  
Controlled Trial ◽  
Cluster Randomised Controlled Trial ◽  
Care Group ◽  
Opportunistic Screening ◽  
Cluster Randomised ◽  
Care Practices ◽  
Randomised Controlled

AbstractObjectiveTo investigate whether opportunistic screening in primary care increases the detection of atrial fibrillation compared with usual care.DesignCluster randomised controlled trial.Setting47 intention-to-screen and 49 usual care primary care practices in the Netherlands, not blinded for allocation; the study was carried out from September 2015 to August 2018.ParticipantsIn each practice, a fixed sample of 200 eligible patients, aged 65 or older, with no known history of atrial fibrillation in the electronic medical record system, were randomly selected. In the intention-to-screen group, 9218 patients eligible for screening were included, 55.0% women, mean age 75.2 years. In the usual care group, 9526 patients were eligible for screening, 54.3% women, mean age 75.0 years.InterventionsOpportunistic screening (that is, screening in patients visiting their general practice) consisted of three index tests: pulse palpation, electronic blood pressure measurement with an atrial fibrillation algorithm, and electrocardiography (ECG) with a handheld single lead electrocardiographic device. The reference standard was 12 lead ECG, performed in patients with at least one positive index test and in a sample of patients (10%) with three negative tests. If 12 lead ECG showed no atrial fibrillation, patients were invited for more screening by continuous monitoring with a Holter electrocardiograph for two weeks.Main outcome measuresDifference in the detection rate of newly diagnosed atrial fibrillation over one year in intention-to-screen versus usual care practices.ResultsFollow-up was complete for 8874 patients in the intention-to-screen practices and for 9102 patients in the usual care practices. 144 (1.62%) new diagnoses of atrial fibrillation in the intention-to-screen group versus 139 (1.53%) in the usual care group were found (adjusted odds ratio 1.06 (95% confidence interval 0.84 to 1.35)). Of 9218 eligible patients in the intention-to-screen group, 4106 (44.5%) participated in the screening protocol. In these patients, 12 lead ECG detected newly diagnosed atrial fibrillation in 26 patients (0.63%). In the 266 patients who continued with Holter monitoring, four more diagnoses of atrial fibrillation were found.ConclusionsOpportunistic screening for atrial fibrillation in primary care patients, aged 65 and over, did not increase the detection rate of atrial fibrillation, which implies that opportunistic screening for atrial fibrillation is not useful in this setting.Trial registrationNetherlands Trial Register No NL4776 (old NTR4914).

scholarly journals OP0279 THE IMPACT OF A REFERRAL STRATEGY FOR AXIAL SPONDYLOARTHRITIS: 12 MONTHS FOLLOW-UP OF PATIENT REPORTED OUTCOMES

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 174.2-174
Author(s):  
M. J. Abdelkadir ◽  
M. Kuijper ◽  
C. Appels ◽  
A. Spoorenberg ◽  
J. Hazes ◽  
...  
Keyword(s):  
Primary Care ◽  
Usual Care ◽  
Axial Spondyloarthritis ◽  
Control Group ◽  
P Value ◽  
Patient Reported ◽  
Referral Strategy ◽  
And Control ◽  
The Impact ◽  
Over Time

Background:Early recognition of axial spondyloarthritis (axSpA) patients is difficult for general practitioners within the large amount of chronic low back pain (CLBP) patients1. As a result, several referral strategies have been developed to help physicians identify patients at risk for axSpA. Most referral strategies were developed in secondary care patients with no available data on their impact. The only referral strategy that was developed and validated in primary CLBP patients is the Case Finding Axial Spondyloarthritis (CaFaSpA) strategy, but required an impact analysis before implementation in daily clinical practice2-3.Objectives:The purpose of this study was to assess the impact of using the CaFaSpA referral strategy on patient reported outcome outcomes (PROs) in primary care patients with CLBP at risk for axSpA.Methods:A clustered randomized controlled trial was performed in a primary care setting in the Netherlands. (ClinicalTrials.gov Identifier:NCT01944163). Each cluster contained the general practices from a single primary care practice and their included patients. Clusters were randomized to either the intervention (use of CaFaSpA referral strategy) or the control group (usual care). Primary outcome was disability after 12 months. Secondary outcome was quality of life, pain and fatigue after 12 months. A linear mixed-effects model was used to explore the effects over time according to intention to treat analysis.Results:In total 679 patients were included within 93 GP clusters. Sixty-four percent of our study population were female and mean age was 36 (7.5) years. Overall RMDQ reduced over time both in the intervention and control group (figure 1). The difference in decrease was not statically significant between the groups (p-value 0.81).Figure 1.Estimated mean RMDQ scores over time for the overall intervention and usual care group.EQ-5D increased by 0.03 after 12 months within the intervention group and 0.01 in the control group (not significant) (table 1). The decrease in pain and fatigue did not differ significantly between the intervention and control group.Table 1.Mean change in PROs after 12 months in the intervention and control groupPROsInterventionUsual careBaseline12 monthsp-valueBaseline12 monthsp-valueEQ-5D mean (SD)0.69 (0.26)0.72 (0.27)0.140.72 (0.24)0.73 (0.25)0.53VAS-pain mean (SD)5.03 (2.42)4.68 (2.69)0.074.96 (2.42)4.55 (2.69)0.02VAS-fatigue mean (SD)5.19 (2.50)5.01 (0.21)0.355.23 (2.45)4.86 (2.73)0.04Conclusion:Although the functional disability due to pain reduces over time, there was no positive effect by referring based on the CaFaSPA model. Further data on PROMs for the axSpA patients are under investigation.References:[1]Jois RN et al. Rheumatology (Oxford) 2008;47:1364-1366.[2]van Hoeven L et al. PLoS One 2015; 22;10(7):e0131963.[2]Moons KG et al. Heart 2012;98(9):691-8.Disclosure of Interests:None declared

