Anticoagulation Therapy in NVAF: A Quality Improvement Initiative

Chair Kun "Kevin" Xiang, MD, PhD, discusses atrial fibrillation in this CME/MOC/NCPD/CPE activity titled “Anticoagulation Therapy in NVAF: A Quality Improvement Initiative.” For the full presentation, downloadable Practice Aids, monograph, and complete CME/MOC/NCPD/CPE information, and to apply for credit, please visit us at https://bit.ly/2UoPplb. CME/MOC/NCPD/CPE credit will be available until June 12, 2025.

1. Anticoagulation Therapy in NVAF

A Quality Improvement Initiative

Kun "Kevin" Xiang, MD, PhD

Assistant Professor of Medicine

Associate Program Director

Clinical Cardiac Electrophysiology Fellowship Program
Division of Cardiovascular Medicine

University of Florida Health

Gainesville, Florida

Go online to access full CME/MOC/NCPD/CPE information, including faculty disclosures.

Copyright © 2000-2024, Peerview

2. Our Goals for Today

Recognize the burden and consequences of untreated
nonvalvular atrial fibrillation (AF)

Assess barriers to optimal use of direct-acting oral
anticoagulants (DOACs)

Employ guidelines, new data, tools, and quality improvement
strategies to overcome barriers to the evidence-based and
guideline-directed use of DOACs in patients with AF

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3. Recognizing Atrial Fibrillation (AF):
Facts, Signs, and Risks14

AF is the most common arrhythmia in the world

3 to 6 million people in the United States have AF—CDC estimates that
number will more than double by 2030

Men have high incidence of AF; lifetime prevalence is similar between men
and women because of longer life expectancy and other factors

AF risk rises with age; 20% to 40% of Americans have AF by age 95
Common symptoms: palpitations, dyspnea, dizziness, fatigue, syncope, and
angina; AF may be associated with no symptoms

Potentially modifiable risks: cigarette smoking, alcohol use, hypertension,
diabetes, obesity, obstructive sleep apnea, and heart failure

1.Komej ta. Cie Ros 2020;127 4.20.2. Turia MP et al. Am J Card 2015:116:733073. m
3.StaerkL otal. BMJ. 2018:260 X1453. 4. its: coc govineardisease/atial_filaton htm, PeerView.com

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4. AF Increases the Risk of Severe Stroke’

~33% of ischemic strokes
are related to AF

>80% of cardioembolic strokes
are related to AF

AF may play a role in ~33%
of cryptogenic strokes

1. Mazurek Met a, Stoke, 2017:48:2198-2205.

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AF-related strokes
cause larger areas
of brain infarction,
greater disability,
and mortality
compared with
strokes
of other etiologies

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5. AF Increases the Risk of Severe Stroke, But the Risk
Is Modifiable With Anticoagulant Therapy!

~33% of ischemic strokes
are related to AF

AF-related strokes

cause larger areas OACs reduce
of brain infarction, Se the risk of

>80% of cardioembolic strokes greater disability, strokes have stroke by >64%

highly
modifiable risk
factors

are related to AF and mortality
compared with
strokes of
other etiologies

and mortality
by >25% vs
placebo

AF may play a role in -33%
of cryptogenic strokes

1. Mazurek M ot al. Stoke. 2017:48:2198-2205, PeerView.com

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6. ACC/AHA/ACCP/HRS Clinical Guidelines Recommend Anticoagulation
Therapy for AF Based on CHA,DS,-VASc Risk Scores

of Stroke Risk in Patients With AF! to help guide anticoagulation recommendations

Treatment Recommendations Based on CHA¿DS,-VASc Score?

CHF/LV dysfunction

CHA¿DS,-VASc Risk Score for Prediction | CHA,DS,-VASc risk calculator estimates AF-related stroke risk |

1
Hypertension 1
Aged 275 years 2
Diabetes mellitus 1
Stroke/TlA/embolism 2
Vascular disease 1

1
1
9

><wo>ro

‘Aged 65 to 74 years
Sc Sex category (female)
Mai

um score
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1. January CT et al. JAm Col Cardiol 2014:54:01-076.2. Joglar JA et al. Circulation, 2024:149:01-0186, 3. Hindrick G et al. Eur Heart J 2021:42:373-498 “CO

