Related Experiment Video
Updated: Feb 7, 2026
Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Electronic physician notifications to improve guideline-based anticoagulation in atrial fibrillation: a randomized
Jeffrey M Ashburner1,2, Steven J Atlas1,2, Shaan Khurshid2,3
1Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
Insights
Electronic notifications did not increase oral anticoagulant prescriptions for atrial fibrillation patients at high stroke risk. Physicians cited bleeding risk and low stroke risk as reasons for not prescribing anticoagulation.
Area of Science:
- Cardiology
- Primary Care Medicine
- Health Informatics
Background:
- Atrial fibrillation increases stroke risk, necessitating oral anticoagulants.
- Many high-risk patients are undertreated with oral anticoagulants.
- Identifying barriers to anticoagulation is crucial for stroke prevention.
Purpose of the Study:
- To evaluate if electronic notifications to primary care physicians increase oral anticoagulant prescriptions.
- To assess the impact of electronic alerts on anticoagulation rates in atrial fibrillation patients.
Main Methods:
- A randomized controlled trial involving 175 primary care physicians and their atrial fibrillation patients.
- Physicians were randomized to receive electronic notifications with patient data and guidelines or usual care.
- The primary outcome was the proportion of patients prescribed oral anticoagulants at 3 months.
Main Results:
- No significant difference in oral anticoagulant prescription rates between the notification (3.9%) and usual care (3.2%) arms.
- Physicians cited high bleeding risk, patient refusal, and transient/paroxysmal atrial fibrillation as reasons for non-prescription.
- Most physicians (95%) indicated no change in management after reviewing alerts.
Conclusions:
- Electronic physician notifications did not improve anticoagulation rates in high-risk atrial fibrillation patients.
- Physician-perceived bleeding risk and low stroke risk were key barriers to prescribing oral anticoagulants.
- Current electronic alert systems may not effectively overcome primary care physician-based barriers to anticoagulation.
Background:
Oral anticoagulants reduce the risk of stroke in patients with atrial fibrillation. However, many patients with atrial fibrillation at elevated stroke risk are not treated with oral anticoagulants.
Objective:
To test whether electronic notifications sent to primary care physicians increase the proportion of ambulatory patients prescribed oral anticoagulants.
Design:
Randomized controlled trial conducted from February to May 2017 within 18 practices in an academic primary care network.
Participants:
Primary care physicians (n = 175) and their patients with atrial fibrillation, at elevated stroke risk, and not prescribed oral anticoagulants.
Intervention:
Patients of each physician were randomized to the notification or usual care arm. Physicians received baseline email notifications and up to three reminders with patient information, educational material and primary care guidelines for anticoagulation management, and surveys in the notification arm.
Main Measures:
The primary outcome was the proportion of patients prescribed oral anticoagulants at 3 months in the notification (n = 972) vs. usual care (n = 1364) arms, compared using logistic regression with clustering by physician. Secondary measures included survey-based physician assessment of reasons why patients were not prescribed oral anticoagulants and how primary care physicians might be influenced by the notification.
Key Results:
Over 3 months, a small proportion of patients were newly prescribed oral anticoagulants with no significant difference in the notification (3.9%, 95% CI 2.8-5.3%) and usual care (3.2%, 95% CI 2.4-4.2%) arms (p = 0.37). The most common, non-exclusive reasons why patients were not on oral anticoagulants included atrial fibrillation was transient (30%) or paroxysmal (12%), patient/family declined (22%), high bleeding risk (20%), fall risk (19%), and frailty (10%). For 95% of patients, physicians stated they would not change their management after reviewing the alert.
Conclusions:
Electronic physician notification did not increase anticoagulation in patients with atrial fibrillation at elevated stroke risk. Primary care physicians did not prescribe anticoagulants because they perceived the bleeding risk was too high or stroke risk was too low.
Trial Registration:
ClinicalTrials.gov identifier NCT02950285.
Related Concept Videos
03:03Amyloid Fibrils
Amyloid deposits were observed as early as 1639 in the liver and the spleen. In 1854, Rudolph Virchow performed iodine staining,...
03:03Amyloid Fibrils
01:18Anticoagulant Drugs: Vitamin K Antagonists and Direct Oral Anticoagulants
Warfarin, a prominent vitamin K antagonist family member, exerts its effect by inhibiting the enzyme VKORC1 (vitamin K epoxide reductase complex 1). By hindering this enzyme, warfarin...
01:11Fibril-associated Collagen
For example, the type II collagen fibrils in cartilage have covalently bound type IX fibril-associated collagens at regular intervals. Other types of fibril-associated collagens are...
01:11Clinical Trials: Overview
01:12Trial and Error and Algorithm