scholarly journals Acceleration of opportunistic atrial fibrillation screening for elderly patients in routine primary care

PLoS ONE ◽  
2020 ◽  
Vol 15 (12) ◽  
pp. e0244240
Author(s):  
Akifumi Suzuki ◽  
Tomonori Okamura ◽  
Masahiro Sasaki ◽  
Hitoshi Matsuoka ◽  
Yoshinobu Ikeda ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Ischemic Stroke ◽  
Anticoagulation Therapy ◽  
Care Practice ◽  
Newly Diagnosed ◽  
Clinical Value ◽  
Risk Patients ◽  
History Of ◽  
First Time

Cardio-embolic ischemic stroke caused by atrial fibrillation is more severe compared with other types of stroke, such as lacunar infarction and atherothrombotic infarction in patients without atrial fibrillation. Therefore, it is important to prevent cardio-embolic ischemic stroke by detecting atrial fibrillation early in at-risk patients and administering appropriate anticoagulation therapy. This prospective observational study aimed to evaluate the effectiveness of opportunistic atrial fibrillation screening at 12 primary clinics in Japan. The study included a 12-month pre-campaign period and a 12-month campaign period. During the campaign period, an awareness campaign was conducted to encourage physicians to be mindful of screening patients aged ≥65 years for atrial fibrillation by checking their pulses and performing subsequent electrocardiography when an irregular pulse was detected. The primary outcome was the proportion of patients with newly diagnosed atrial fibrillation. A sub-analysis focusing on first-time outpatients was performed. There were 9921 and 10,282 patients with no history of atrial fibrillation in the pre-campaign and campaign periods, respectively. In the whole population, the proportion of patients with newly diagnosed atrial fibrillation was 0.9% throughout the pre-campaign and campaign periods. In the sub-analysis limited to first-time outpatients, the detection proportion increased from 1.6% to 1.9% during the campaign period. In terms of age stratification, a large increase in detection was observed, especially among patients aged 65–74 years (detection increased from 0.9% to 1.5%) and ≥85 years (detection increased from 2.9% to 3.3%) during the campaign period. Our findings suggest the feasibility of opportunistic atrial fibrillation screening in routine primary care practice in Japan. Of note, our findings suggest that opportunistic atrial fibrillation screening targeting first-time outpatients may be of clinical value.

Therapeutic effect of gradual attention training on language function in patients with post-stroke aphasia: a pilot study

2019 ◽  
Vol 33 (11) ◽  
pp. 1767-1774 ◽  
Author(s):  
Hong Zhang ◽  
He Li ◽  
Ruojin Li ◽  
Guoxing Xu ◽  
Zhenlan Li
Keyword(s):  
Controlled Trial ◽  
Attention Training ◽  
Control Group ◽  
Language Function ◽  
Auditory Comprehension ◽  
Post Stroke ◽  
The Mean ◽  
One Year ◽  
And Control ◽  
Experimental Group

Objective: To investigate the effect of gradual attention training on language function with aphasia. Design: Randomized controlled trial. Participants: A total of 40 patients (mean age: 53.47 years) with post-stroke aphasia came from the stroke rehabilitation unit of rehabilitation department in the First Hospital of Jilin University, of which 13 (32.5%) had intracerebral hemorrhage, 28 inpatients and 12 outpatients, 11 women and 29 men, 34 within three-month stroke and 6 within three months to one year. Interventions: All participants were divided into control and experimental groups. Both groups received language treatment 20 minutes a day, six days/week, for five weeks, and the experimental group received gradual attention training 20 minutes a day, six days/week, for five weeks. Main measures: Language function was assessed pre- and post-treatment by components of the Western Aphasia Battery (WAB) which included spontaneous speech, auditory comprehension, repetition, and naming and then calculated the aphasia quotient (AQ). Results: The mean (SD) AQ of the experimental group and control group, respectively, was 25.71 (12.63) and 26.2 (12.31) at baseline. After treatment, the AQ mean (SD) was 43.08 (15.14) in the experimental group, which showed a significant improvement compared to 33.48 (14.04) in the control group ( P = 0.02).All items of WAB were higher in experimental group than those in control group, especially in auditory comprehension and naming ( P = 0.02, 0.01). Conclusion: Gradual attention training seemed to improve language function in post-stroke aphasia, specifically function of listening comprehension and naming.

