Abstract
BackgroundPatients with atrial fibrillation (AF) are at significantly increased risk of stroke. Oral anticoagulants (OACs) substantially reduce this risk, with gains seen across the spectrum of baseline risk. Despite the benefit to patients, OAC prescribing remains suboptimal in the United Kingdom (UK). We will investigate whether an automated software system, operating within primary care electronic medical records, can improve the management of AF by identifying patients eligible for OAC therapy and increasing uptake of this treatment.Methods/DesignWe will conduct a cluster randomised controlled trial, involving general practices using the Egton Medical Information Systems (EMIS) Web clinical system. We will randomise practices to use an electronic software tool or to continue with usual care. The tool will a) produce (and continually refresh) a list of patients with AF who are eligible for OAC therapy - practices will invite these patients to discuss therapy at the start of the trial - and b) generate electronic screen reminders in the medical records of those eligible, appearing throughout the trial. The software will run for 6 months in 23 intervention practices. A total of 23 control practices will manage their AF register in line with the usual care offered. The primary outcome is change in proportion of eligible patients with AF who have been prescribed OAC therapy after six months. Secondary outcomes are incidence of stroke, transient ischaemic attack, other major thromboembolism, major haemorrhage and reports of inappropriate OAC prescribing in the data collection sample - those deemed eligible for OACs. We will conduct a process evaluation in parallel with the randomised trial. We will use qualitative methods to examine patient and practitioner views of the intervention and its impact on primary care practice, including its time implications.DiscussionAURAS-AF will investigate whether a simple intervention, using electronic primary care records, can improve OAC uptake in a high risk group for stroke. Given previous concerns about safety, especially surrounding inappropriate prescribing, we will also examine whether electronic reminders safely impact care in this clinical area.Trial registrationhttp://ISRCTN 55722437
Highlights
Patients with atrial fibrillation (AF) are at significantly increased risk of stroke
AURAS-AF will investigate whether a simple intervention, using electronic primary care records, can improve Oral anticoagulant (OAC) uptake in a high risk group for stroke
Aim The aim of this trial is to investigate the impact of an automated system to identify patients with AF who are eligible for oral anticoagulant therapy to reduce stroke risk and to identify barriers to commencing recommended care using the tool. The objectives of this trial are as follows: 1. To examine whether an automated software system operating within electronic medical records to identify patients with AF who are eligible for oral anticoagulant therapy will increase uptake
Summary
Patients with atrial fibrillation (AF) are at significantly increased risk of stroke. Improved management of risk factors has been central to recent improvements in outcomes [3], but a notable exception is the management of stroke risk in patients with atrial fibrillation (AF). Recent studies place UK prescribing at as low as 53 percent of those eligible (based on national clinical guidelines of the time) [8], with up to 34 percent not prescribed and without a recorded contraindication or refusal [9]. This underuse is evident internationally [10,11]. The pros and cons of anticoagulation are, often misjudged by clinicians, and based on the balance between haemorrhage and thromboembolism risk, most should be considered for OACs [13]
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