a trial of pharmacist management of oral anticoagulation therapy versus enhanced usual care in the community for af

Conditions: Atrial Fibrillation; Stroke

Summary: this is a prospective, open-label, cluster-randomized controlled trial of 400 participants (aged 60 years or older, with additional stroke risk factors and 'actionable' undertreated af) from a total of 40 retail and outpatient community pharmacies. participants will be randomized (by pharmacy) to either to an intervention arm of pharmacist-led oac management versus an enhanced usual care arm, wherein physicians receive notification of 'actionable' af and patients are advised to schedule a physician clinic visit. the primary objective will be to determine the difference in proportion of patients with 'actionable af' receiving guideline concordant oac therapy at 3 months in those randomized to intervention arm versus control arm.

oral anticoagulation therapy for stroke prevention in af is safe and effective but under-utilized. optimal delivery of existing therapies would prevent af-related stroke. therefore alternative strategies to increase adherence to current guidelines for oac use for af stroke prevention should be explored. accumulating data indicate that pharmacist-led or pharmacist-collaborative care in cardiovascular disease monitoring, risk factor control, and medication optimization leads to greater adherence to guideline-directed targets and improved outcomes. in this prospective, open-label, cluster-randomized controlled trial the investigators intend to enroll 400 participants (aged 60 years or older, with additional stroke risk factors and 'actionable' undertreated af) from a total of 40 retail and outpatient community pharmacies in los angeles. participants will be randomized (by pharmacy) to either to an intervention arm of pharmacist-led oac management versus an enhanced usual care arm, wherein physicians receive notification of 'actionable' af and patients are advised to schedule a physician clinic visit. the primary objective will be to determine the difference in proportion of patients with 'actionable af' receiving guideline concordant oac therapy at 3 months in those randomized to intervention arm versus control arm. secondary outcomes include: patient satisfaction with pharmacist services (at 3 months), pharmacists' perspective on study implementation (at study end), and oac adherence (at 1 year). in an exploratory aim, the investigators will assess healthcare utilization and clinical outcomes at 1 year. this research will generate new knowledge on an innovative, and potentially sustainable stroke prevention strategy to increase evidence-based use of oac therapy in patients with af.

Eligibility criteria:
inclusion criteria: 1. age \> 60 years 2. men (chads-vasc score ≥2) and women (chads-vasc score ≥3) 3. af and not on oac therapy but eligible 4. af and on sub-optimal or inappropriate oac therapy 5. written informed consent exclusion criteria: 1. af on optimal oac therapy 2. oac required for other conditions (i.e. dvt/pe, pci in prior year, left ventricular thrombus, etc.) 3. currently taking two antiplatelet agents 4. uncontrolled hypertension (defined as sbp ≥160 mmhg x 2 bp readings measured at screening) 5. end-stage renal disease (crcl \<15 ml/min or dialysis) 6. major surgery in prior month (defined as surgery requiring general anesthesia and overnight inpatient hospital stay) 7. history of "major bleeding" in prior year (defined as overt bleeding at critical site including intracranial, intraspinal, intraocular, pericardial, gi bleed, bleed requiring hospitalization, bleed resulting in ≥20 g/l drop in hemoglobin or requiring transfusion of ≥2 units packed cells) 8. excess alcohol intake (≥8 alcoholic drinks/week) 9. inability to read or understand english or spanish 10. participants considered unreliable by the investigator or designated pharmacy team member concerning the requirements of follow-up, or those with foreshortened life expectancy precluding 3-month follow-up 11. severe cognitive impairment (≥5 errors on the short portable mental status questionnaire) 12. pregnant women

Keywords: atrial fibrillation stroke oral anticoagulants pharmacist case management