Introduction: Oral anticoagulants (OAC) are effective for stroke prevention in patients with atrial fibrillation (AF). However, many AF patients with an elevated stroke risk are not treated with OAC. We tested whether an automated electronic notification alert to primary care providers (PCPs) would increase the proportion of ambulatory patients prescribed OAC.
Methods: In a randomized controlled trial, eligible PCPs (n=175) received notifications for a random subset of up to 10 of their patients (to minimize PCP burden) with AF that were not prescribed OAC and at an elevated stroke risk (CHA2DS2-VASc score ≥2). Alerts included patient-level stroke and bleed risk information, OAC educational materials, and a survey to assess reasons for not prescribing OAC. The primary outcome was the proportion of patients prescribed OAC at 3-months in the notification vs. usual care arms, modeled using logistic regression with clustering by PCP.
Results: Patient characteristics were similar between the notification (n=972) and usual care (n=1364) arms. The mean age was 76, 48% were men, and the mean CHA2DS2-VASc score was 4.2. Over 3-months, there was no significant difference in the proportion of patients prescribed OAC in the notification (3.9%) and usual care (3.2%) arms (p=0.37). In total 57% of PCPs completed surveys. Most PCPs felt that the PCP (65%) or cardiologist (65%) made decisions regarding OAC, with 31% indicating both. The most common non-exclusive reasons why a patient was not on OAC included: AF was transient (30%), AF was paroxysmal (12%), patient/family declined (22%), high bleeding risk (20%), fall risk (19%), and frailty (10%). For 95% of patients, PCPs stated they would not change their management after reviewing the alert.
Conclusions: Automated PCP notifications did not result in more AF patients at elevated stroke risk being anticoagulated. PCPs did not prescribe OACs because they perceived bleed risk was too high or stroke risk was too low, the latter predominantly due to a history of transient AF. Despite notifications, most PCPs felt their decisions not to use OAC were appropriate. Electronic alerts and PCP education are unlikely to substantially increase OAC utilization in patients with AF.