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7. NCDR PINNACLE Registry:
OAC Is the Standard of Care, But Gaps Remain’

No antithrombotic therapy

Despite increasing risk
of stroke, the use

Proportion of Patients

x
2
E
3
2
É
E
£
3
8
3
13
rs
<
£
=

o

-4-.- -- - -- of OAC in patients
40 with AF peaks at -50%
° |

o 1 2

cHA,DS.-vAse sion
N 12348 36,976 61557 87008 97878 70212 37.314 17814 6385 1,161

1. Hsu J etal. JAMA Cardiol. 2016:1:5-62. 2. Joglar JA et al. Ciculaon.2024:149:01-0156. 3. Hindicks G otal. Eur Hoar J. 2021:42:373-498. PeerView.com

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8. Wide Practice Variations Have Been Documented
in OAC Prescriptions for Patients With AF

121

The median practice treatment prevalence with OACs was
51.7% with an IQR of 37.7% to 58.3%; each practice is given
‘a number representing the proportion of patients with AF
within that practice prescribed an OAC'*

101

81
o
2 Wide practice variations are
5 a an indicator of suboptimal
ality of care?
© quality
La
21

10 20 30 40 50 60 70 80 90 100
Proportion of Patients in Practice Prescribed an OAC, %

+ 420,417 outpatients wih AF rom 144 practices in 38 states: NCOR PINNACLE Registry, 2008-2012. Pi
1. Hsu JC et al JANA Cardo! 2016:1:85.62.2. LIC et a. MMWR Survoll Summ. 2011;60:1-250. 3. Schuster MA el al. Mibank O. 1998:76:517.56. eerView.com

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9. Barriers to the Use of DOACs

FAS Practice-Level e Provider-Level

Barriers! GED Barriers?

Patient-Level
Barriers*#

+ Poor communication
+ Lack of case

Risk of bleeding
Availability of a reversal

management support agent

+ Barriers to timely patient + Underuse of risk
information stratification tools

+ Work schedules do not Epic aEs)
support care continuity + Lack of knowledge/

experience of DOACs

Risk of drug-drug
interactions

+ Medication shortages

+ Discordant appointment
expectations

Forgetfulness
Fear of severe bleeding
Do not think it's needed

Think it’s ok to skip
some doses

No symptoms

Bothered by
bruising/minor bleeding

Out-of-pocket costs

+ Suyoy of 0 aber user) AL. Patata slo a appt rss om a
1. Hat 'PLOS One. 2021:16 20257798. 2. Saeed Ha a. Cin App! Thromb Hemost. 2020:26:1076020620952550.
5 Budntz DS ot a JAM 20213261200-1909.4 Tom DM al Am Col Garde Ad, 20232100178

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10. Key Findings From Previous AF QI Initiatives

Study Type of Intervention Key Findings

Provider intervention
SUPPORT-AF 1113 through EHR, email, and
mobile apps

Anticoagulation prescription
rate increased

Significant reduction in patients’
decisional conflict about OACs
compared to usual care

Patient-clinician shared

al 4,5
ENHANCE-AF decision-making tool

Home-based, structured, Patient education materials have
HELP-AF67 patient-centered been published, but primary
educational intervention study outcomes have not
1. Kapoor At a. Cr Carovese Qua! Outcomes 202013005871. 2, Sad et. Tvomt Thrombolyis. 20252008816,

3. Patel Jot al. Cardiovase Digt Heath J. 2021.2 222-230. 4. Baykaner T at al. Am Heart J. 2022:247-68-75, 5. Wang PJ etal. J Am Heart Assoc. 2023:12-2023562. e
6. Hondrks JM et al. Can J Carl. 2019.35:846-854. 7. Gallagher C ot al al. JACC Cin Electrophysiol 2019,5:1101-1114, PeerView.com

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11. University of Florida/Heart Rhythm Society AF QI Initiative:
Preventing Preventable Strokes (PPS) Pilot Project

( 339°
Patient
A A Practice
PPS Pilot Project a
+ Best practice alert
* Clinician education a» Rhathm
« Patient communication S À Society.

