Plain English Summary
Background and study aims
Atrial fibrillation is a heart condition that causes an irregular and often abnormally fast heart rate. Patients with atrial fibrillation (AF) can be 5 times more likely to suffer a stroke. Oral anticoagulants (blood thinning agents) reduce this risk by up to 70 percent. Despite this benefit to the patients, anticoagulants remain under-prescribed in UK primary care. Recent estimates place prescribing at 53 percent of those potentially eligible, whilst over 30 percent of patients remain both without a prescription, and without a recorded reason. We aim to see whether an automated software system, operating within general practices' electronic medical records, will improve management of atrial fibrillation by identifying patients eligible for anticoagulation and increasing prescriptions.
Who can participate?
The study aims to recruit 46 general practices operating the EMIS-Web clinical system, which will be included in the main phase of the trial. Before this, we will carry out a pilot study including 3 practices. Within the study, we will interview 30 patients in the participating practices and 10 general practitioners.
What does the study involve?
We will randomly allocate practices to use an electronic software tool or to continue with usual care. The tool will a) produce (and continually refresh) a list of patients with atrial fibrillation eligible for therapy - practices will invite these patients to discuss treatment at the start of the trial; b) generate electronic on-screen reminders in the medical records of those eligible, appearing throughout the trial. We will run the tool for 6 months, in 23 of the practices. The other 23 practices will manage their atrial fibrillation register as usual. We will find out how many eligible patients with atrial fibrillation have been prescribed anticoagulation therapy after six months. We will also look at incidence of stroke, transient ischaemic attack, other major thromboembolism, major haemorrhage (bleed) and reports of inappropriate anticoagulant prescribing. We will also look at patient and practitioner views of the intervention; its impact on care and the general practice - notably its time implications.
What are the possible benefits and risks of participating?
Participating practices will, if allocated to the treatment arm, have use of a software tool designed to assist them in improving care in an important clinical area. If the intervention is found to be effective and safe, control practices will also be offered the opportunity to use it after the trial. Depending on the results of the trial, the intervention could be made available to all UK primary care centres.
We foresee two main potential risks for practices; harm from the electronic reminder system to the consultation process, such as negative impacts on the length and flow of consultations and reducing patient choice. Secondly, there is a risk of prescribing anticoagulants in patients who are unsuitable for anticoagulation, despite being apparently eligible. We will monitor these carefully during the trial.
Where is the study run from?
The Department of Primary Health Care Sciences at the University of Oxford with local support from the Universities of Birmingham and Nottingham
When is the study starting and how long is it expected to run for?
We propose to begin the 3 month pilot study on 1st April 2013, recruiting practices in the month before to this. We shall recruit practices for the main-phase from March to May 2013, aiming to begin the 6 month intervention period on 1st July 2013. The trial is expected to end by 30th June 2014.
Who is funding the study?
NIHR School for Primary Care research
Who is the main contact?
Dr. Andrew R H Dalton
Dr Andrew Dalton
Department of Primary Care Health Sciences
Radcliffe Observatory Quarter
Automated Risk Assessment for Stroke in Atrial Fibrillation: A cluster randomised controlled trial of an electronic reminder intervention to promote anticoagulation and reduce stroke risk (AURAS-AF)
We hypothesise that an automated software system, operating within electronic medical records in primary care, that identifies patients with atrial fibrillation who are eligible for oral anticoagulant therapy, will increase the uptake of therapy.
More details can be found at: http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=13972
NRES Committee South Central - Berkshire, 11/02/2013, ref: 13/SC/0026
Cluster-randomised controlled trial
Primary study design
Secondary study design
Cluster randomised trial
Patient information sheet
Not available in web format, please use the contact details below to request a patient information sheet
Intervention will have a piece of software activated in their primary carer databases. The software will generate a list of all patients registered in the practice diagnosed with atrial fibrillation, who are deemed eligible for anticoagulation (based on criteria in NICE TA249) but not currently prescribed it. Practices will invite these patients (excluding those clearly unsuitable) for a consultation to discuss anticoagulation. They will include an information sheet about anticoagulation, provided by the study team, in the invite. Practices will send reminders to non-attenders one month into the study.
