Stroke QUERI Project - Improved Clinical Decision Making for Stroke Prevention

Project Number RRP 06-153 funded by Medical Care.
June 1, 2006 - June 30, 2007

High-quality epidemiological studies have demonstrated that atrial fibrillation (AF) is the most potent common risk factor for stroke and six randomized trials of anticoagulants in AF consistently have demonstrated a risk reduction of stroke by approximately two-thirds. Nonetheless anticoagulants remain underused in clinical practice in AF patients despite its proven efficacy for stroke reduction. Reasons for the under-use of anticoagulation in AF patients are not totally known, but include patient, provider, as well as healthcare system barriers.

This project addresses the gaps in decision making by developing an implementation process and testing the feasibility of using a previously validated clinical decision making tool, “Making Choices: An Atrial Fibrillation Treatment Decision-Making Aid” developed by the Atrial Fibrillation Decision Aid Group at the University of Ottawa (permission obtained).

The program has both a physician and patient component. Specifically, the physician component consists of a physician manual. The patient component consists of an audio cassette, a personnel worksheet, and education booklets which are specific to four levels of stroke risk (low, medium, high, and very high) that detail the risk and benefits of therapy for stroke prevention in AF as described by the current national accepted American College of Chest Physicians recommendations. Using the Department of Veteran Affairs (VA) automated databases (Patient Treatment Files (PTF) and Outpatient Clinic file (OPC) we will first determine all potentially eligible patients with atrial fibrillation by identifying patients with ICD9 code 427.31 (atrial fibrillation) who had either a discharge diagnosis or outpatient clinic visit for atrial fibrillation at the North Florida/South Georgia Veterans Health System in the past fiscal year. From this list we will categorize these potentially eligible patients by the provider of record in the databases. We will then contact the providers by letter asking them to inform the patient of the study. Patients will contact us and arrange telephone meetings. Enrolled patients will be mailed an informed consent form and the clinical decision making tool kit, and followed up for outcomes assessment by phone. Physician satisfaction with the Decision Aid will be assessed by a self-administered mail questionnaire. Analyses: Descriptive statistics will be used. Our outcomes of interest include (1) number of patients who complete the decision tool kit, (2) satisfaction, (3) knowledge/expectations, (4) decisional conflicts, and (5) number of patients who make an appointment with their physician in 30 day period. We will also assess reasons for and against therapy.

No results at this time.

Start-up activities.

Expected contribution of research: This research will provide an understanding of the AF decision making tool’s acceptability among and effect on AF patients. Our results will provide important information about the feasibility of using the decision making tool throughout the VA on a national level.