Trad model image © Heart Rhythm Society, 2023, Used with permission. PeerView.com

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12. Results From the UF Jacksonville/HRS Experience’

Patients on AC, % + Attime of launch, 2,357 of 3,555
eligible patients (56.3%) were on ACs

+ At study end, six months later, the
percentage of patients on AC
increased by 1.5% to 57.8%

+ Based on the population of untreated
patients, a 1.5% increase in the AC
treatment percentage was estimated
to prevent 1.5 strokes over one year

Patients, %
E

+ Steady increase in AC, though not
statistically significant

Baseline Aug24 Sop8 Sop 20 O4 Oct18 Nov2 Nov 15 Nov29 Doc 31

Date a
1. Xiang K etal. Circulation. 2021:144:A6907. PeerView.com

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13. University of Florida AF Q Initiative:
Preventing Preventable Strokes Scalability (PPSS) Project

=

UF Gainesville
PPS Pilot
+ Best practice alert

+ Clinician education
+ Patient communication

PPSS

+ Best practice alert
+ Clinician education
— Grand rounds
— Self-assessment module
atient communication

iad model image © Heart Rhythm Society, 2023. Used wit permission. PeerView.com

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14. The Plan-Do-Study-Act Model!

EDCEHR

Best Practice Advisory (BPA) to alert
clinical providers

+ Educational materials to assist
decision making

Clinic office group performance

feedback

1. Xiang K et al. Heat Rhythm. 2024:21(58)S1. O1-482986-001,

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Benchmark data were collected in the EHR based on the ICD-10 code
Core Team

“Triad” intervention approach was designed and conducted Snel nice! ee

+ Pharmacy team
+ Administration

representative
+ Collaborating teams
(HRS and PVI)

Pharmacy team generated monthly data report to monitor progress
(Core team held bi-weekly meetings to analyze data and form a plan of action
Core team presented progress to UF steering committee every other month

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15. UF Gainesville PPSS Project Goals!

The goals of the PPSS Project at UF Gainesville were to increase

1. Guideline-directed use of OACs to 5. Clinician knowledge of clinical practice

prevent patient stroke at UF guidelines for the use of OACs to
Gainesville by testing the prevent patient stroke
transferability and scalability of the 6, Clinician use of shared decision-
UF Jacksonville/HRS PPS project making tools with patients at risk
2. Patient awareness of stroke risk for stroke
3. Patient adherence to medication 7. Efficiency of PPSS implementation in

4. Clinician awareness of their comparison to PPS implementation

guidelines-directed use of OACs to
prevent patient stroke in comparison
to their peers

1. Xiang K eta Heart Rhythm. 2026:21(8S):S1. QI-482986-01. PeerView.com

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16. Lessons Learned From
the UF Jacksonville/HRS Pilot Project!

What Went Well What Could Be Changed?
+ ~3,000 patients + Create steering committee and get more
+ UF clinics across the city administration support
+ EHR-based intervention — PPS pilot did not emphasize clinical practice enough
+ 8 PDSAcycles + Target specific patients with messaging through
multiple tools, at a larger scale, and with clinical
pharmacy support
— Patient communication was not sufficient in the
PPS pilot
+ Add online self-assessments questions and webinar
— Clinician education was not sufficient in the
PPS pilot

+ Slow but steady
improvement over
8 cycles

+ Grand rounds and
physician supports

1. Xiang K etal. Circulation. 2021:144:A6907. PeerView.com

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17. Organizing the UF Gainesville QI Initiative’

UF College of Medicine

Steering Committee

Core Team

12 individuals 18 individuals
Principal investigator UF pharmacy Principal investigator 1 medical society
1 medical society UF cardiology 2 CME providers
UF cardiology 2 CME providers UF pharmacy
1. Xiang K etal. Heart Rhythm. 2024:21(55)51. 0182986001. PeerView.com

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18. PPSS Timeline!

Develop
+ BPA
+ Baseline data

Launch

+ Data collection
+ 6-month study

Report

+ Internal
presentations

Interventions

+ Grand rounds
+ Self-study cases
+ Patient education

1. Xiang K et al. Heat Rhythm. 2024:21(5S)51. Q1-482986-001,

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Analyze

+ Data collection
+ Statistical
‘outcomes

Disseminate

+ Abstract
presentations
+ Publications

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19. UF Jacksonville/HRS PPS Pilot
Best Practice Advisory Alert ...

