| Affiliation: | 1.Institute for Clinical Evaluation Sciences,Toronto,Canada;2.Institute of Health Policy, Management and Evaluation,University of Toronto,Toronto,Canada;3.Department of Family and Community Medicine,Women’s College Hospital,Toronto,Canada;4.Department of Family and Community Medicine,University of Toronto,Toronto,Canada;5.Women’s College Hospital Institute for Health System Solutions and Virtual Care,Toronto,Canada;6.Department of Family and Community Medicine,The Scarborough Hospital,Scarborough,Canada;7.Department of Medicine,University of Toronto,Toronto,Canada;8.Division of Cardiology,St. Michael’s Hospital,Toronto,Canada;9.Sunnybrook Academic Family Health Team,Toronto,Canada;10.Centre for Innovation in Complex Care,University Health Network,Toronto,Canada;11.Leslie Dan Faculty of Pharmacy,University of Toronto,Toronto,Canada;12.Institute for Better Health, Trillium Health Partners,Mississauga,Canada;13.Taddle Creek Family Health Team,Toronto,Canada;14.Toronto Western Hospital Family Health Team,University Health Network,Toronto,Canada |
| Abstract: | BackgroundThe prevalence of atrial fibrillation (AF) is growing as the population ages, and at least 15% of ischemic strokes are attributed to AF. However, many high-risk AF patients are not offered guideline-recommended stroke prevention therapy due to a variety of system, provider, and patient-level barriers.MethodsWe will conduct a pragmatic, cluster-randomized controlled trial randomizing primary care clinics to test a “toolkit” of quality improvement interventions in primary care. In keeping with the recommendations of the chronic care model to simultaneously activate patients and facilitate proactive care by providers, the toolkit includes provider-focused strategies (education, audit and feedback, electronic decision support, and reminders) plus patient-directed strategies (educational letters and reminders). The trial will include two feedback cycles at baseline and approximately 6 months and a final data collection at approximately 12 months. The study will be powered to show a difference of 10% in the primary outcome of proportion of patients receiving guideline-recommended stroke prevention therapy. Analysis will follow the intention-to-treat principle and will be blind to treatment allocation. Unit of analysis will be the patient; models will use generalized estimating equations to account for clustering at the clinical level.DiscussionStroke prevention therapy using anticoagulation in patients with AF is known to reduce strokes by two thirds or more in clinical trials, but most studies indicate under-use of this treatment in real-world practice. If the toolkit successfully improves care for patients with AF, stakeholders will be engaged to facilitate broader application to maximize the potential to improve patient outcomes. The intervention toolkit tested in this project could also provide a model to improve quality of care for other chronic cardiovascular conditions managed in primary care. |
