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      Electronic physician notifications to improve guideline-based anticoagulation in atrial fibrillation: a randomized controlled trial

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          Abstract

          <div class="section"> <a class="named-anchor" id="d201209e256"> <!-- named anchor --> </a> <h5 class="section-title" id="d201209e257">Background</h5> <p id="Par1">Oral anticoagulants reduce the risk of stroke in patients with atrial fibrillation. However, many patients with atrial fibrillation at elevated stroke risk are not treated with oral anticoagulants. </p> </div><div class="section"> <a class="named-anchor" id="d201209e261"> <!-- named anchor --> </a> <h5 class="section-title" id="d201209e262">Objective</h5> <p id="Par2">To test whether electronic notifications sent to primary care physicians increase the proportion of ambulatory patients prescribed oral anticoagulants. </p> </div><div class="section"> <a class="named-anchor" id="d201209e266"> <!-- named anchor --> </a> <h5 class="section-title" id="d201209e267">Design</h5> <p id="Par3">Randomized controlled trial conducted from February to May 2017 within 18 practices in an academic primary care network. </p> </div><div class="section"> <a class="named-anchor" id="d201209e271"> <!-- named anchor --> </a> <h5 class="section-title" id="d201209e272">Participants</h5> <p id="Par4">Primary care physicians ( <i>n</i> = 175) and their patients with atrial fibrillation, at elevated stroke risk, and not prescribed oral anticoagulants. </p> </div><div class="section"> <a class="named-anchor" id="d201209e279"> <!-- named anchor --> </a> <h5 class="section-title" id="d201209e280">Intervention</h5> <p id="Par5">Patients of each physician were randomized to the notification or usual care arm. Physicians received baseline email notifications and up to three reminders with patient information, educational material and primary care guidelines for anticoagulation management, and surveys in the notification arm. </p> </div><div class="section"> <a class="named-anchor" id="d201209e284"> <!-- named anchor --> </a> <h5 class="section-title" id="d201209e285">Main Measures</h5> <p id="Par6">The primary outcome was the proportion of patients prescribed oral anticoagulants at 3 months in the notification ( <i>n</i> = 972) vs. usual care ( <i>n</i> = 1364) arms, compared using logistic regression with clustering by physician. Secondary measures included survey-based physician assessment of reasons why patients were not prescribed oral anticoagulants and how primary care physicians might be influenced by the notification. </p> </div><div class="section"> <a class="named-anchor" id="d201209e295"> <!-- named anchor --> </a> <h5 class="section-title" id="d201209e296">Key Results</h5> <p id="Par7">Over 3 months, a small proportion of patients were newly prescribed oral anticoagulants with no significant difference in the notification (3.9%, 95% CI 2.8–5.3%) and usual care (3.2%, 95% CI 2.4–4.2%) arms ( <i>p</i> = 0.37). The most common, non-exclusive reasons why patients were not on oral anticoagulants included atrial fibrillation was transient (30%) or paroxysmal (12%), patient/family declined (22%), high bleeding risk (20%), fall risk (19%), and frailty (10%). For 95% of patients, physicians stated they would not change their management after reviewing the alert. </p> </div><div class="section"> <a class="named-anchor" id="d201209e303"> <!-- named anchor --> </a> <h5 class="section-title" id="d201209e304">Conclusions</h5> <p id="Par8">Electronic physician notification did not increase anticoagulation in patients with atrial fibrillation at elevated stroke risk. Primary care physicians did not prescribe anticoagulants because they perceived the bleeding risk was too high or stroke risk was too low. </p> </div><div class="section"> <a class="named-anchor" id="d201209e308"> <!-- named anchor --> </a> <h5 class="section-title" id="d201209e309">Trial Registration</h5> <p id="Par9"> <a data-untrusted="" href="http://clinicaltrials.gov" id="d201209e313" target="xrefwindow">ClinicalTrials.gov</a> identifier NCT02950285 </p> </div><div class="section"> <a class="named-anchor" id="d201209e316"> <!-- named anchor --> </a> <h5 class="section-title" id="d201209e317">Electronic supplementary material</h5> <p id="d201209e319">The online version of this article (10.1007/s11606-018-4612-6) contains supplementary material, which is available to authorized users. </p> </div>

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          Most cited references 27

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          2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.

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            Is Open Access

            Response rates in postal surveys of healthcare professionals between 1996 and 2005: An observational study

            Background Postal surveys are a frequently used method of data collection in health services research. Low response rates increase the potential for bias and threaten study validity. The objectives of this study were to estimate current response rates, to assess whether response rates are falling, to explore factors that might enhance response rates and to examine the potential for non-response bias in surveys mailed to healthcare professionals. Methods A random sample of postal or electronic surveys of healthcare workers (1996-2005) was identified from Medline, Embase or Psycinfo databases or Biomed Central. Outcome measures were survey response rate and non response analysis. Multilevel, multivariable logistic regression examined the relationship between response rate and publication type, healthcare profession, country and number of survey participants, questionnaire length and use of reminders. Results The analysis included 350 studies. Average response rate in doctors was 57.5% (95%CI: 55.2% to 59.8%) and significantly lower than the estimate for the prior 10 year period. Response rates were higher when reminders were sent (adjusted OR 1.3; 95%CI 1.1-1.6) but only half the studies did this. Response rates were also higher in studies with fewer than 1000 participants and in countries other than US, Canada, Australia and New Zealand. They were not significantly affected by publication type or healthcare profession (p > 0.05). Only 17% of studies attempted assessment of possible non-response bias. Conclusion Response rates to postal surveys of healthcare professionals are low and probably declining, almost certainly leading to unknown levels of bias. To improve the informativeness of postal survey findings, researchers should routinely consider the use of reminders and assess potential for non-response bias.
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              Risk Factors for Stroke and Efficacy of Antithrombotic Therapy in Atrial Fibrillation

                (1994)
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                Author and article information

                Journal
                Journal of General Internal Medicine
                J GEN INTERN MED
                Springer Nature
                0884-8734
                1525-1497
                December 2018
                August 3 2018
                December 2018
                : 33
                : 12
                : 2070-2077
                Article
                10.1007/s11606-018-4612-6
                6258628
                30076573
                © 2018

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