Alert-based computerized decision support for high-risk hospitalized patients with atrial fibrillation not prescribed anticoagulation: a randomized, controlled trial (AF-ALERT)

Gregory Piazza; Shelley Hurwitz; Claire E Galvin; Lindsay Harrigan; Sofia Baklla; Benjamin Hohlfelder; Brett Carroll; Adam B Landman; Srinivas Emani; Samuel Z Goldhaber

doi:10.1093/eurheartj/ehz385

Alert-based computerized decision support for high-risk hospitalized patients with atrial fibrillation not prescribed anticoagulation: a randomized, controlled trial (AF-ALERT)

Eur Heart J. 2020 Mar 7;41(10):1086-1096. doi: 10.1093/eurheartj/ehz385.

Authors

Affiliations

¹ Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA.
² Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA.
³ Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA.
⁴ Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, USA.
⁵ Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA.
⁶ Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA.

PMID: 31228189
DOI: 10.1093/eurheartj/ehz385

Abstract

Aims: Despite widely available risk stratification tools, safe and effective anticoagulant options, and guideline recommendations, anticoagulation for stroke prevention in atrial fibrillation (AF) is underprescribed. We created and evaluated an alert-based computerized decision support (CDS) strategy to increase anticoagulation prescription in hospitalized AF patients at high risk for stroke.

Methods and results: We enrolled 458 patients (CHA2DS2-VASc score ≥1) with AF who were not prescribed anticoagulant therapy and were hospitalized at Brigham and Women's Hospital. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) vs. control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription. The CDS tool assigned 248 patients to the alert group and 210 to the control group. Patients in the alert group were more likely to be prescribed anticoagulation during the hospitalization (25.8% vs. 9.5%, P < 0.0001), at discharge (23.8% vs. 12.9%, P = 0.003), and at 90 days (27.7% vs. 17.1%, P = 0.007). The alert reduced the odds of a composite outcome of death, myocardial infarction (MI), cerebrovascular event, and systemic embolic event at 90 days [11.3% vs. 21.9%, P = 0.002; odds ratio (OR) 0.45; 95% confidence interval (CI) 0.27-0.76]. The alert reduced the odds of MI at 90 days by 87% (1.2% vs. 8.6%, P = 0.0002; OR 0.13; 95% CI 0.04-0.45) and cerebrovascular events or systemic embolism at 90 days by 88% (0% vs. 2.4%, P = 0.02; OR 0.12; 95% CI 0.0-0.91).

Conclusion: An alert-based CDS strategy increased anticoagulation in high-risk hospitalized AF patients and reduced major adverse cardiovascular events, including MI and stroke.

Clinicaltrials.gov identifier: NCT02339493.

Keywords: Anticoagulation; Atrial fibrillation; Computerized decision support; Electronic alerts; Myocardial infarction; Stroke.

Publication types

Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Anticoagulants / therapeutic use
Atrial Fibrillation* / complications
Atrial Fibrillation* / drug therapy
Embolism*
Female
Humans
Myocardial Infarction*
Risk Factors
Stroke* / etiology
Stroke* / prevention & control
Treatment Outcome

Substances

Anticoagulants

Associated data

ClinicalTrials.gov/NCT02339493