scholarly journals Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial

2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Melina Gattellari ◽  
Andrew Hayen ◽  
Dominic Y. C. Leung ◽  
Nicholas A. Zwar ◽  
John M. Worthington
Keyword(s):  
Atrial Fibrillation ◽  
Decision Making ◽  
Stroke Prevention ◽  
Randomised Trial ◽  
Treatment Decision ◽  
Cluster Randomised Trial ◽  
Anticoagulant Treatment ◽  
Treatment Decision Making ◽  
Cluster Randomised ◽  
Complex Patients

scholarly journals Barriers to a software reminder system for risk assessment of stroke in atrial fibrillation: a process evaluation of a cluster randomised trial in general practice

2018 ◽  
Vol 68 (677) ◽  
pp. e844-e851
Author(s):  
Tim A Holt ◽  
Andrew RH Dalton ◽  
Susan Kirkpatrick ◽  
Jenny Hislop ◽  
Tom Marshall ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Risk Assessment ◽  
General Practice ◽  
Process Evaluation ◽  
Oral Anticoagulants ◽  
Qualitative Interviews ◽  
Randomised Trial ◽  
Software Tool ◽  
Cluster Randomised Trial ◽  
Cluster Randomised

BackgroundOral anticoagulants reduce the risk of stroke in patients with atrial fibrillation (AF), but are underused. AURAS-AF (AUtomated Risk Assessment for Stroke in AF) is a software tool designed to identify eligible patients and promote discussions within consultations about initiating anticoagulants.AimTo investigate the implementation of the software in UK general practice.Design and settingProcess evaluation involving 23 practices randomly allocated to use AURAS-AF during a cluster randomised trial.MethodAn initial invitation to discuss anticoagulation was followed by screen reminders appearing during consultations until a decision had been made. The reminders required responses, giving reasons for cases where an anticoagulant was not initiated. Qualitative interviews with clinicians and patients explored acceptability and usability.ResultsIn a sample of 476 patients eligible for the invitation letter, only 159 (33.4%) were considered suitable for invitation by their GPs. Reasons given were frequently based on frailty, and risk of falls or haemorrhage. Of those invited, 35 (22%) started an anticoagulant (7.4% of those originally identified). A total of 1695 main-screen reminders occurred in 940 patients. In 883 instances, the decision was taken not to initiate and a range of reasons offered. Interviews with 15 patients and seven clinicians indicated that the intervention was acceptable, though the issue of disruptive screen reminders was raised.ConclusionAutomated risk assessment for stroke in atrial fibrillation and prompting during consultations are feasible and generally acceptable, but did not overcome concerns about frailty and risk of haemorrhage as barriers to anticoagulant uptake.

Abstract P114: A Nurse-Led Multi-Component Behavioral Activation Program to Improve Treatment Decision-Making and Health Outcomes in Patients With Atrial Fibrillation

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Wai Chi Polly LI ◽  
Doris Yu
Keyword(s):  
Atrial Fibrillation ◽  
Decision Making ◽  
Standard Care ◽  
Decision Aid ◽  
Stroke Risk ◽  
Behavioral Activation ◽  
Treatment Decision ◽  
Treatment Decision Making ◽  
Mba Program ◽  
Post Test

Introduction: Atrial fibrillation (AF) is a complex condition that requires a multifaceted management approach to reduce disease- and treatment-related complications. However, under-prescription of oral anticoagulant (OAC), non-adherence, suboptimal anticoagulation and risk factor control leave patients to increased risks of adverse outcomes. Methods: This mixed-methods study comprised a randomized controlled trial and an exploratory qualitative study. Community-dwelling patients with AF but no OAC treatment (N = 89) were randomized to receive either the Nurse-led Multi-component Behavioral Activation (N-MBA) program or standard care. The N-MBA program equipped patients as an active agent to manage their AF. Firstly, the nurse enabled patients to be aware of their stroke risk by using a decision-aid, then empowered them to discuss OAC use with physicians actively and be responsible for the medication and lifestyle-related self-care for stroke prevention. A purposive subsample (n=10) from the N-MBA program were interviewed for their engagement experience. Results: As compared with those received the standard care, the N-MBA group showed significantly greater intention to use OAC, and their OAC treatment option was more compatible with physician’s decision at immediate post-test ( p = .002). They also reported greater improvements on health-related quality of life (HRQoL) (immediate post-test: p = .023; 6-month post-test: p = .047) and AF knowledge (immediate post-test: p = .004) after attending the program. The N-MBA program was highly receptive with excellent attendance (92%) and mean satisfaction score (4.94/5.00 ± 0.88). The participants expressed that the decision-aid enabled them to make the OAC treatment decision through better understanding of their stroke risk, pros and cons of different treatments. Through attending the interactive health counseling, they found themselves as more assertive to discuss the treatment options with their physicians. Together with the prompt access of a nurse for advice, they perceived themselves as capable to perform AF-related self-care. Conclusions: The preliminary analysis showed that the N-MBA program is feasible and effective to optimize treatment decision making and HRQoL in AF patients.

