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An automated software system to promote anticoagulation and reduce stroke risk: cluster-randomized controlled trial

Holt, Tim A.; Dalton, Andrew; Marshall, Tom; Fay, Matthew; Qureshi, Nadeem; Kirkpatrick, Susan; Hislop, Jenny; Lasserson, Daniel; Kearley, Karen; Mollison, Jill; Yu, Ly-Mee; Hobbs, F.D. Richard; Fitzmaurice, David

Authors

Tim A. Holt

Andrew Dalton

Tom Marshall

Matthew Fay

Nadeem Qureshi

Susan Kirkpatrick

Jenny Hislop

Daniel Lasserson

Karen Kearley

Jill Mollison

Ly-Mee Yu

F.D. Richard Hobbs

David Fitzmaurice



Abstract

Background and Purpose:
Oral anticoagulants (OAC) substantially reduce risk of stroke in atrial fibrillation, but uptake is suboptimal. Electronic health records enable automated identification of people at risk but not receiving treatment. We investigated the effectiveness of a software tool (AURAS-AF [Automated Risk Assessment for Stroke in Atrial Fibrillation]) designed to identify such individuals during routine care through a cluster-randomized trial.

Methods:
Screen reminders appeared each time the electronic health records of an eligible patient was accessed until a decision had been taken over OAC treatment. Where OAC was not started, clinicians were prompted to indicate a reason. Control practices continued usual care. The primary outcome was the proportion of eligible individuals receiving OAC at 6 months. Secondary outcomes included rates of cardiovascular events and reports of adverse effects of the software on clinical decision-making.

Results:
Forty-seven practices were randomized. The mean proportion–prescribed OAC at 6 months was 66.3% (SD=9.3) in the intervention arm and 63.9% (9.5) in the control arm (adjusted difference 1.21% [95% confidence interval −0.72 to 3.13]). Incidence of recorded transient ischemic attack was higher in the intervention practices (median 10.0 versus 2.3 per 1000 patients with atrial fibrillation; P=0.027), but at 12 months, we found a lower incidence of both all cause stroke (P=0.06) and hemorrhage (P=0.054). No adverse effects of the software were reported.

Conclusions:
No significant change in OAC prescribing occurred. A greater rate of diagnosis of transient ischemic attack (possibly because of improved detection or overdiagnosis) was associated with a reduction (of borderline significance) in stroke and hemorrhage over 12 months.

Clinical Trial Registration:
URL: http://www.isrctn.com. Unique Identifier: ISRCTN55722437.%U http://stroke.ahajournals.org/content/strokeaha/early/2017/01/24/STROKEAHA.116.015468.full.pdf

Journal Article Type Article
Publication Date Jan 24, 2017
Journal Stroke
Print ISSN 0039-2499
Electronic ISSN 1524-4628
Publisher American Heart Association
Peer Reviewed Peer Reviewed
Volume 48
Issue 3
Pages 787-790
APA6 Citation Holt, T. A., Dalton, A., Marshall, T., Fay, M., Qureshi, N., Kirkpatrick, S., …Fitzmaurice, D. (2017). An automated software system to promote anticoagulation and reduce stroke risk: cluster-randomized controlled trial. Stroke, 48(3), 787-790
Keywords Atrial Fibrillation; Primary Prevention; Health Services; Stroke; Electronic Health Records; Reminder Systems; Anticoagulants.
Publisher URL https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.116.015468
Copyright Statement Copyright information regarding this work can be found at the following address: http://eprints.nottingh.../end_user_agreement.pdf
Additional Information

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Holt Stroke 2017 AAM.pdf (122 Kb)
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Copyright Statement
Copyright information regarding this work can be found at the following address: http://eprints.nottingham.ac.uk/end_user_agreement.pdf





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