{"id":1701,"date":"2018-05-18T10:19:29","date_gmt":"2018-05-18T10:19:29","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmjebmspotlight\/?p=1701"},"modified":"2018-05-18T10:29:12","modified_gmt":"2018-05-18T10:29:12","slug":"evidence-watch-can-clinical-decision-support-tools-optimise-anticoagulant-therapy","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmjebmspotlight\/2018\/05\/18\/evidence-watch-can-clinical-decision-support-tools-optimise-anticoagulant-therapy\/","title":{"rendered":"Evidence Watch: Can clinical decision support tools optimise anticoagulant therapy?"},"content":{"rendered":"<p><strong>\u00a0<\/strong><\/p>\n<p><em>High baseline adherence rates for guidelines recommendations means that a clinical decision support system makes only a small difference in clinical outcomes for atrial fibrillation patients.\u00a0\u00a0<\/em><\/p>\n<p style=\"text-align: right\">Carl Heneghan<\/p>\n<hr \/>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-thumbnail wp-image-1324 alignleft\" src=\"https:\/\/blogs.bmj.com\/bmjebmspotlight\/files\/2017\/06\/Carl-Heneghan-150x150.png\" alt=\"\" width=\"150\" height=\"150\" \/><\/p>\n<p>The evidence for the association of atrial fibrillation with stroke risk is clear. However, there remain persistent levels of under treatment in clinical practice.<\/p>\n<p>Clinical decision support tool (CDS) integrated into the electronic health record offer one way to improve uptake of guidelines that recommend anticoagulation in patients with atrial fibrillation and therefore reduce stroke.<\/p>\n<p>A r<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/29534063\">ecent cluster-randomized<\/a> trial of 43 primary care clinics in Sweden randomized practices to alert clinicians for patients with AF and at increased risk for thromboembolism and to recommend therapy according to the CHA2DS2-VASc score.<\/p>\n<p>After 1 year there was a small but significant increase in guideline adherence in the CDS practices (73.0% versus 71.2% p = 0.013). However, there was no difference in the incidence of stroke, transient ischemic attack, or systemic thromboembolism in the two groups. The CDS group did have a lower incidence of significant bleeding, 12 per 1,000 (95% CI 9-15) patients in CDS practices compared to 16 (95% CI 12-20) per 1,000 patients in control practices (p = 0.04).<\/p>\n<p>Having high baseline adherence rates for guidelines recommendations at the outset (in this case 70% adherence to the recommendation for anticoagulation therapy) means that a clinical decision support system makes only a small difference to adhering to guideline recommendations, it seemingly has more impact on safety.<\/p>\n<p>I call this the evidence optimisation gap: the level at which it becomes difficult to attain further benefits because clinicians, patients or the system make it difficult to achieve perfect optimisation, or patient values mean perfect levels of adherence to treatment recommendations misses the point.<\/p>\n<hr \/>\n<p><strong>Reference: <\/strong><strong>\u00a0<\/strong><\/p>\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/29534063\">A clinical decision support tool for improving adherence to guidelines on anticoagulant therapy in patients with atrial fibrillation at risk of stroke<\/a>: A cluster-randomized trial in a Swedish primary care setting (the CDS-AF study).\u00a0Karlsson L.O. et al.\u00a02018.\u00a0<em>PLoS Medicine<\/em>,\u00a0<em>15<\/em>(3),\u00a0e1002528.<\/p>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-1618 alignright\" src=\"https:\/\/blogs.bmj.com\/bmjebmspotlight\/files\/2018\/01\/Picture1-2-1.png\" alt=\"\" width=\"380\" height=\"203\" srcset=\"https:\/\/blogs.bmj.com\/bmjebmspotlight\/files\/2018\/01\/Picture1-2-1.png 380w, https:\/\/blogs.bmj.com\/bmjebmspotlight\/files\/2018\/01\/Picture1-2-1-300x160.png 300w\" sizes=\"auto, (max-width: 380px) 100vw, 380px\" \/><\/p>\n<p>BMJ\u00a0<a href=\"http:\/\/ebm.bmj.com\/\">Evidence-Based Medicine<\/a>\u00a0\u2013\u00a0original evidence-based research, insights and opinion<\/p>\n<p>Read more about BMJ EBM content in the <a href=\"http:\/\/ebm.bmj.com\/content\/early\/2018\/01\/24\/bmjebm-2018-110906\">Welcome to BMJ Evidence-Based Medicine Editorial<\/a>.<\/p>\n<p><b>Competing interests<\/b><\/p>\n<p>Carl has received expenses and fees for his media work including BBC Inside Health. He holds grant funding from the NIHR, the NIHR School of Primary Care Research, The NIHR Oxford BRC\u00a0 and the WHO. He has also received income from the publication of a series of toolkit books. CEBM jointly runs the\u00a0<a title=\"\" href=\"http:\/\/evidencelive.org\/\">EvidenceLive<\/a>\u00a0Conference with the BMJ and the\u00a0<a title=\"\" href=\"http:\/\/www.preventingoverdiagnosis.net\/\">Overdiagnosis Conference<\/a>\u00a0with some international partners which are based on a\u00a0 non-profit model.<strong>\u00a0<\/strong><\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>\u00a0 High baseline adherence rates for guidelines recommendations means that a clinical decision support system makes only a small difference in clinical outcomes for atrial fibrillation patients.\u00a0\u00a0 Carl Heneghan The evidence for the association of atrial fibrillation with stroke risk is clear. However, there remain persistent levels of under treatment in clinical practice. Clinical decision [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmjebmspotlight\/2018\/05\/18\/evidence-watch-can-clinical-decision-support-tools-optimise-anticoagulant-therapy\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":1706,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[14374,14388],"tags":[],"class_list":["post-1701","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-carl-heneghan","category-evidence-watch"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Evidence Watch: Can clinical decision support tools optimise anticoagulant therapy? - BMJ EBM Spotlight<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmjebmspotlight\/2018\/05\/18\/evidence-watch-can-clinical-decision-support-tools-optimise-anticoagulant-therapy\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Evidence Watch: Can clinical decision support tools optimise anticoagulant therapy? - BMJ EBM Spotlight\" \/>\n<meta property=\"og:description\" content=\"\u00a0 High baseline adherence rates for guidelines recommendations means that a clinical decision support system makes only a small difference in clinical outcomes for atrial fibrillation patients.\u00a0\u00a0 Carl Heneghan The evidence for the association of atrial fibrillation with stroke risk is clear. 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