Electronic Alert System for Improving Stroke Prevention Among Hospitalized Oral‐Anticoagulation‐Naïve Patients With Atrial Fibrillation: A Randomized Trial

Abstract

BackgroundMany patients with atrial fibrillation (AF) do not receive oral anticoagulants (OAC) for the prevention of stroke and systemic embolism. We aimed to improve the prescription of (OAC) among hospitalized patients with AF.Methods and ResultsWe developed a computer‐based electronic alert system for identifying hospitalized OAC‐naïve patients with AF. The alert system contained a CHA 2 DS 2‐VASc score calculation tool and provided recommendations for OAC prescription. The alert system was tested in a 1:1 randomized controlled trial at the University Hospital Bern: Patients with suspected AF without an active prescription order were allocated to an alert group in which an alert was issued in the electronic patient chart and order entry system or to a control group in which no alert was issued. The primary end point was the rate of adequate OAC prescription at hospital discharge, defined as prescription in OAC‐naïve men and women with CHA 2 DS 2‐VASc score ≥1 and ≥2, respectively. Overall, 889 OAC‐naïve patients (455 from the alert group and 434 from the control group) were eligible for analysis. Although the CHA 2 DS 2‐VASc score module was used in only 48 (10.5%) patients from the alert group, 100 (22.0%) patients from the alert group versus 69 (15.9%) from the control group received adequate OAC prescription (relative risk 1.38; P=0.021). OAC or antiplatelet therapy was prescribed in 325 (71.4%) patients from the alert group versus 271 (62.4%) from the control group (P=0.004).ConclusionsVersus standard care, the alert system modestly improved OAC prescription among consecutive hospitalized AF patients.Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02455102.

Electronic physician notifications to improve guideline-based anticoagulation in atrial fibrillation: a randomized controlled trial

“…A prior randomized trial of an electronic alert for improving oral anticoagulant use among hospitalized oral anticoagulant-naïve AF patients demonstrated modest improvements in the proportion receiving anticoagulation at hospital discharge. 17 A nonrandomized cohort study of a clinical alert for newly diagnosed hospitalized AF patients did not result in an increase in oral anticoagulant prescribing. 15 In contrast, our study evaluated the impact of implementing an electronic alert for ambulatory primary care patients in a pragmatic randomized fashion.…”

“…Structured interventions using electronic medical record (EMR) decision support and electronic alert tools in patients with AF are feasible. [15][16][17] We conducted a randomized controlled trial to test whether an electronic notification distributed to primary care physicians (PCPs) would increase the proportion of patients prescribed oral anticoagulants. Within the notification, we embedded educational support materials and a survey to assess who was making decisions regarding anticoagulation for each patient, the reasons why patients were not prescribed oral anticoagulants, and how PCPs might be influenced by the notification.…”

Temporal Trends in the Use and Comparative Effectiveness of Direct Oral Anticoagulant Agents Versus Warfarin for Nonvalvular Atrial Fibrillation: A Canadian Population‐Based Study

“…It is important to explore and address patient preference and physician perception of the risk–benefit balance, particularly because evidence from this and other studies confirms the greater safety of DOACs . Intervention trials based on education, measurement, and feedback and electronic alert systems aiming to improve anticoagulation rates are relevant and currently under way …”

“…34,35 Intervention trials based on education, measurement, and feedback and electronic alert systems aiming to improve anticoagulation rates are relevant and currently under way. 36,37 Our study has several strengths, including the analysis of a complete population and a long duration of follow-up. In addition, we studied all DOACs currently available in Canada (dabigatran, rivaroxaban, apixaban), and we treated anticoagulation exposure as a time-varying variable to reflect realworld treatment patterns.…”

Reducing Alert Burden in Electronic Health Records: State of the Art Recommendations from Four Health Systems

“…13 While alerts can change clinician behavior and improve care processes, clinicians largely dismiss them, an action known as overriding. 14 Overrides may be clinically appropriate, such as when a clinician deems the likely benefit of administering a medication to far exceed the potential medication risks. In other cases, overrides may represent not carefully considered clinical decisions, but reflexive dismissals by clinicians who have become inured to the large number of EHR alerts.…”