Sadiq Hammad, Hoque Laboni, Shi Qiming, Manning Gordon, Crawford Sybil, McManus David, Kapoor Alok
University of Massachusetts Medical School, Worcester, MA, USA.
UMass Memorial Health Care, Worcester, MA, USA.
J Thromb Thrombolysis. 2021 Oct;52(3):808-816. doi: 10.1007/s11239-021-02420-8. Epub 2021 Mar 10.
Only half of atrial fibrillation (AF) patients with elevated stroke risk receive anticoagulation (AC). Electronic health record (EHR) alerts have the potential to close the gap. We designed an outpatient EHR alert (linked to an order set for ordering AC, labs, and specialty referrals) that fired when cardiology and primary care providers (PCPs) saw AF patients not on AC. We assigned all untreated patients seen by cardiology providers and PCPs in the 8 months before and after the alert launch to pre- and post-launch intervention cohorts, respectively. Untreated AF patients seeing other types of providers became controls. We then compared the difference in AC starts between intervention and control patients post-launch to the same difference prelaunch (adjusting for covariates). We measured alert responsiveness as how often patients had at least one encounter with a provider, who interacted with the alert. The adjusted percentage of AC starts for the prelaunch cohort was 20% for intervention patients and 17% for controls (difference = 3%); post-launch, the percentage was 13% for both post-launch intervention and controls (difference = 0%). The difference in difference was - 3% (p value 0.63). For half of patients, at least one provider was responsive to our alert. Reasons for no AC commonly included relative contraindications (e.g. fall, gastrointestinal bleed). Our alert did not increase AC starts but responsiveness to it was high. Increasing AC starts will likely require education surrounding relative contraindications.
仅有一半中风风险升高的心房颤动（AF）患者接受了抗凝治疗（AC）。电子健康记录（EHR）警报有可能缩小这一差距。我们设计了一种门诊EHR警报（与用于订购AC、实验室检查和专科转诊的医嘱集相关联），当心脏病专家和初级保健提供者（PCP）查看未接受AC治疗的AF患者时触发该警报。我们将警报发布前后8个月内心脏病专家和PCP诊治的所有未治疗患者分别分配到发布前和发布后的干预队列。诊治其他类型提供者的未治疗AF患者成为对照。然后，我们将发布后干预组和对照组患者AC启动率的差异与发布前的相同差异进行比较（对协变量进行调整）。我们将警报响应性衡量为患者与触发警报的提供者至少有一次接触的频率。发布前队列中，干预组患者AC启动的调整百分比为20%，对照组为17%（差异=3%）；发布后，发布后干预组和对照组的百分比均为13%（差异=0%）。差异的差异为-3%（p值0.63）。对于一半的患者，至少有一名提供者对我们的警报有响应。未进行AC治疗的常见原因包括相对禁忌症（如跌倒、胃肠道出血）。我们的警报并未增加AC的启动率，但对其的响应性较高。提高AC的启动率可能需要围绕相对禁忌症开展教育。
