Enhancing adherence to guideline-directed use of anticoagulant therapy in atrial fibrillation: a triad of quality improvement interventions in an academic outpatient setting.

BACKGROUND: Anticoagulation for stroke prevention is often recommended for patients with non-valvular atrial fibrillation (AF), yet many eligible patients do not receive guideline-concordant anticoagulation. Prior quality improvement (QI) initiatives to improve anticoagulation in AF have had mixed results. METHODS: Preventing Preventable Strokes: Scalability used a triad of interventions to increase the number of eligible patients with AF receiving guideline-concordant anticoagulation, including (1) a best practice alert integrated with the electronic health record, (2) clinician education and (3) patient communication about the anticoagulation therapy that encouraged shared decision-making with clinicians. These interventions were conducted in primary care and cardiology outpatient clinics at (University of Florida Health). Patient-level data were collected during a 6-month intervention period and compared with a 6-month historical control period. Generalised estimating equations with a logistic link were used to estimate the odds of anticoagulant use, adjusting for demographic and clinical characteristics. RESULTS: A total of 3274 individuals were included during the intervention period and 3200 during the preintervention period. The average anticoagulation rate increased from 75.7% to 79.2% across the two periods. In the fully adjusted model, patients in the intervention period had significantly higher odds of anticoagulant use compared with the preintervention period (adjusted OR (aOR) 1.13, 95% CI 1.05 to 1.21, p=0.0007). MyChart activation (aOR 1.38, 95% CI 1.19 to 1.61, p<0.0001) was also associated with increased anticoagulant use. Older age and higher CHA2DS2-VASc scores were associated with greater odds of anticoagulant use, while higher HAS-BLED scores and care in primary care (rather than cardiology) were associated with lower odds. CONCLUSIONS: A triad of QI interventions at the practice, clinician and patient levels increased guideline-concordant anticoagulation use among patients with AF in half of the primary care and cardiology clinics in the University of Florida Health system.