Improving medical decision making: Stroke prevention in atrial fibrillation

This thesis consists of three parts. In part of A of this thesis we investigated guideline adherence to the guideline for atrial fibrillation (AF) of the Dutch College of General Practitioners (NHG) and appraised the guideline to identify barriers to adherence. We found low adherence to the guideline resulting in both over and under treatment. During our appraisal of the guideline we identified several potential improvements for the structure and contents of the guideline. Next we searched the literature and categorized reasons for intentional non-adherence in a systematic review. Reasons for guideline non-adherence were frequently and sometimes valid, pertaining to patient preferences and contra-indications. Part B presents the main study of this thesis: The Expert-AF trial. We implemented a clinical decision support system (CDSS) to improve adherence to the Dutch NHG AF guideline and evaluated its effectiveness in a cluster randomized trial. We could not show a significant increase in guideline adherence as a result of the implementation of the system. We did, however, identify valuable insights into barriers to usage in a mixed-methods evaluation of the system. In Part C we take a first step towards better prediction of stroke using complex prediction models, and show that these models hold promise for the future of stroke prediction. Chapter 10 contains a summary of each individual chapter