TELEMAM: A cluster randomised trial to assess the use of telemedicine in multi-disciplinary breast cancer decision making

2007 ◽  
Vol 43 (17) ◽  
pp. 2506-2514 ◽  
Author(s):  
I.H. Kunkler ◽  
R.J. Prescott ◽  
R.J. Lee ◽  
J.A. Brebner ◽  
J.A. Cairns ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Decision Making ◽  
Randomised Trial ◽  
Cluster Randomised Trial ◽  
Cluster Randomised

scholarly journals Process evaluation of the Bridging the Age Gap in Breast Cancer decision support intervention cluster randomised trial.

2020 ◽  
Author(s):  
Maria Burton ◽  
Kate J Lifford ◽  
Lynda Wyld ◽  
Fiona Armitage ◽  
Alistair Ring ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Decision Making ◽  
Decision Support ◽  
Process Evaluation ◽  
Randomised Trial ◽  
Cluster Randomised Trial ◽  
Routine Practice ◽  
Online Tool ◽  
Cluster Randomised ◽  
Age Gap

Abstract BackgroundThe Bridging the Age Gap in Breast Cancer research programme sought to improve treatment decision-making for older women with breast cancer by developing and testing, in a cluster randomised trial, two decision support interventions (DESIs). One DESI supported the decision to have either primary endocrine therapy (PET) or surgery with adjuvant therapies and the second supported the decision to have adjuvant chemotherapy after surgery or not.MethodsSixteen sites were randomly selected to take part in the process evaluation. Multiple methods of data collection were used. Medical Research Council (MRC) guidelines for the evaluation of complex interventions were used.ResultsEighty-two patients, mean age 75.5, (range 70–93) provided data for the process evaluation. Seventy-three interviews were completed with patients. Ten clinicians from six intervention sites took part in telephone interviews. Dose: Ninety-one members of staff in the intervention arm received intervention training. Reach: The online tool was accessed on 324 occasions by 27 clinicians. Reasons for non-use of the online tool were commonly that the patient had already made a decision or that there was no online access in the clinic. Of the 32 women for whom there were data available, fifteen from the intervention arm and six from the usual care arm were offered a choice of treatment. Fidelity: Clinicians used the online tool in different ways, with some using it during the consultation and others checking the online survival estimates before the consultation. Adaptation: There was evidence of adaptation when using the DESIs. A lack of infrastructure, e.g. internet access, was a barrier to the use of the online tool. The brief decision aid was rarely used. Mediators: Shared decision-making: Most patients felt able to contribute to decision-making and expressed high level of satisfaction with the process. Participants’ responses to intervention: Six patients reported the DESIs to be very useful, one somewhat useful and two moderately useful.ConclusionsClinicians were mainly supportive of the interventions and had attempted some adaptations to make the interventions applicable, but there were practical and engagement barriers that led to sub-optimal adoption in routine practice.Trial Registered11th August 2016 - Retrospectively registered, http://www.isrctn.com/(ISRCTN: 46099296)

scholarly journals The 4S-AF Scheme (Stroke Risk; Symptoms; Severity of Burden; Substrate): A Novel Approach to In-Depth Characterization (Rather than Classification) of Atrial Fibrillation

