Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF): A cluster randomized trial of a computerized clinical decision support tool - 19/06/20

Doi : 10.1016/j.ahj.2020.02.019

Jafna L. Cox, MD ^a,^b,^c,^{^⁎} , Ratika Parkash, MD ^a, Gary A. Foster, PhD ^d,^e, Feng Xie, PhD ^f,^g, James H. MacKillop, MD ^h, Antonio Ciaccia, MSc ⁱ, Shurjeel H. Choudhri, MD ^j, Laura M. Hamilton, MAHSR ^k, Joanna M. Nemis-White, BSc ^l, Lehana Thabane, PhD ^f,^m,^n,^o,^p
for the IMPACT-AF Investigators
^a Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
^b Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
^c Heart and Stroke Foundation of Nova Scotia Endowed Chair in Cardiovascular Outcomes Research, Halifax, Nova Scotia, Canada
^d Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
^e Biostatistics Unit, St Joseph's Healthcare, Hamilton, Ontario, Canada
^f Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
^g Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
^h Sydney Primary Care Medical Clinic, Sydney, Nova Scotia, Canada
ⁱ Bayer Inc, Mississauga, Ontario, Canada
^j Bayer Inc, Mississauga, Ontario, Canada
^k QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
^l Strive Health Management Consulting Ltd, Halifax, Nova Scotia, Canada
^m Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
ⁿ Departments of Anesthesia/Pediatrics, McMaster University, Hamilton, Ontario, Canada
^o Biostatistics Unit, Centre for Evaluation of Medicine, McMaster University, Hamilton, Ontario, Canada
^p Population Health Research Institute (PHRI), Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada

^⁎Reprint requests: Dr Jafna L. Cox, MD, Department of Medicine, Dalhousie University, QEII Health Sciences Ctr, Halifax Infirmary, 1796 Summer St, Room 2147, Halifax, Nova Scotia, Canada B3H 3A7.Department of MedicineDalhousie University, QEII Health Sciences CtrHalifax Infirmary, 1796 Summer St, Room 2147, HalifaxNova ScotiaCanadaB3H 3A7

Abstract

Background

Clinical decision support (CDS) tools designed to digest, filter, organize, and present health data are becoming essential in providing clinical and cost-effective care. Many are not rigorously evaluated for benefit before implementation. We assessed whether computerized CDS for primary care providers would improve atrial fibrillation (AF) management and outcomes as compared to usual care.

Methods

Overall, 203 primary care providers were recruited, randomized, and then cluster stratified by location (urban, rural) to usual care (n = 99) or CDS (n = 104). Providers recruited 1,145 adult patients with AF to participate. The intervention was access to an evidenced-based, point-of-care computerized CDS designed to support guideline-based AF management. The primary efficacy outcome was a composite of unplanned cardiovascular hospitalizations and AF-related emergency department visits; the primary safety outcome was major bleeding, both over 1 year. Patients were the units of intention-to-treat analysis.

Results

No significant effects on the primary efficacy (130 control, 118 CDS, hazard ratio: 0.98 [95% CI 0.71-1.37], P = .926) or safety (n = 7 usual care, n = 8 CDS, 1.3% total, P = .939) outcomes were observed at 12-months.

Conclusions

IMPACT-AF rigorously assessed a CDS tool in a highly representative sample of primary care providers and their patients; however, no impact on outcomes was observed. Considering the proliferating use of CDS applications, this study highlights the need for efficacy assessments prior to adoption and clinical implementation.

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Vol 224

P. 35-46 - juin 2020 Retour au numéro

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Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF): A cluster randomized trial of a computerized clinical decision support tool - 19/06/20

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