Effect of Clinical Decision Support Alerts on Anticoagulation Management in Atrial Fibrillation

Abstract

Background

Anticoagulation decisions in atrial fibrillation (AF) depend on balancing stroke and bleeding risk, often guided by CHA₂DS₂-VASc (a validated clinical score used to estimate stroke risk in patients with atrial fibrillation) and HAS-BLED (a validated clinical score used to estimate bleeding risk in patients treated with anticoagulation) scores. Manual calculation of these scores can be time-consuming and inconsistently performed.

Objective

This study evaluated whether implementing real-time, electronic health record (EHR)-integrated alerts in a rural academic primary care clinic would influence physician and non-physician provider (NPP) behavior around anticoagulation management.

Methods

A single-arm observational study was conducted from March 2024 to September 2025 at a West Virginia University (WVU) Family Medicine Clinic. A rules-based engine in Epic calculated risk scores using 1 year of structured data and displayed them within a non-interruptive “Our Practice Advisory” alert. Physician or NPP interaction—defined as initiation of anticoagulation, documentation of rationale, or adding exclusion diagnosis to problem list—was analyzed using chi-square testing.

Results

Among 313 patients triggering the alert, 53 (16.9%) were newly started on anticoagulation, 112 (35.8%) had a documented rationale for not initiating therapy, and 2 had the exclusion diagnosis added to their chart. In total, 50.5% of patients had a clinically meaningful interaction with the tool (χ²= 9.82, p = 0.0017). Across 2,447 encounters, the overall alert success rate was 19.8%, reflecting encounter-level engagement. Common acknowledgment reasons included corrective measures completed, high bleeding risk, recent procedures, and patient refusal. Physician and NPP comments informed iterative refinement, leading to expanded acknowledgment options.

Conclusion

Real-time alerts displaying stroke and bleeding risk scores were associated with meaningful physician and NPP engagement, particularly for initiating anticoagulation in high-risk patients. While most interactions reflected review rather than treatment change, the tool appeared to support point-of-care decision-making. These findings support further investigation of EHR-based advisories to improve anticoagulation management in AF.

Keywords

clinical decision support - standards and best practices - ambulatory care/primary care - cardiology - medication management

Protection of Human and Animal Subjects

This project was reviewed by the West Virginia University institutional review board and determined to qualify as Not Human Subjects Research (NHSR) under federal regulations (Protocol no.: 2403940507).

Ethical Approval

This study was reviewed and approved by the West Virginia University Institutional Review Board (Protocol no.: 2403940507).

Publikationsverlauf

Eingereicht: 10. Juli 2025

Angenommen: 04. Dezember 2025

Artikel online veröffentlicht:
18. Dezember 2025

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