Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
Department of Medicine, Harvard Medical School, Boston, MA, USA.
J Gen Intern Med. 2018 Dec;33(12):2070-2077. doi: 10.1007/s11606-018-4612-6. Epub 2018 Aug 3.
Oral anticoagulants reduce the risk of stroke in patients with atrial fibrillation. However, many patients with atrial fibrillation at elevated stroke risk are not treated with oral anticoagulants.
To test whether electronic notifications sent to primary care physicians increase the proportion of ambulatory patients prescribed oral anticoagulants.
Randomized controlled trial conducted from February to May 2017 within 18 practices in an academic primary care network.
Primary care physicians (n = 175) and their patients with atrial fibrillation, at elevated stroke risk, and not prescribed oral anticoagulants.
Patients of each physician were randomized to the notification or usual care arm. Physicians received baseline email notifications and up to three reminders with patient information, educational material and primary care guidelines for anticoagulation management, and surveys in the notification arm.
The primary outcome was the proportion of patients prescribed oral anticoagulants at 3 months in the notification (n = 972) vs. usual care (n = 1364) arms, compared using logistic regression with clustering by physician. Secondary measures included survey-based physician assessment of reasons why patients were not prescribed oral anticoagulants and how primary care physicians might be influenced by the notification.
Over 3 months, a small proportion of patients were newly prescribed oral anticoagulants with no significant difference in the notification (3.9%, 95% CI 2.8-5.3%) and usual care (3.2%, 95% CI 2.4-4.2%) arms (p = 0.37). The most common, non-exclusive reasons why patients were not on oral anticoagulants included atrial fibrillation was transient (30%) or paroxysmal (12%), patient/family declined (22%), high bleeding risk (20%), fall risk (19%), and frailty (10%). For 95% of patients, physicians stated they would not change their management after reviewing the alert.
Electronic physician notification did not increase anticoagulation in patients with atrial fibrillation at elevated stroke risk. Primary care physicians did not prescribe anticoagulants because they perceived the bleeding risk was too high or stroke risk was too low.
ClinicalTrials.gov identifier NCT02950285.
口服抗凝剂可降低房颤患者发生中风的风险。然而，许多处于高中风风险的房颤患者并未接受口服抗凝剂治疗。
检测电子通知发送给初级保健医生是否会增加开具口服抗凝剂处方的门诊患者比例。
在学术初级保健网络的 18 个实践中，于 2017 年 2 月至 5 月进行的随机对照试验。
初级保健医生（n=175）及其处于高中风风险且未开具口服抗凝剂的房颤患者。
每位医生的患者被随机分配至通知组或常规护理组。医生在通知组中收到基线电子邮件通知和最多三次带有患者信息、教育材料和抗凝管理初级保健指南的提醒，以及调查。
主要结局为通知组（n=972）和常规护理组（n=1364）在 3 个月时开具口服抗凝剂的患者比例，采用按医生聚类的逻辑回归进行比较。次要观察指标包括基于调查的医生评估未开具口服抗凝剂的患者的原因以及初级保健医生如何受到通知的影响。
在 3 个月期间，新开具口服抗凝剂的患者比例很小，通知组（3.9%，95%CI 2.8-5.3%）和常规护理组（3.2%，95%CI 2.4-4.2%）之间无显著差异（p=0.37）。患者未服用口服抗凝剂的最常见且非排他性原因包括房颤是一过性（30%）或阵发性（12%）、患者/家属拒绝（22%）、高出血风险（20%）、跌倒风险（19%）和虚弱（10%）。对于 95%的患者，医生表示在查看警报后不会改变他们的治疗方案。
电子医生通知并未增加处于高中风风险的房颤患者的抗凝治疗。初级保健医生未开具抗凝剂是因为他们认为出血风险过高或中风风险过低。
ClinicalTrials.gov 标识符 NCT02950285。
