What question did this study set out to answer?

To evaluate the effectiveness of a triad of interventions aimed at improving guideline-directed anticoagulant use in patients with atrial fibrillation.

January 10, 2026BMJ Open Quality0 citationsOpen Access

Enhancing adherence to guideline-directed use of anticoagulant therapy in atrial fibrillation: a triad of quality improvement interventions in an academic outpatient setting

KXKun Kevin Xiang ANAsinamai M Ndai RRRachel Reise

Key Result

A triad of quality improvement interventions increased guideline-concordant anticoagulant use from 75.7% to 79.2%, with an adjusted OR of 1.13 (95% CI 1.05 to 1.21).

Key Points

To evaluate the effectiveness of a triad of interventions aimed at improving guideline-directed anticoagulant use in patients with atrial fibrillation.
Implemented a best practice alert in electronic health records
Provided clinician education on anticoagulation
Enhanced patient communication for shared decision-making
Conducted a 6-month intervention and compared with a historical control period
Utilized generalized estimating equations to analyze anticoagulant use
Anticoagulation rate increased from 75.7% to 79.2% after interventions
Adjusted odds of anticoagulant use significantly higher during intervention (aOR 1.13)
MyChart activation correlated with increased anticoagulant use (aOR 1.38)
Older patients and those with higher CHA 2 DS 2 -VASc scores had better odds of anticoagulant use
Higher HAS-BLED scores and care in primary care linked to lower use of anticoagulants

Structured PICO

Does a triad of quality improvement interventions (EHR alerts, clinician education, and patient messaging) increase guideline-concordant anticoagulant prescribing rates in eligible patients with non-valvular atrial fibrillation?

Population

6,474 adults (aged ≥18 years) with non-valvular atrial fibrillation and a CHA2DS2-VASc score of ≥2 (men) or ≥3 (women) seen in primary care and cardiology outpatient clinics. Excluded: mechanical heart valves, moderate to severe mitral stenosis, and prior left atrial appendage occlusion devices.

Intervention

A triad of quality improvement interventions over a 6-month period: (1) an electronic health record best practice alert (BPA) with embedded CHA2DS2-VASc and HAS-BLED calculators, (2) clinician education via webinars and clinical vignettes, and (3) direct-to-patient educational messaging via the MyChart patient portal to encourage shared decision-making.

Comparator

A 6-month historical control period (preintervention) with usual care, as well as two comparator clinics (one cardiology, one general internal medicine) where the best practice alert was not implemented.

Outcome

Anticoagulation rate (defined as an active prescription of warfarin, apixaban, edoxaban, rivaroxaban, or dabigatran at the time of the visit)

A multifaceted quality improvement intervention involving EHR alerts, clinician education, and direct-to-patient messaging significantly increased guideline-concordant oral anticoagulation prescribing in patients with atrial fibrillation.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Background Anticoagulation for stroke prevention is often recommended for patients with non-valvular atrial fibrillation (AF), yet many eligible patients do not receive guideline-concordant anticoagulation. Prior quality improvement (QI) initiatives to improve anticoagulation in AF have had mixed results. Methods Preventing Preventable Strokes: Scalability used a triad of interventions to increase the number of eligible patients with AF receiving guideline-concordant anticoagulation, including (1) a best practice alert integrated with the electronic health record, (2) clinician education and (3) patient communication about the anticoagulation therapy that encouraged shared decision-making with clinicians. These interventions were conducted in primary care and cardiology outpatient clinics at (University of Florida Health). Patient-level data were collected during a 6-month intervention period and compared with a 6-month historical control period. Generalised estimating equations with a logistic link were used to estimate the odds of anticoagulant use, adjusting for demographic and clinical characteristics. Results A total of 3274 individuals were included during the intervention period and 3200 during the preintervention period. The average anticoagulation rate increased from 75.7% to 79.2% across the two periods. In the fully adjusted model, patients in the intervention period had significantly higher odds of anticoagulant use compared with the preintervention period (adjusted OR (aOR) 1.13, 95% CI 1.05 to 1.21, p=0.0007). MyChart activation (aOR 1.38, 95% CI 1.19 to 1.61, p<0.0001) was also associated with increased anticoagulant use. Older age and higher CHA 2 DS 2 -VASc scores were associated with greater odds of anticoagulant use, while higher HAS-BLED scores and care in primary care (rather than cardiology) were associated with lower odds. Conclusions A triad of QI interventions at the practice, clinician and patient levels increased guideline-concordant anticoagulation use among patients with AF in half of the primary care and cardiology clinics in the University of Florida Health system.

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