Optimizing Stroke Prophylaxis of Acute Atrial Fibrillation with an Electronic Clinical Decision Support Tool: A Stepped-Wedge Cluster Randomized Trial Design

使用电子临床决策支持工具优化急性心房颤动的中风预防：阶梯楔形集群随机试验设计

• 批准号: 10415095
• 负责人: Bory Kea
• 金额: $ 29.7万
• 依托单位: OREGON HEALTH & SCIENCE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-06-01 至 2026-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10415095
• 关键词: Accident and Emergency department; Acute; Address; Adult; Affect; American; Anticoagulants; Anticoagulation; Arrhythmia; Atrial Fibrillation; Atrial Flutter; Car Phone; Cardiovascular system; Caring; Case Study; Cessation of life; Chronic; Client satisfaction; Clinic; Clinical; Cluster randomized trial; Computers; Data; Development; Diagnosis; Disease; Electronic Health Record; Emergency Care; Emergency Department Physician; Emergency Department evaluation; Emergency Department patient; Emergency department visit; Environment; Feedback; Future; Goals; Guideline Adherence; Guidelines; Health; Health Care Costs; Health system; Healthcare Systems; Heart Diseases; Heart failure; Hospitals; Incentives; Individual; Intervention; Knowledge; Manuals; Medicare; Methods; Mission; Monitor; Morbidity - disease rate; National Heart, Lung, and Blood Institute; Online Systems; Oral; Outcome; Outpatients; Patient Care; Patient-Focused Outcomes; Patients; Pattern; Pharmaceutical Preparations; Physicians; Prevention; Primary Health Care; Prophylactic treatment; Proxy; Research; Research Personnel; Resource-limited setting; Resources; Risk; Rural; Scientist; Stroke; Stroke prevention; System; Testing; Time; Training; United States; Update; Variant; Warfarin; acute care; base; care outcomes; clinical decision support; clinical decision-making; comorbidity; computerized physician order entry; cost; cost estimate; design; emergency settings; empowerment; evidence based guidelines; experience; heart rhythm; high risk; implementation tool; improved; mortality; organizational readiness; patient engagement; patient oriented; patient population; payment; prevent; primary outcome; secondary outcome; shared decision making; stroke patient; stroke risk; support tools; tool; trial design; web portal

Abstract Statement Atrial fibrillation (AF) is the most common arrhythmia in the world, with significant morbidity and mortality. With appropriate oral anticoagulation, the risk of stroke due to atrial fibrillation decreases by 64%. Although atrial fibrillation is commonly diagnosed and treated in the Emergency Department (ED), oral anticoagulation is significantly underprescribed. Underprescribing has been attributed to a lack of empowerment and deferral of prescribing to longitudinal care clinicians. However, patients often do not follow-up with longitudinal care clinicians, resulting in missed opportunities to provide guideline-recommended care. Our proposal focuses on this missed opportunity to change the trajectory of care in the ED for patients with atrial fibrillation with appropriate early prescribing of oral anticoagulants, and thereby, improve clinical outcomes. This R01 Physician-Scientist Early Investigator proposal is in keeping with the mission of NHLBI "to promote the prevention and treatment of heart disease … and enhance the health of all individuals so that they can live longer and more fulfilling lives." We leverage an existing outpatient shared-decision making clinical decision support tool to improve stroke prevention for patients with atrial fibrillation and test its ability to improve guideline-recommended care in the acute care setting of the Emergency Department—a fast-paced, episodic, high-intensity environment. Electronic health record clinical decision support (CDS) tools have emerged as a means to guide clinicians on best practices and can make a significant impact on clinical outcomes. By increasing guideline adherence and improving the transition of care from the ED to the outpatient setting, this proposal could significantly reduce the risk of stroke for patients with atrial fibrillation with an intervention that could be rapidly and effectively disseminated across other settings. The project is a convergent parallel quantitative-qualitative study (mixed-methods) consisting of three components: (1) Implement a clinical decision support tool in a multi-centered stepped-wedge cluster randomized trial, (2) Identify clinician facilitators and barriers to ideal AF care and refine CDS tools for different settings using qualitative approaches, and (3) Explore patient satisfaction with the tool for future scalability and generalizability. This research will allow Dr. Kea to gain knowledge on how the unique environments of each hospital setting interacts with the CDS tool and how to refine the tool for large-scale dissemination, including rural and resource-poor environments, on a national scale.

摘要陈述 心房颤动（AF）是世界上最常见的心律失常，具有显着的发病率和死亡率。和 适当的口服抗凝药物，因房颤引起的中风风险降低64%。虽然心房 颤动通常在急诊科 (ED) 进行诊断和治疗，口服抗凝药物是 处方明显不足。处方不足的原因是缺乏授权和推迟 向纵向护理临床医生开处方。然而，患者通常不会进行纵向护理随访 临床医生，导致错过提供指南推荐护理的机会。我们的建议重点是 这错失了改变急诊室对心房颤动患者护理轨迹的机会 适当的早期处方口服抗凝剂，从而改善临床结果。这个R01 医师-科学家早期研究者的提案符合 NHLBI 的使命“促进 预防和治疗心脏病……并增强所有人的健康，使他们能够生存 更长、更充实的生活。”我们利用现有的门诊共享决策来制定临床决策 改善房颤患者中风预防的支持工具并测试其改善能力 急诊科急症护理环境中指南推荐的护理——快节奏、间歇性、 高强度环境。电子健康记录临床决策支持 (CDS) 工具已成为一种 旨在指导临床医生采用最佳实践，并对临床结果产生重大影响。经过 提高指南的遵守率并改善从急诊室到门诊的护理过渡，这 该提案可以通过以下干预措施显着降低房颤患者中风的风险： 可以在其他环境中快速有效地传播。该项目是一个收敛并行 定量-定性研究（混合方法）由三个部分组成：（1）实施临床 多中心阶梯楔形集群随机试验中的决策支持工具，(2) 识别临床医生 理想 AF 护理的促进因素和障碍，并使用定性方法针对不同设置完善 CDS 工具 方法，(3) 探索患者对该工具的满意度，以实现未来的可扩展性和普遍性。 这项研究将使 Kea 博士了解每个医院环境的独特环境如何 与 CDS 工具交互以及如何完善该工具以进行大规模传播，包括农村和农村地区 全国范围内资源匮乏的环境。