Reviewing a clinical decision aid for the selection of anticoagulation treatment in patients with nonvalvular atrial fibrillation: applications in a US managed care health plan database
This is a review for Steven B. Deitelzweig, MD, MMM, Yonghua Jing, PhD, Jason P. Swindle, PhD, MPH, and Dinara Makenbaeva's, MD, MBA Reviewing a Clinical Decision Aid for the Selection of Anticoagulation Treatment in Patients With Nonvalvular Atrial Fibrillation: Applications in a US Managed Care Health Plan Database.
There have been many anticoagulant, besides Warfarin (which has many negative interactions) such as apixaban, dabigatran, and rivaroxaban that have been introduced and accepted as effective treatment options to prevent and treat stroke and systemic embolism patients. All of these therapy alternatives have their own risks as well as unique benefits and it can be difficult for clinicians to pick the best one for each specific patient's circumstance. In order to help mitigate this issue, a clinical decision aid was created to help prescribing clinicians choose the best type of coagulation therapy by comparing the available treatment options with a particular patient's individual factors such as risk values and bleeding ratio.
The authors gathered national medical claims data for patients diagnosed with AF, who had two or more healthcare encounters that were at least thirty days apart between 2005 and June 2010. These patients were divided into two subgroups - those on commercial health insurance plans, and those on with medicare Advantage part D coveragee. All of the patients' HAS-BLED and CHA2DS2-VASc stroke risk score was calculated with the information from the claims and the percentage distribution of each possible combination of HAS-BLED and CHA2DS2-VASc scores was created and each combination's clinical decision aid recommendation was recorded using a baseline bleeding ratio of 2:1. The percentage of the patients that would be recommended to use each choice of anticoagulant was calculated.
The study's findings suggested that there was a strong positive correlation between HAS-BLED and CHA2DS2-VASc scores. Both the mean HAS-BLED and CHA2DS2-VASc stroke risk scores were higher in the sample of patients with Medicare Advantage with part D coverage than the sample with commercial insurance plans.
If the Clinical Decision Aid chose the treatment for the total sample population the distribution of recommended therapies would be:
70.50% apixaban 25.86% no treatment 3.62% ASA 0.01% dabigatran 150
ASA + clopidogrel, dabigatran 110, and rivaroxaban would not have been recommended by the clinical decision aid for any of these patients.
The clinical decision aid generates recommends therapies based on risks for stroke and major bleeding (which together create the net clinical outcome). The clinical decision aid uses the findings of several anticoagulation medication trial studies to help calculate which therapy would be best for people with various risk factors. This and other evidence-based tools can help physicians when many treatment options are available but many risk and benefit factors go into selecting the best option for a specific patient. With the availability of a relative abundance of new antithrombotic agents this has created a knowledge gap between reasearch and clinical practice. There still exists a great deal of indecision among clinical experts and between organizations and jurisidictions.
In this article, the authors point out that this also might be helpful to not only physicians and healthcare providers, but also to healthcare plan payers for population-level patient care optimization which I think is a very interesting point. Since, such a high majority of patients would have been recommended to try apixaban, I'm not sure how this aid would be so important. This seems to me that the majority of patients would be prescribed apixaban and special cases would be more fully analyzed by a patient's care team to determine the be st solution.
- Steven B. Deitelzweig, MD, MMM, Yonghua Jing, PhD, Jason P. Swindle, PhD, MPH, and Dinara Makenbaeva's, MD, MBA Reviewing a Clinical Decision Aid for the Selection of Anticoagulation Treatment in Patients With Nonvalvular Atrial Fibrillation: Applications in a US Managed Care Health Plan Database. Clin Ther. 2014 Nov 1;36(11):1566-1573.e3. doi: 10.1016/j.clinthera.2014.09.016. Epub 2014 Oct 23. http://www.ncbi.nlm.nih.gov/pubmed/25438725
- A clinical decision aid for the selection of antithrombotic therapy for the prevention of stroke due to atrial fibrillation.http://eurheartj.oxfordjournals.org/content/33/17/2163