ED Anticoagulation Unchanged Despite Use of Support Tool

TOPLINE:

A multipronged intervention in US emergency departments (EDs) has been found to not significantly increase anticoagulation initiation within 30 days of discharge for patients with primary atrial fibrillation or flutter (AFF).

METHODOLOGY:

• The O’CAFÉ trial was a pragmatic, stepped-wedge cluster randomized clinical trial conducted from July 2021 to April 2023 across nine ED site clusters within the Kaiser Permanente Northern California healthcare system. The trial aimed to optimize care for patients with AFF by implementing a multipronged intervention.
• The study included 1203 patients with primary AFF (median age, 74 years; 51.4% men; 66.7% White) who had elevated CHA2DS2-VASc scores (median, 4), were not on anticoagulants, and were discharged home.
• Of all the patients, 816 were included in the intervention group, which involved educating ED clinicians about the best practices for AFF management, introducing a clinical decision support system (CDSS) called Risk Stratification-AF, and providing performance feedback on stroke prevention metrics. The CDSS, integrated into the electronic health record, offered tools such as stroke and bleed risk calculators, anticoagulation recommendations, and patient-specific educational materials.
• The primary outcome was the initiation of oral anticoagulants (OACs) in eligible patients discharged from the ED.

TAKEAWAY:

• The intervention increased anticoagulation rates from 63% to 68.4%, but this increase was not statistically significant (adjusted odds ratio, 1.33; P =.13).
• The anticoagulation rates were significantly higher (75.6% vs 65.8%; P =.008) in patients for whom CDSS was used (26.6%) than in those for whom it was not used.

IN PRACTICE:

“In this pragmatic, stepped-wedge cluster randomized clinical trial conducted in a US community-based integrated healthcare system, a multipronged intervention including physician education, facility-specific audit and feedback, and CDSS access was not associated with a statistically significant change in OAC initiation on or within 30 days of ED discharge among patients with primary AFF,” the authors wrote.

SOURCE:

The study was led by David R. Vinson, MD, Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California, and was published online on November 6, 2024, in JAMA Network Open.

LIMITATIONS:

The study limitations included high baseline anticoagulation rates (64.5%), a small sample size, and a focus on OAC initiation without directly studying stroke prevention, which could have introduced selection bias. The integrated care delivery setting may also have limited the generalizability of the findings.

DISCLOSURES:

The study was supported by The Permanente Medical Group DARE program and its Physician Researcher Program. Some authors reported receiving grants from Bristol Myers Squibb, Edwards Lifesciences, the Bristol Myers Squibb–Pfizer Alliance, the National Institute of Diabetes and Digestive and Kidney Diseases, and other sources, outside the submitted work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.