Related Experiment Video
Updated: Jun 8, 2025
The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
Published on: February 28, 2012
Decision Support Intervention and Anticoagulation for Emergency Department Atrial Fibrillation: The O'CAFÉ
David R Vinson1,2,3, E Margaret Warton2, Edward J Durant1,4
1The Permanente Medical Group, Oakland, California.
Insights
A multipronged intervention did not significantly increase oral anticoagulation initiation for atrial fibrillation patients discharged from the emergency department. Further strategies are needed to improve stroke prevention in this population.
Area of Science:
- Cardiology
- Emergency Medicine
- Pharmacology
Background:
- Oral anticoagulation is crucial for preventing ischemic stroke in adults with atrial fibrillation or flutter (AFF) but is underutilized.
- Previous efforts to boost anticoagulation initiation upon emergency department (ED) discharge have shown inconsistent outcomes.
Purpose of the Study:
- To assess the effectiveness of a comprehensive intervention aimed at increasing anticoagulation initiation for eligible adult patients with AFF in the ED.
Main Methods:
- A pragmatic, stepped-wedge cluster randomized trial (O'CAFÉ) involving 13 medical centers.
- The intervention included physician education, audit and feedback, and clinical decision support for identifying eligible patients and recommending anticoagulation.
- The primary outcome was anticoagulation initiation at discharge or within 30 days, analyzed via intention-to-treat and per-protocol methods.
Main Results:
- The multipronged intervention did not significantly increase anticoagulation initiation rates (adjusted odds ratio, 1.33; P=.13).
- However, the clinical decision support tool, when used (26.6% of eligible cases), was associated with a significant increase in anticoagulation initiation (75.6% vs 65.8%; P=.008).
Conclusions:
- A comprehensive intervention did not significantly improve oral anticoagulation initiation for eligible ED patients with AFF.
- Opportunities remain to enhance stroke prevention strategies for this patient group, particularly through effective use of decision support tools.
Importance:
Oral anticoagulation for adults with atrial fibrillation or atrial flutter (AFF) who are at elevated stroke risk reduces the incidence of ischemic stroke but remains underused. Efforts to increase anticoagulation initiation on emergency department (ED) discharge have yielded conflicting results.
Objective:
To evaluate the effectiveness of a multipronged intervention supporting anticoagulation initiation for eligible adult ED patients.
Design, Setting, And Participants:
The Clinical Decision Support to Optimize Care of Patients With Atrial Fibrillation or Flutter in the Emergency Department (O'CAFÉ) pragmatic, stepped-wedge cluster randomized clinical trial was conducted from July 1, 2021, through April 30, 2023, at 13 community medical centers (in 9 clusters) of an integrated health system in Northern California. The study included adult ED patients with primary AFF eligible for anticoagulation initiation when discharged home. Clusters were randomly assigned to staggered dates for 1-way crossover from the control phase (usual care) to the intervention phase.
Intervention:
Physician education, facility-specific audit and feedback, and access to decision support, which identified eligible patients and recommended shared decision-making, anticoagulation initiation (if suitable), and timely follow-up.
Main Outcomes And Measures:
The main outcome was a composite of anticoagulation on discharge or within 30 days. A primary intention-to-treat analysis (decision support access regardless of use) and a secondary per-protocol analysis (decision support use) were performed. Multivariable analyses adjusted for intervention and exposure months with random effects, accounting for clustering by facility and patient.
Results:
A total of 3388 eligible patients with atrial fibrillation were discharged home: 2185 (64.5%) were receiving pre-ED arrival anticoagulation and 1203 (35.5%) were eligible for anticoagulation. Among the 1203 patients with an initiation-eligible encounter, the median age was 74.0 (IQR, 68.0-82.0) years and approximately half (618 [51.4%]) were men. Among the 387 patients with an initiation-eligible control encounter, 244 (63.0%) received anticoagulation (190 [49.0%] at discharge and 54 [14.0%] within 30 days). Among the 816 patients with an initiation-eligible intervention encounter, 558 (68.4%) received anticoagulation (428 [52.5%] on discharge and 130 [15.9%] within 30 days). There was no statistically significant change in initiation of anticoagulation associated with the intervention (adjusted odds ratio, 1.33 [95% CI, 0.75-2.35]; P = .13). Decision support was used for 217 eligible case patients (26.6%) (per protocol) and was associated with a statistically significant change in anticoagulation initiation when compared with 599 patients for whom decision support was not used (164 [75.6%] vs 394 [65.8%]; P = .008).
Conclusions And Relevance:
In this trial, a multipronged intervention to facilitate thromboprophylaxis among eligible ED patients with AFF did not significantly increase anticoagulation initiation. Opportunities exist to further improve stroke prevention among ED patients with primary AFF.
Trial Registration:
ClinicalTrials.gov Identifier: NCT05009225.
Related Concept Videos
01:30Anticoagulant Drugs: Low-Molecular-Weight Heparins
01:28Disturbances in Heart Rhythm
Arrhythmias are categorized by their speed, rhythm, and origin. A slow...