2020 ◽  
Author(s):  
Tatjana S. Potpara ◽  
Gregory Y. H. Lip ◽  
Carina Blomstrom-Lundqvist ◽  
Giuseppe Boriani ◽  
Isabelle C. Van Gelder ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Decision Making ◽  
Clinical Practice ◽  
Stroke Risk ◽  
Treatment Options ◽  
Symptom Control ◽  
Treatment Decision ◽  
Treatment Decisions ◽  
Treatment Decision Making

AbstractAtrial fibrillation (AF) is a complex condition requiring holistic management with multiple treatment decisions about optimal thromboprophylaxis, symptom control (and prevention of AF progression), and identification and management of concomitant cardiovascular risk factors and comorbidity. Sometimes the information needed for treatment decisions is incomplete, as available classifications of AF mostly address a single domain of AF (or patient)-related characteristics. The most widely used classification of AF based on AF episode duration and temporal patterns (that is, the classification to first-diagnosed, paroxysmal, persistent/long-standing persistent, and permanent AF) has contributed to a better understanding of AF prevention and treatment but its limitations and the need for a multidimensional AF classification have been recognized as more complex treatment options became available. We propose a paradigm shift from classification toward a structured characterization of AF, addressing specific domains having treatment and prognostic implications to become a standard in clinical practice, thus aiming to streamline the assessment of AF patients at all health care levels facilitating communication among physicians, treatment decision-making, and optimal risk evaluation and management of AF patients. Specifically, we propose the 4S-AF structured pathophysiology-based characterization (rather than classification) scheme that includes four AF- and patient-related domains—Stroke risk, Symptoms, Severity of AF burden, and Substrate severity—and provide a hypothetical model for the use of 4S-AF characterization scheme to aid treatment decision making concerning the management of patients with AF in clinical practice.

scholarly journals Integrated management of atrial fibrillation including tailoring of anticoagulation in primary care: study design of the ALL-IN cluster randomised trial

BMJ Open ◽  
2017 ◽  
Vol 7 (9) ◽  
pp. e015510 ◽  
Author(s):  
Carline J van den Dries ◽  
Ruud Oudega ◽  
Arif Elvan ◽  
Frans H Rutten ◽  
Sjef J C M van de Leur ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Cost Effectiveness ◽  
The Netherlands ◽  
Major Bleeding ◽  
Dominant Role ◽  
Randomised Trial ◽  
Cluster Randomised Trial ◽  
Ageing Society ◽  
Cluster Randomised

IntroductionIn our ageing society, we are at the merge of an expected epidemic of atrial fibrillation (AF). AF management requires an integrated approach, including rate or rhythm control, stroke prevention with anticoagulation and treatment of comorbidities such as heart failure or type 2 diabetes. As such, primary care seems to be the logical healthcare setting for the chronic management of patients with AF. However, primary care has not yet played a dominant role in AF management, which has been in fact more fragmented between different healthcare providers. This fragmentation might have contributed to high healthcare costs. To demonstrate the feasibility of managing AF in primary care, studies are needed that evaluate the safety and (cost-)effectiveness of integrated AF management in primary care.Methods and analysisThe ALL-IN trial is a multicentre, pragmatic, cluster randomised, non-inferiority trial performed in primary care practices in a suburban region in the Netherlands. We aim to include a minimum of 1000 patients with AF aged 65 years or more from around 18 to 30 practices. Duration of the study is 2 years. Practices will be randomised to either the intervention arm (providing integrated AF management, involving a trained practice nurse and collaboration with secondary care) or the control arm (care as usual). The primary endpoint is all-cause mortality. Secondary endpoints are cardiovascular mortality, (non)-cardiovascular hospitalisation, major adverse cardiac events, stroke, major bleeding, clinically relevant non-major bleeding, quality of life and cost-effectiveness.Ethics and disseminationThe protocol was approved by the Medical Ethical Committee of the Isala Hospital Zwolle, the Netherlands. Patients in the intervention arm will be asked informed consent for participating in the intervention. Results are expected in 2019 and will be disseminated through both national and international journals and conferences.Trial registration numberThis trial is registered at the Netherlands Trial Register (NTR5532).

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