Electronic Decision support for Improvement of Contemporary Therapy for Stroke Prevention

Despite ample clinical trial data demonstrating that oral anticoagulation (OAC) treatment is highly effective in reducing stroke for patients with atrial fibrillation (AF), OAC treatment remains underutilized in current clinical practice. Targeting hospitalist and emergency department providers with electronic decision support represents a potential quality improvement opportunity in the use of OAC medication in AF patients.

We conducted a 3-center study in which 2 sites utilized an electronic alert (EA) embedded in the electronic health record and 1 site provided usual care. The EA calculated the CHA₂DS₂-VASc score for clinicians. Patients were tracked following discharge from either the emergency department or hospital. We hypothesized that the EA would increase the rate of OAC use by 15% compared to usual care, with a study sample size of 360 patients. Study exclusions included severe heart valve disease, advanced renal disease, and severe dementia. The primary endpoint was OAC use at the time of hospital discharge or 30 days after hospital discharge (whichever was the last observation recorded).

Among 309 patients included for analysis (mean age 70.2 years), the median CHA₂DS₂-VASc score was 3.5. The frequency of OAC use at follow-up at the usual care hospital was 55.9% (95% confidence interval 47.4-67.9). At the 2 EA sites, the rate of OAC use at the last observation point was 43.9% (P = .06). Aspirin use at follow-up was similar at the usual care site and the EA sites (53.8% versus 46.3%). The rate of OAC use in patients greater than 75 years was 60.0% in the usual care site and 48.4% (P = .09) at the EA sites.

The EA in our study was not sufficient to ameliorate therapeutic inertia in the use of OAC for stroke prevention in AF.