Education and monitoring improves the use of stroke-prevention therapies
Only about half of patients with atrial fibrillation worldwide take anticoagulant drugs, despite the medications being highly effective in preventing strokes.
Increasing the use of anticoagulation therapies could prevent hundreds of thousands of strokes each year. A new study shows that education, measurement and feedback are effective approaches to increasing the use of anticoagulants, and demonstrate on a large scale how this improvement can be achieved.
In a large, international study led by the Duke Clinical Research Institute and five coordinating centers around the world, a multi-faceted informational campaign aimed at patients, families and physicians led to a 9-percent absolute increase in the use of anticoagulation therapies. The increased use of the drugs was accompanied by a small, but notable reduction in the risk of stroke.
“If this intervention could be broadly applied, which we believe is possible, the public health implications would be substantial,” said Christopher Granger, MD, professor of medicine at Duke and senior author of a study presented at the European Society of Cardiology meeting. The findings were simultaneously published Aug. 28 in Lancet. “More than 33 million people worldwide have atrial fibrillation, which is a leading cause of stoke. Improving adherence to anticoagulation therapy would be a lifesaver.”
Granger and colleagues conducted a study in five countries -- Argentina, Brazil, China, India and Romania -- to test their intervention.
More than 2,200 patients were enrolled at 48 hospitals and monitored for a year. The centers were randomly divided to either provide standard care or a comprehensive educational effort -- customized to each country -- that explained the benefits of anticoagulant therapies, as well as their risks.
Patients were given brochures and shown videos, and then monitored at doctor visits to get their feedback and learn of any problems that kept them from being on the medication. Physicians received education on treatment of atrial fibrillation through articles and webinars. They also received audits for the specific treatment of each of their patients via regular phone calls.
The researchers reported that among patients at centers that received the educational intervention, the use of anticoagulation therapies rose by 11.7 percent, compared to a 2.6 percent rise in their usage in the non-intervention group. In the intervention group of patients not treated at baseline, 48 percent were on an anticoagulant at one year.
“Our study also found a reduction in strokes in the intervention group compared to the control group,” said Renato Lopes, MD, PhD, professor of medicine at Duke and the principal investigator for Brazil. “While this was a secondary outcome, it highlights the potential benefit of improved anticoagulation care.”
A limitation of the cluster-randomization design, in which recruited expert centers were assigned to one or the other arms of the study, was a potential overestimation of the baseline use of anticoagulants in the non-intervention sites.
Granger said additional studies are needed to better understand why such a large proportion of patients remains untreated. In the meantime, he said, applying the interventions tested in this study has been shown to improve care.
In addition to Granger and Lopes, study authors include the Neurology Department's Ying Xian, MD, PhD, Dragos Vinereanu, M. Cecilia Bahit, Denis Xavier, Jie Jiang, Hussein R. Al-Khalidi, Wensheng He, Andrea O. Ciobanu, Deepak Y. Kamath, Kathleen A. Fox, Meena P. Rao, Sean D. Pokorney, Otavio Berwanger, Carlos Tajer, Pedro Barros, Mayme L. Roettig and Yong Huo.
The investigator-initiated study received support through education and research grants from pharmaceutical companies that market anticoagulation drugs, including Boehringer Ingelheim Pharmaceuticals Inc., Daiichi Sankyo, Bayer Pharmaceuticals, Bristol-Myers Squibb and Pfizer, Inc.