Courtesy of UF Jackson PeerView.com

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20. ... Versus the UF Gainesville PPSS
Best Practice Advisory Alert

‘This isthe programming point forthe SmartLink to run in the BPA
+ SmartLink AMB CHADSZVASC RISK SCORE [101516]
+ Code: d smart PGALHHS4LPG(21016302,0.0.0)

Open Smartser NE OOACS for Non-Vatvular Atal Fibritation Preview
Open Smartser MER Corciciogy Consult Order Preview
The following actions have been applied:
Y Sent: 2 This advisory has been sent va In Bas
‘Acknowledge Reason
Patient decines Not appropriate Patent already on Ant-coag Patent does not have AFI
Pharmacist Review Pending

‘courtesy of UF Ganosvie. PeerView.com

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21. Impact of Data Integrity’

gl depends es on sourate ineorikeenng, EHR systems are the

EHR identified some patients incorrectly coded as having AF
j |

DE performed manual chat review for patent who received

EHR retained AF asa deansian! when, it was as merely being

Problem and medication lists lack system tools to
tom: lly te or reconcile records; wo!

1. Xiang K ot al. Heart Rhythm. 202520854. PeerView.com

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22. Clinician Education: Grand Rounds Presentation

MAYO.
CLINIC

Stroke Prevention in Atrial Fibrillation
“Special” circumstances (actually the issues we face daily)

Fred Kusumeto MO November 10, 2022

Course available at:
www.HeartRhythm365.org!

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Stroke Prevention in AF

Presented by Fred Kusumoto, MD
November 10, 2022

Archived on HRS365

3.0 credit hours

Learning Objectives

+ Cite the indications for anticoagulation for
stroke prevention for patients with AF

Identify whether a DOAC is appropriate for
patients with risk of bleeding and falls

+ Determine whether warfarin or a DOAC is the
better choice for a patient with NVAF

+ Know when a patient with AF should be
referred for specialty care

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23. Clinician Education:
Self-Assessment Module Sample Question

mei mé Toe ptt ci i ese pu an con ge mh en
© Sn gene nn nh swt a ne dl ocean con neue

ee mein we Tec tota tk Meld op nd edge oon iconos con

E__>AA>> IIA BEE

HEART RHYTHM
(36 Bau:
Dé PRE PeerView.com

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24. Clinician Education:
Self-Assessment Module Sample Question With Results

| ol a at mondo tee monte pr am pi gt lio me eh at eas mg me ino pm nd
E Vo ed ey sy de (AD roe 1 pus El ad ph oy espe is me re oar? menage ered

ia $i mpl sa a por mp dl Sat ws ate oe mg Aur
iano b on pri ented cs nei te meted opel
eva eras rias ery de Me de nytt pm pp
nao re

opto 12 months thes dsp clopidogrel and contin api He boat sax
‘itis een arabe de log term cee his CHASDSS-VASC acre of suggests irn ke fae 15%

ic pote eig he shoul step asp ad coca lopioge wp to 12 won np
ra irren dv ng br caos En hao CHAZDES-VASe ton of 4 gente aan

page nd cote prin He ca ao ak a Lern of esa 18 mg day bee N CHADS
inet ak

eos elias well To roc potential esting risk be sad so api cd clopidogrel u: He shold cnn ore ara Ds

So GDS VAS sara En

a HEART RHYTHM
One earngesourcs tom
@ 3 65 GP hear nnrimsociey. PeerView.com

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25. Clinician Learner Feedback!

What was most valuable to your learning experience?

Deeper understanding of cel
medications,

The summary in the lecture of current data
with practical application for practicing
clinicians was excellent. Taking the exam
pointed out unforeseen gaps in my
knowled.

This lesson has taught me many
important knowledge points, and | will
continue studying in the future to.

® enhance my skills

The two areas that were particularly
useful were 1) validation of the concept

Excellent review with adequate depth but
not belaboring the point for real-world

Great discussion about female gender

E 3 a
and CHA,DS,-VASC score, | willbe more that patients at risk for falls, but who
le 1d low(ish) Strok have not had previous falls/injury,
roke should still be treated with

Prevention in AF
286 learners
66 responses

Great leaming experience. Especially
difficult situations like post-Gl bleed
or ICH

1. Smith AM. HRS Onine. Personal communication, March 11, 2024,

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26. Patient Education Materials!

