Improving Stroke Prevention in Atrial Fibrillation Through Pharmacist Prescribing

University of Alberta79 enrolled

Overview

The purpose of this study is to compare the effectiveness of prescribing oral anticoagulation therapy by pharmacist intervention compared to enhanced usual care in participants with unrecognized AF and/or known AF but not taking blood thinners.

Background: AF is the most common arrhythmia and the leading cause of stroke. Despite robust evidence oral anticoagulation (OAC) therapy is effective and safe for stroke prevention in patients with AF; there is a lack of real-world application. Alternative strategies to deliver stroke prevention therapy need to be explored. Although pharmacists' prescribing of antihypertensive and lipid lowering drug therapy has been shown to increase adherence to guideline-based targets and warfarin management improve control of international normalized ratios in anticoagulation clinics, the role of pharmacist initiation of OAC therapy compared to usual care in AF patients for stroke prevention in a community setting is unclear. In this study, the investigators will screen participants presenting to community pharmacies to identify participants with unrecognized AF and/or known AF but not taking blood thinners or not on optimal OAC therapy and randomize care to either the pharmacist or enhanced usual care (family physician notification by pharmacist).

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

PREVENTION

Masking

NONE

Enrollment

Conditions

Atrial Fibrillation Stroke

Interventions

AnticoagulantsDRUG

Anticoagulant therapy will be initiated/titrated in patients with atrial fibrillation in accordance with the Canadian Cardiovascular Society Guidelines for Atrial Fibrillation.

Eligibility

Sex: ALLMin age: 65 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Age ≥ 65 years with one additional stroke risk factor (hypertension, diabetes, heart failure history of or left ventricular ejection fraction \<0.40), previous stroke or transient ischemic attack). * Atrial fibrillation and not on oral anticoagulation (OAC) therapy but eligible * Atrial fibrillation on sub-optimal OAC Exclusion Criteria: * Uncontrolled hypertension (defined as average SBP ≥ 160 mmHg \[2 readings taken at time of screening\]). * End stage renal disease (CrCl \< 15 ml/min) * Valvular Heart Disease including those with prosthetic valve, mitral stenosis (moderate to severe) or valve repair. * Excess alcohol intake (males: ≥ 28 units/week, females: ≥ 21 units/week. One unit of alcohol = 8 oz beer, 1 oz hard liquor or 4 oz wine). * Intracranial bleed at any point. * History of "Major Bleeding" at any point (defined as overt bleeding at a critical site including intracranial, intraspinal, intraocular, pericardial, or retroperitoneal; or bleed requiring hospitalization). * Foreshortened life-expectancy or severe comorbidities precluding study follow-up period * Unable to read/understand English * Severe cognitive impairment (defined as score ≥ 5 on the Short Portable Mental Status Questionnaire)

Locations (1)

University of Alberta

Edmonton, Alberta, Canada

Outcomes

Primary Outcomes

Optimal Oral Anticoagulant (OAC) Therapy for Atrial Fibrillation Stroke Prevention

Proportion of participants receiving optimal OAC therapy in accordance with the Canadian Cardiovascular Society Guidelines for Atrial Fibrillation in the early intervention arm compared to the delayed intervention arm. Optimal defined as a new prescription for OAC in a previously untreated AF or known AF who should be on an OAC or adjustment of an existing OAC prescription.

Time frame: 3 months

Secondary Outcomes

Prevalence of AF

To determine the prevalence of participants with unrecognized AF eligible for OAC therapy and those with AF who should be on OAC therapy but are either not on or their existing OAC prescriptions; require adjustment due to contraindications, or sub-optimal levels (hereafter referred to those with "actionable" AF)

Time frame: Through study completion, an average of 1 year

Patient Satisfaction with Pharmacists Services

Assessed using the validated Participant Satisfaction with Pharmacists Services Questionnaire (consists of 22 questions with 4 point Likert scale).

Time frame: 3 months

Qualitative Assessment of Implementation by Pharmacist

Assessed using the questionnaire developed by the SEARCH-AF study

Time frame: Through study completion, an average of 1 year

Healthcare Utilization

To determine the number of hospital, emergency department and physician visits related to AF

Time frame: One year

Healthcare Utilization

To determine the number of laboratory testing performed related to oral anticoagulation therapy

Data from ClinicalTrials.gov

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