Care for atrial fibrillation (AF) and its complications leads to substantial utilization of healthcare resources and creates a financial burden, primarily driven by the occurrence of stroke. While AF-related strokes are particularly devastating, numerous trials have demonstrated that oral anticoagulation (OAC) is highly effective at reducing the risk of stroke and all-cause mortality. Nevertheless, implementation of OAC in the routine clinical care of AF patients has been disappointing. There are multiple pitfalls that can impair the appropriate prescription and utilization of OAC for stroke prevention in patients with AF (Figure 1A). Numerous studies have documented underutilization of OAC in patients with AF at risk for stroke, and across multiple healthcare settings and patient populations. While rates of OAC may be affected by analytical methodologies (e.g. failure to capture appropriate OAC contraindications), as well as variations in local practice patterns, it is clear that a large proportion of AF patients with indications for OAC never receive treatment. This is a significant missed opportunity to improve outcomes in patients with AF, using proven, available therapies. While there have been many randomized clinical trials assessing the efficacy and safety of pharmacological and non-pharmacological therapies to prevent stroke in patients with AF, there are relatively few studies demonstrating effective interventions to improve the proportion of eligible patients who actually receive these treatments. In this issue of the European Heart Journal, Piazza and colleagues present the results of the Alert-Based Computerized Decision Support for High-Risk Hospitalized Patients with Atrial Fibrillation Not Prescribed Anticoagulation (AF-ALERT) trial. The investigators randomized clinicians caring for 458 inpatients with AF to an active, best-practice advisory (BPA) through the electronic health record (EHR), or to usual care (no BPA). The active BPA led to improved inpatient prescription of OAC, but also improved rates of outpatient OAC use at 90 days post-discharge (28% vs. 17%). Moreover, the patients in the BPA group were observed to have a lower odds of death, myocardial infarction, stroke, transient ischaemic attack, or a systemic embolic event at 90 days (11% vs. 22%). The authors should be commended for testing the effectiveness of this simple intervention, instead of simply saddling clinicians with more ‘clicks without evidence.’ One of the components that sets the current trial apart from other, similar studies, is the link to clinical outcomes. While some (but not all) EHR-based interventions for OAC have demonstrated improvement in prescription rates (Figure 1B), the evidence for improved clinical outcomes has been limited. Furthermore, the improved outcomes in AF-ALERT suggest that there was substantial compliance and persistence of therapy. This is important as the clinical community has struggled with high rates of OAC discontinuation, particularly with vitamin K antagonist oral anticoagulants (e.g. warfarin). Up to half of all OAC users will discontinue therapy at 1 year and, while the present study did not look that far, the data do support the idea that inpatient hospitalization provides valuable opportunities to improve chronic, outpatient treatment—a paradigm also observed in the treatment of heart failure. Nevertheless, there are shortcomings to the AF-ALERT trial. For example, the authors nicely describe the rationale for randomizing at the clinician level (by provider identification number), yet this methodology has limitations as well. First, as noted in the manuscript, it yielded an imbalance in the number of patients assigned to each group. Secondly, it allows for individual provider characteristics to vary and possibly impact treatment decisions; there may be patients assigned to BPA clinicians who are inherently more likely to prescribe OAC, whereas another entire group of patients may not get alerts and may simultaneously be treated by a clinician less likely to use OAC. In short, clinician-level randomization makes it more difficult to isolate the effect of the BPA from clinician-specific variation in OAC utilization for inpatients with AF. Importantly, we are not given any characteristics about the clinician groups, and whether

中文翻译：

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打电话给我，可能的话？EHR 中 BPA 的正确时间和地点

心房颤动 (AF) 及其并发症的护理导致医疗资源的大量利用并造成经济负担，主要由中风的发生驱动。虽然 AF 相关的中风尤其具有破坏性，但大量试验表明，口服抗凝剂 (OAC) 在降低中风和全因死亡率方面非常有效。然而，在 AF 患者的常规临床护理中实施 OAC 令人失望。有多种缺陷会影响 AF 患者中 OAC 预防卒中的适当处方和使用（图 1A）。许多研究已经证明，在有卒中风险的 AF 患者以及多个医疗机构和患者群体中，OAC 的利用不足。虽然 OAC 的发生率可能会受到分析方法（例如未能捕捉到适当的 OAC 禁忌症）以及当地实践模式的变化的影响，但很明显，很大一部分有 OAC 适应症的 AF 患者从未接受过治疗。这是一个重要的机会，可以使用经过验证的可用疗法来改善 AF 患者的预后。虽然有许多随机临床试验评估药物和非药物治疗预防 AF 患者中风的有效性和安全性，但相对较少的研究表明有效的干预措施可以提高实际接受这些治疗的合格患者的比例。在本期《欧洲心脏杂志》中，Piazza 及其同事介绍了基于警报的计算机化决策支持对未处方抗凝治疗的房颤高危住院患者的计算机化决策支持 (AF-ALERT) 试验的结果。研究人员通过电子健康记录 (EHR) 将 458 名住院 AF 患者的临床医生随机分配到积极的最佳实践咨询 (BPA) 或常规护理（无 BPA）。活性 BPA 改善了住院 OAC 处方，但也提高了出院后 90 天门诊 OAC 的使用率（28% 对 17%）。此外，观察到 BPA 组的患者在 90 天时死亡、心肌梗塞、中风、短暂性脑缺血发作或全身性栓塞事件的几率较低（11% 对 22%）。应该赞扬作者测试这种简单干预的有效性，而不是简单地让临床医生承担更多“没有证据的点击”。将当前试验与其他类似研究区分开来的组成部分之一是与临床结果的联系。虽然一些（但不是全部）基于 EHR 的 OAC 干预措施已证明处方率有所提高（图 1B），但改善临床结果的证据有限。此外，AF-ALERT 的改善结果表明治疗的依从性和持续性很高。这一点很重要，因为临床社区一直在努力解决 OAC 停用率高的问题，尤其是维生素 K 拮抗剂口服抗凝剂（例如华法林）。多达一半的 OAC 使用者将在 1 年后停止治疗，虽然目前的研究并没有那么远，数据确实支持这样一种观点，即住院治疗为改善慢性门诊治疗提供了宝贵的机会——在心力衰竭的治疗中也观察到了这一范例。然而，AF-ALERT 试验也存在缺陷。例如，作者很好地描述了在临床医生级别（通过提供者识别号）随机化的基本原理，但这种方法也有局限性。首先，正如手稿中所指出的，它导致分配给每组的患者数量不平衡。其次，它允许个体提供者特征发生变化并可能影响治疗决策；可能有一些患者被分配给 BPA 临床医生，他们天生就更有可能开 OAC，而另一整组患者可能不会收到警报，并且可能同时由不太可能使用 OAC 的临床医生进行治疗。简而言之，临床医生级别的随机化使得更难将 BPA 的影响与 AF 住院患者 OAC 使用率的临床医生特定变化区分开来。重要的是，我们没有得到关于临床医生群体的任何特征，以及