Patients were sorted into 1 of 3 groups based on their CHA;DS,-VASc risk ae Heart
score and AC status in the EHR ann

Group 1 Group 2

Epic MyChart triggered communications to patients. The content of each mailed letter varied by group, but all prompted patients to learn
more about AF, risk factors for stroke, and what to do next. All letters used language of positive intent and partnership.

= T r
Letter communicated they are not at risk
Letter communicated they are at f risk Letter communicated they are at } risk for stroke
Knie for stroke Group 3 Call to Action: self-monitor
Group 1 Call to Action: continue AC to Group 2 Call to Action: discuss ways to | | @nd follow up with their HCP if they have
} risk for stroke | risk with their HOP ASAP questions
Tone: informative, helpful, cautionary Tone: informative, urgent, advisory Tone: informative, future-focused,

cautionary

All letters closed by directing patients to access additional AF resources at UpBeat.org and take a short survey to provide feedback

1. Xiang K et al. Heart Rhythm. 202421(5S)S1. 01482986001, PeerView.com

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27. Patient Survey Feedback Highlights

Group 1 Group 2 Group 3

Question Need AC, on AC Need AC, not on AC Don't need AC, not on AC
n=84 n=26 =8

Discussed/planning to
discuss stroke risk with Yes: 82% Yes: 58% Nervios El oly

provider?

Forgot: 29% Still taking AC: 31%

Why do you skip a Me 5% Doctor said not needed anymore: 25% Very ov somewhat ely 10
doses?/Why have you Dre Concern about bleeding: 12.5% pended to
stopped AC? pial ae Don't lke taking meds: 6.2% puc
Other reasons: 69% iS
Were UpBeat
educational materials Agree or strongly agree: ‘Agree or strongly agree: Agree or strongly agree:
understandable and 91% 83% 83%
useful?
Courtesy of Anne-Marie Smith, Heart Rhythm Society PeerView.com

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28. Flow Chart for Inclusion and Exclusion Criteria
for Pre- and Post-Intervention!

Preintervention Flow Chart

Patients with mechanical
heart valve
n= 132

Patients with CHA2DS¿VASc
score <2 (male) or <3 (female)
n=451

Included unique

patients
n=3,200

1. Xiang K et al. Heat Rhythm. 2024:21(5S)51. Q1-482986-001,

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Postintervention Flow Chart

Patients with mechanical
ug] heart valve
n=285

Patients with CHAzDS:VASc
= score <2 (male) or <3 (female)
n=482

Included unique

patients
n= 3,274

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29. Comparing Practice Variations in OAC Prescriptions for
Patients With AF: UF vs NCDR PINNACLE Average?

121

1 Median NCDR PINNACLE
| performance = 51.7%!

101
! Lowest-performing UF Gainesville clinical

ñ
1
1

81 ı | site at PPSS baseline = 56.8%?
1
1
1

o 1
2 ! Highest-performing UF
© 61 1 Gainesville clinical site at
fl 4 PPSS baseline = 76.5%?
La 4
1
1
21 4
H
1
10 20 30 40 50 60 70 80 90 100
Proportion of Patients in Practice Prescribed an OAC, %
ARS JANA Car. 20161 S608, 2 UFI Pomacy Serves, Ansoopuaionm patas van AE (seine dt], Apt 26,2022. PeerView.com

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30. Changes in Anticoagulation Rates,
Aggregate vs Individual Clinics!

Aggregate Outcomes Stratified Outcomes
wAnticoagulated, % + Statistically significant improvements
æ 90 P=.123 were seen in 7 of 14 (50%) individual
ges A, practice sites
E 80 778 1 of 2 ‘diol fini
E +5 747 — 10f2 cardiology clinics
El 5 — 5 of9 family medicine clinics
E
Les — 1.0f3 internal medicine clinics
E
5 60 + Reanalysis using an interrupted time-
$ 55 series with the Wilcoxon signed-rank
% 50 test found significant improvement,
Before After P<.02
1. Xiang K eta. Heart Rhythm. 2024:21(55)51. Q1-482986-001. PeerView.com

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31. Anticoagulation Rate by Practice Sites
Pre- and Post-Intervention!

