Hi, attached you can find my assignment 3. I was not sure if my aims are specific enough, so let me know if I should go into more details!
Great work Christine with the background section. It sounds like there's a definite implementation gap here that is poorly understood. Guideline writers feel that patients with atrial fibrillation are at sufficiently high risk of stroke that they should be on long-term anticoagulation, but physicians are not recommending this treatment to their patients.
I like the use of COM-B for this problem. In my limited experience of addressing this as a clinician, it seemed as though there was sometimes a paradox. There were relatively few patients that had clearly elevated CHADS-2 scores for whom it wasn't either a major inconvenience to be on anticoagulation, they were already on Aspirin and Plavix and 3 forms of anticoagulation seemed like to much, or they were very frail and the risks of falling seemed like too much. The other situation was that you diagnose Afib when they have a CHADS-2 of 0, but then don't reassess as people age and their score increases. So I had theknowledge that anticoagulation is important in Afib, but I wasn't being sharp enough to treat all appropriate patients.
It seems like this problem would benefit a lot from having an automatic way to flag patients who based on their EHR data would benefit from anticoagulation and nudge physicians towards giving them anticoagulation. Other possibilities from the Behavior Change Wheel would be enablement and environmental restructuring. Maybe having medical assistants teach patients and handle patient tracking once the decision to anticoagulate has been made. Maybe existing interventions to address this problem could be mapped onto the middle layer of the Behavior Change Wheel?
Hi Christine,
This is very well organized and has clear evidence supporting your gap and potential intervention. I like Kevin's ideas stated above regarding a potential intervention such as flagging in the EHR or having notes populate that could potentially be initiated by MA's who typically go over past medical history and current medications. Those not on anti-coagulants with AF could then be flagged by MA's so that the provider would be more likely to prescribe for these patients. I think most providers are unaware of how often they are under-prescribing so having an intervention where they would be made aware of this on a daily or weekly basis might be most effective. Overall I think you have progressed well with the development of the assignments and I am interested to see where you choose to focus in on for your intervention.
Christine,
This is really well thought out, clear and concise. I really like the ideas Kevin and Adrienne propose in regards to some automated system for encouraging correct use and tracking said use. Another potential area for intervention would be targeting the patient’s Kevin mention, who have a low CHADS2 score initially, but subsequently developed increased scores over time. Perhaps a system that has an automated system that requires completion of a CHADS2 assessment yearly, or every other year as a part of routine follow-up.