Abstract 10984: Alert-Based Computerized Decision Support for High-Risk Ambulatory Clinic Patients With Atrial Fibrillation Not Prescribed Anticoagulation: A Randomized, Controlled Trial (AF-Alert2)

Introduction: Despite widely available risk stratification tools, safe and effective anticoagulants, and guideline recommendations, antithrombotic therapy for stroke prevention in atrial fibrillation (AF) is under-prescribed in ambulatory clinic patients. Hypothesis: We hypothesized that alert-based computerized decision support (CDS) would increase anticoagulation prescription in ambulatory clinic patients with AF and high-risk for stroke. Methods: We enrolled 798 patients (CHA 2 DS 2- VASc score≥2) with AF who were not prescribed anticoagulant therapy and had an ambulatory clinic visit at Brigham and Women’s Hospital. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) versus control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription. Results: The CDS tool assigned 395 and 403 patients to the alert and control groups, respectively. Patients in the alert group were more likely to be prescribed anticoagulation within 48 hours of the clinic visit (15.4% vs. 7.7%, p<0.001) and at 90 days (17.2% vs. 9.9%, p<0.01). Direct oral anticoagulants (DOACs) comprised the majority of increased prescriptions of anticoagulation at 48 hours and 90 days. No differences in stroke, TIA, or systemic embolic events (0% vs. 0.8%, p=0.09), symptomatic VTE (0.5% vs. 1%, p=0.43), CV mortality (0.5% vs. 0.7%, p=0.99), or a composite of major adverse cardiovascular events (2.8% vs. 2.5%, p=0.79) were observed at 90 days ( Figure ). Conclusions: An alert-based CDS strategy increased anticoagulation in ambulatory clinic patients with AF and high-risk for stroke who were not receiving anticoagulation at the time of the office visit. ClinicalTrials.gov Identifier: NCT02958943