March 13, 2020American Heart JournalOpen Access

Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF): A cluster randomized trial of a computerized clinical decision support tool

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Why the study?

Clinical decision support tools are increasingly essential but often lack rigorous evaluation before implementation, leaving it unclear whether they improve AF management and outcomes in primary care compared with usual care.

Does a computerized clinical decision support tool improve outcomes in adult patients with atrial fibrillation compared to usual care?

Structured PICO

Does a computerized clinical decision support tool improve outcomes in adult patients with atrial fibrillation compared to usual care?

Population

1,145 adult patients with atrial fibrillation (AF) recruited by 203 primary care providers (cluster stratified by urban/rural location)

Intervention

Access to an evidenced-based, point-of-care computerized clinical decision support (CDS) tool designed to support guideline-based AF management for primary care providers

Comparator

Usual care

Outcome

Composite of unplanned cardiovascular hospitalizations and AF-related emergency department visits over 1 yearcomposite

A computerized clinical decision support tool for primary care providers did not significantly reduce unplanned cardiovascular hospitalizations or AF-related ED visits in patients with atrial fibrillation.

Implication

CDS for AF in primary care may improve management; leaves open whether outcomes benefit in larger trials.

Abstract

BACKGROUND: Clinical decision support (CDS) tools designed to digest, filter, organize, and present health data are becoming essential in providing clinical and cost-effective care. Many are not rigorously evaluated for benefit before implementation. We assessed whether computerized CDS for primary care providers would improve atrial fibrillation (AF) management and outcomes as compared to usual care. METHODS: Overall, 203 primary care providers were recruited, randomized, and then cluster stratified by location (urban, rural) to usual care (n = 99) or CDS (n = 104). Providers recruited 1,145 adult patients with AF to participate. The intervention was access to an evidenced-based, point-of-care computerized CDS designed to support guideline-based AF management. The primary efficacy outcome was a composite of unplanned cardiovascular hospitalizations and AF-related emergency department visits; the primary safety outcome was major bleeding, both over 1 year. Patients were the units of intention-to-treat analysis. RESULTS: No significant effects on the primary efficacy (130 control, 118 CDS, hazard ratio: 0.98 [95% CI 0.71-1.37], P = .926) or safety (n = 7 usual care, n = 8 CDS, 1.3% total, P = .939) outcomes were observed at 12-months. CONCLUSIONS: IMPACT-AF rigorously assessed a CDS tool in a highly representative sample of primary care providers and their patients; however, no impact on outcomes was observed. Considering the proliferating use of CDS applications, this study highlights the need for efficacy assessments prior to adoption and clinical implementation.