An interview with Alok Kapoor, MD, MSc a cardiovascular investigator at the University of Massachusetts, Worcester about his work on the SUPPORT-AF II Study.
By Mike Fischer, MD, MS, NaRCAD Director and written by Winnie Ho, Program Coordinator.
Tags: Cardiovascular Health, Data, Detailing Visits, Evaluation, Primary Care
Mike: We’re glad to have you join us to talk about your recent work using AD to improve anticoagulant use in patients with atrial fibrillation (AF). Could we start out by getting an understanding of your work and the goal you had set for your SUPPORT AF II intervention?
Alok: I am an internist doing cardiovascular outcomes research, and for the last few years I have been really laser-focused on how to fill the gap in anticoagulation use for patients with AF who have an elevated risk for stroke. These patients tend to be older adults with multiple co-morbidities, which presents certain challenges for primary care providers and cardiology specialists. The goal of our particular AD intervention was to provide evidence and patient case scenarios to show some of the common situations where patients go untreated for stroke prevention despite experts’ suggestions that therapy is warranted.
M: The underuse of anticoagulants is more common than we would like, and the impact of that underuse is substantial. What made you decide to utilize AD as a part of the intervention for your study?
A: I was thinking about an intervention that would be more than a simple reminder to providers, and thought that perhaps something more customized that would take into consideration the individual provider’s practice and experience with prescribing anticoagulants made more sense. AD was suggested as a potential strategy by our grant sponsor to address those concerns, so I began to read more into it. The SUPPORT AF II intervention is a combination of the audit and feedback reminders given in our original study, SUPPORT AF I, plus the new offering of AD.
M: How did you anticipate that those different components of the SUPPORT AF I and II interventions would work together? Were there any unanticipated surprises during the implementation?
A: I believed that the reminders would encourage providers to reach out to their subspecialty colleagues and also remind them to have discussions about anticoagulation with their patients. Then, AD would allow us to get closer to the underlying belief and resistance factors that might be making it more difficult to prescribe in challenging situations, such as a patient with prior falls, bleeds, or on other medications that can make bleeding more common. Some of these barriers included also unfamiliarity with initiating direct oral anticoagulants and guiding patients to coverage information for the cost of newer anticoagulants.
There were some specialists who were not necessarily enthusiastic about receiving messages from us. There were also providers during the course of messaging that indicated that they did not think that these messages were helpful for them, so we adapted. However, most people were appreciative or otherwise silent when receiving messages. The harder work was the convincing needed during the AD visit that could help lead to a more impactful intervention.
M: Yes, an impactful intervention is the goal. In your paper, you talked about the importance of patient choice as a factor in anticoagulant use, and this has been consistent with a few other studies of anticoagulation in AF that highlighted similar challenges. Are there any ways that you’ve thought about to adapt an AD intervention to address the importance of patient choice?
A: As part of our AD intervention, we gave prescribers a Jeopardy-type menu where you could choose which themes to explore, and one of those was a shared decision making module with resources including an app designed by my co-collaborator David McManus. This app allowed patients to input their unique conditions and circumstances into our risk stratification algorithm. Knowing the patient risk level, the provider would then be shown questions frequently asked by AF patients that would presumably help the provider address certain concerns during the next patient visit.
M: As you reflect on your experience implementing this intervention, were there themes that especially connected with the primary care providers or cardiology specialists who were receiving AD?
A: I was responsible for AD with the primary care physicians while my collaborator worked with cardiology specialists. The providers I spoke with seemed to be really drawn to the evidence in the guidelines and often requested support from me in identifying specific evidence that would be helpful as they developed their own improved management strategy around anticoagulants. I think where we could have added something more robust would be to offer providers a way to deliver these messages to their patients and how to do motivational interviewing with patients who are resistant to start a recommended therapy.
M: Support AF II is an impressive piece of work that provides many insights. Do you see other topics in cardiovascular care, or other clinical specialties where it might be useful to do similar studies to test AD to increase the use of evidence-based care?
A: There are other types of adherence issues in cardiovascular medicine that are potential targets such as blood pressure management. The issue doesn’t seem to be starting the medication, but in continuing to take it on a daily basis. The AD intervention would be done directly to the providers, but there might be value in also directly approaching the patients.
M: It would certainly be interesting to understand whether management issues are based on clinical inertia and hesitation in taking the next step, versus barriers in patient adherence itself. Thank you for taking the time to speak with us today, you’ve given us all a lot to think about!
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Alok Kapoor, MD, MSc is an investigator who has developed several projects related to anticoagulation and conditions requiring anticoagulation. He is one of the former directors of the medical consultation service at Boston Medical Center. In that role, he routinely educated other providers on the need for anticoagulation versus potential harm, particularly for underserved populations. At the University of Massachusetts, he has established a focus on filling the gap in anticoagulation of patients with atrial fibrillation. This started with SUPPORT-AF, an audit and feedback project funded to give providers a snapshot of their AC prescribing rates relative to their peers and to a national benchmark. In SUPPORT-AF II, he expanded the team's previous efforts to include educational outreach in the form of academic detailing. In his subsequent efforts, he have collaborated with informatics experts to understand the potential for electronic health record-based decision support to fill the gap in AC use.
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