scholarly journals Home and Online Management and Evaluation of Blood Pressure (HOME BP) using a digital intervention in poorly controlled hypertension: randomised controlled trial

BMJ ◽  
2021 ◽  
pp. m4858
Author(s):  
Richard J McManus ◽  
Paul Little ◽  
Beth Stuart ◽  
Katherine Morton ◽  
James Raftery ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Primary Care ◽  
Systolic Blood Pressure ◽  
Usual Care ◽  
Controlled Trial ◽  
Self Monitoring ◽  
Digital Intervention ◽  
Online Management ◽  
One Year ◽  
Randomised Controlled

Abstract Objective The HOME BP (Home and Online Management and Evaluation of Blood Pressure) trial aimed to test a digital intervention for hypertension management in primary care by combining self-monitoring of blood pressure with guided self-management. Design Unmasked randomised controlled trial with automated ascertainment of primary endpoint. Setting 76 general practices in the United Kingdom. Participants 622 people with treated but poorly controlled hypertension (>140/90 mm Hg) and access to the internet. Interventions Participants were randomised by using a minimisation algorithm to self-monitoring of blood pressure with a digital intervention (305 participants) or usual care (routine hypertension care, with appointments and drug changes made at the discretion of the general practitioner; 317 participants). The digital intervention provided feedback of blood pressure results to patients and professionals with optional lifestyle advice and motivational support. Target blood pressure for hypertension, diabetes, and people aged 80 or older followed UK national guidelines. Main outcome measures The primary outcome was the difference in systolic blood pressure (mean of second and third readings) after one year, adjusted for baseline blood pressure, blood pressure target, age, and practice, with multiple imputation for missing values. Results After one year, data were available from 552 participants (88.6%) with imputation for the remaining 70 participants (11.4%). Mean blood pressure dropped from 151.7/86.4 to 138.4/80.2 mm Hg in the intervention group and from 151.6/85.3 to 141.8/79.8 mm Hg in the usual care group, giving a mean difference in systolic blood pressure of −3.4 mm Hg (95% confidence interval −6.1 to −0.8 mm Hg) and a mean difference in diastolic blood pressure of −0.5 mm Hg (−1.9 to 0.9 mm Hg). Results were comparable in the complete case analysis and adverse effects were similar between groups. Within trial costs showed an incremental cost effectiveness ratio of £11 ($15, €12; 95% confidence interval £6 to £29) per mm Hg reduction. Conclusions The HOME BP digital intervention for the management of hypertension by using self-monitored blood pressure led to better control of systolic blood pressure after one year than usual care, with low incremental costs. Implementation in primary care will require integration into clinical workflows and consideration of people who are digitally excluded. Trial registration ISRCTN13790648 .

Levels of Prothrombin Fragment F1+2 in Patients with Hyperhomocysteinemia and a History of Venous Thromboembolism

1997 ◽  
Vol 78 (05) ◽  
pp. 1327-1331 ◽  
Author(s):  
Paul A Kyrle ◽  
Andreas Stümpflen ◽  
Mirko Hirschl ◽  
Christine Bialonczyk ◽  
Kurt Herkner ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Thrombin Generation ◽  
Oral Anticoagulant Therapy ◽  
Oral Anticoagulants ◽  
Control Group ◽  
Prothrombin Fragment ◽  
Hemostatic System ◽  
Significant Difference ◽  
System Activation ◽  
One Year

SummaryIncreased thrombin generation occurs in many individuals with inherited defects in the antithrombin or protein C anticoagulant pathways and is also seen in patients with thrombosis without a defined clotting abnormality. Hyperhomocysteinemia (H-HC) is an important risk factor of venous thromboembolism (VTE). We prospectively followed 48 patients with H-HC (median age 62 years, range 26-83; 18 males) and 183 patients (median age 50 years, range 18-85; 83 males) without H-HC for a period of up to one year. Prothrombin fragment Fl+2 (Fl+2) was determined in the patient’s plasma as a measure of thrombin generation during and at several time points after discontinuation of secondary thromboprophylaxis with oral anticoagulants. While on anticoagulants, patients with H-HC had significantly higher Fl+2 levels than patients without H-HC (mean 0.52 ± 0.49 nmol/1, median 0.4, range 0.2-2.8, versus 0.36 ± 0.2 nmol/1, median 0.3, range 0.1-2.1; p = 0.02). Three weeks and 3,6,9 and 12 months after discontinuation of oral anticoagulants, up to 20% of the patients with H-HC and 5 to 6% without H-HC had higher Fl+2 levels than a corresponding age- and sex-matched control group. 16% of the patients with H-HC and 4% of the patients without H-HC had either Fl+2 levels above the upper limit of normal controls at least at 2 occasions or (an) elevated Fl+2 level(s) followed by recurrent VTE. No statistical significant difference in the Fl+2 levels was seen between patients with and without H-HC. We conclude that a permanent hemostatic system activation is detectable in a proportion of patients with H-HC after discontinuation of oral anticoagulant therapy following VTE. Furthermore, secondary thromboprophylaxis with conventional doses of oral anticoagulants may not be sufficient to suppress hemostatic system activation in patients with H-HC.

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