Preintervention

2 2 ©
as & 8

ES
&

Proportion Anticoagulated, %
A =
3 3

a
a

a
8

90
85
80
75
70
65
60
55
50

Postintervention

CARO

ms
mi
—m2

Oct21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22

1. Xiang K et al. Heat Rhythm. 2024:21(55)51. O1-482986-001,

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Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23

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32. Anticoagulation Status Pre- and Post-Intervention
by MyChart Status!

Pre-Intervention
MyChart Status Overall, n (%) Anticoagulated, n (%) Not Anticoagulated, n (%)
Activated 2,294 (71.7) 1,786 (78.9) 508 (22.1)
Inactivated 236 (7.4) 144 (61.0) 92 (39.0)
Pending activation 670 (20.9) 493 (73.6) 177 (26.4)

Post-Intervention

MyChart Status Overall, n (%) Anticoagulated, n (%) Not Anticoagulated, n (%) P
Activated 2,513 (76.8) 2,017 (80.3) 496 (19.7)
Inactivated 64 (2.0) 34 (53.1) 30 (46.9) <.001
Pending activation 697 (21.3) 542 (77.8) 155 (22.2)

Patients with an activated MyChart status were more likely to receive
anticoagulation than those with inactivated status (80.3% vs 53.1%, P < .001)

1. Xiang K et al. Heart Rhythm. 2024:21(58):81. OL-482986:001, PeerView.com

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33. Measuring Changes in Monthly Anticoagulation Rates
Before, During, and After PPSS: Sample Interim Report

Trends of Patients on Anticoagulant, %
Baseline BPA Webinar MyChart

Interventions

were introduced
sequentially

Oct Jan Apr Jul Oct Jan
2021 2022 2022 2022 2022 2023
Courtesy of UF Gainesvile Time, y PeerView.com

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34. Measuring Changes in Monthly Anticoagulation Rates
Before, During, and After PPSS: Sample Interim Report

AC Rate After
85 Intervention

82%

80%

AC Rate Before

AC Rates, %
a
3
ES

Intervention
70 72% =
65+
Oct Nov Dec Jan Feb Mar
Month .
Courtesy of UF Gainesvile PeerView.com

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35. Measuring Changes in Types of DOACs Prescribed

‘Types of DOAC Prescribed or Reported by Patients With AF in Each Quarter

o Type of DOAC
en 1 Rivaroxaban
70 M Datigatran
1 Edoxaban
ge
M Apicaban
F so
w
»
»
0
o
Ort 2 Qr3 Ora [Ori 02 Q3 Qr4 | Qt Qrz ara Qr4 | Qr1 02 Qr3 Qrd
2019 4 2020 1 2021 4 2022
Apixaban was the most frequently selected DOAC, followed by rivaroxaban and then dabigatran; edoxaban was rarely prescribed
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36. Measuring Changes in Monthly Anticoagulation
Prescriptions: Stratified Analyses

Stratification by Sex =e Stratification by Race
Female Male Asian or Pacific Islander Black or African American
so w eo»
ss la" == no A
" CEI ” En
o a “ es “ ra E
2 $ 73 “|. os De iw
3 > A sn 2.
2» AE y ”
$ a $ ” NA, » F
Bo Fo
y [pomo a ms
e ue RR mm mm
7
A? ES
dia 2
. 2. .
a wo »| whee oF Tun
BESELSSEE RHEEEEEE in de dem amo A at Az az MO ENEE
Year Quarter ‘Year Quarter Year Quarter Year Quarter
| __DOAC use gradually increased in all demographic subgroups .
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37. Anticoagulation Rate Stratified by CKD and Renal Disease
(Post-BPA)

Percentage of Patients on AC by CKD Percentage of Patients on AC by Renal Disease
(based on most recent visit) (based on most recent vi
‘On anticoagulant On anticoagulant
No MYes No MYes
100 100
: — eu mu
© « De
D» Br
ge ge
So Ss
2 76 go 81 78
x x0
a» E
10 10
o + o -
No CKD ckD No Renal Dx Renal Dx
2,289 985 No. of Patients 1,792 1,482

as 2 so ps
1,844 749 | onac | 1,443 1,150

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38. Key Takeaways

lation use at three levels: practice

The Q! initiative required the ski

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39. Acknowledgements

poate PeerView
UFHealth Ri Gi Sar

UNIVERSITY OF FLORIDA HEALTH

Together we have moved the needle to improve AF care and prevent strokes
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