The tool will also produce pop-up reminders whenever patients (on the list above) medical records are opened. These remind the member of the practice team to discuss anticoagulation. The reminders will appear throughout the trial until they are resolved. Pop-ups must be addressed in order to continue using the medical record, with one of 5 options taken.
Control practices will manage patients on their atrial fibrillation register in the normal manner, in line with the quality and outcomes framework and clinical guidelines.
Primary outcome measures
Proportion of patients with diagnosed AF and eligible for anticoagulation under recent guidelines (NICE TA249) who are prescribed this therapy six months after the start of the intervention
Secondary outcome measures
1. Proportion of patients with CHADS2 score ≥2 who are prescribed anticoagulants
2. Record of inappropriate care or prescribing decisions related to anticoagulation in patients with AF
3. Incidence of stroke, transient ischaemic attack (TIA), other major thromboembolism or major haemorrhage during the trial
4. Outcomes of the discussion of/ decisions about the prescription of anticoagulants - including number of patients eligible /invited for a discussion about anticoagulation /reasons for not inviting patients /number attending discussion /outcomes of discussion / reasons for not to using OAC
1. Limitations to usability and appropriateness of intervention and trial material [to improve the intervention, not directly answer objectives
2. Ease of adoption of electronic system by primary care team
1. Responses to screen reminders
2. Patient views on opportunistic (using the electronic reminders) and systematic (from the invitation of the eligible list) approaches to anticoagulant prescribing, and views on the appropriateness and usefulness of electronic reminders
3. Practitioner views on the use of electronic reminders and audit lists of eligible patients to promote anticoagulant prescribing, and of their impact on the consultation process
Overall trial start date
Overall trial end date
Participant inclusion criteria
1. Practices using clinical software compatible with the intervention (i.e. the EMIS-Web system)
2. Within the study region, namely covering the South East of England, Central England and East Midland & South Yorkshire Primary Care Research Networks (PCRNs)
3. Within participant practices, outcome data will be recorded in patients with diagnosed atrial fibrillation, who justify anticoagulation according to the criteria in NICE guidance TA249
For the pilot study the above criteria (as well as the exclusion criteria below) apply, simply confined to the Thames Valley research partnership area.
Target number of participants
UK Sample Size: 49 general practices (46 in the main phase, with a further 3 pilot practices)
Participant exclusion criteria
The practice may not enter the study if ANY of the following apply:
1. Practices using other clinical software systems than EMIS-Web
2. Practices have recently (within the last 2 years) carried out a major audit of OAC prescribing in eligible patients, including the systematic invitation of patients, using bespoke software tool such as GRASP-AF
3. Practices previously involved in a trial concerning anticoagulation in AF.
4. For the main phase of the trial, practices participating in the pilot will be excluded
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
University of Oxford
University of Oxford (UK)
Department of Primary Health Care
Institute of Health Sciences
NIHR (UK) - School for Primary Care Research
Funding Body Type
Funding Body Subtype
Results and Publications
Publication and dissemination plan
Not provided at time of registration
Intention to publish date
Participant level data
Not provided at time of registration
Results - basic reporting
2013 protocol in: http://www.ncbi.nlm.nih.gov/pubmed/24220602
Holt TA, Fitzmaurice DA, Marshall T, Fay M, Qureshi N, Dalton AR, Hobbs FD, Lasserson DS, Kearley K, Hislop J, Jin J, AUtomated Risk Assessment for Stroke in Atrial Fibrillation (AURAS-AF)--an automated software system to promote anticoagulation and reduce stroke risk: study protocol for a cluster randomised controlled trial., Trials, 2013, 14, 385, doi: 10.1186/1745-6215-14-385.