Decision Support Tool Fails to Boost Anticoagulation Initiation in US Emergency Departments

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.

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.

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