Atrial fibrillation is the most common cardiac arrhythmia, or irregular heartbeat. It may cause no symptoms, but it is often associated with palpitations, fainting, chest pain or congestive heart failure.
In this Q&A, Eckman describes the scope of his project and how it could impact patient care.
What are the specifics behind your research?
“The title of my project is ‘Impact of a Quality Improvement and Education Initiative on ‘Appropriate’ Use of Anticoagulant Therapy in Women with Atrial Fibrillation,’ and it is funded by a grant from the Pfizer Medical Education Group. Atrial fibrillation is the most common significant cardiac rhythm disorder and is also the most powerful common risk factor for stroke—about 15 percent of all strokes in the U.S. are attributable to atrial fibrillation. Its frequency increases with age, reaching a prevalence of 10 percent in people over age 80. With the aging of the U.S. population, the prevalence of atrial fibrillation will increase substantially from over 2.2 million to more than 3 million by the year 2020. In particular, the risk of stroke in women is underappreciated.
“A recent study showed middle-aged women to be at significantly increased risk of death from atrial fibrillation. Furthermore, studies have shown that populations of women at equivalent risk of stroke are less likely to receive anticoagulant therapy than men. Over the past decade, numerous randomized trials have established that anticoagulation can significantly reduce the stroke risk posed by atrial fibrillation. However, studies have documented widespread underutilization of this therapy, or at times, inappropriate use. As a result the recognition of stroke risk from atrial fibrillation and its prevention have become a high profile issue for many organizations, including UC Health. The American College of Physicians recently has moved ahead with an initiative on atrial fibrillation and stroke prevention. Similar initiatives have been promulgated by the American Heart Association and treatment guidelines continue to be publicized by the American College of Chest Physicians and the American College of Cardiology.”
What will you do to conduct this research?
“This is a two-year-long project to develop an educational program and a performance improvement initiative around the clinical issue of oral anticoagulation therapy for patients with atrial fibrillation in UC Health’s primary care network practices and the Hoxworth-based ambulatory practices of the division of general internal medicine. We will work hand-in-hand with the leadership of UC Health’s primary care network, general medicine’s ambulatory hospital-based practices and with the performance improvement teams at the practice sites to tailor the program to their needs. The research team consists of members of the Department of Neurology and Rehabilitation Medicine’s Stroke Team—Drs. Brett Kissela, Matt Flaherty and Dawn Kleindorfer—Dr. Jack Kues and Barbara Speer in the Center for Continuous Professional Development, members of UC’s Center for Health Informatics (CHI)—Brett Harnett, MS, Pete Baker and Dave Hoskins—Ruth Wise from the division of general internal medicine, Tony Leonard, PhD, from family and community medicine, Lora Arduser, PhD, from the department of English on the main campus and Megan Sullivan, quality manager for UC Physicians.
“As part of the performance improvement intervention we will use clinical information from UC’s clinical data warehouse to calculate patient-specific stroke and bleeding risks for all of UC Health’s ambulatory patients with an active diagnosis of atrial fibrillation and determine current blood-thinning therapy. In addition, once the annual stroke and major hemorrhage rates have been calculated, we will run each case through a decision analytic model we have developed that estimates the gain or loss in quality-adjusted life expectancy resulting from the use of anticoagulant therapy, or warfarin in the base case, for each individual patient. Using a decision analytic model allows us to examine tradeoffs between the risks and benefits of anticoagulant therapy. Finally, current blood thinning therapy determined from the clinical data warehouse will be classified as either concordant or discordant with model recommendations as above. We will share that information with physicians and practices and the practice-based performance improvement teams.”
Why is this important? How could this improve patient care or save money?
“At the completion of this project we will have accomplished several important goals: the development and dissemination of a valuable educational activity through our local health care system’s primary care network; and development, dissemination and testing of a quality improvement intervention to improve decision making about oral anticoagulation therapy for patients with atrial fibrillation. Given the broadening use of electronic health records, if this intervention proves effective, it should be scalable and generalizable to other sites and health care systems in the United States. This project requires a retrospective chart review to identify atrial patients to which the decision support tool is applied. However, the real impact of this tool is at the point of care when patients are diagnosed with atrial fibrillation and physicians are discussing treatment plans with patients. This tool is an adjunct to patient education and engagement and should have a direct impact on patient adherence as well as other barriers to optimal care.”