Key PointsQuestionAre system-level direct oral anticoagulant (DOAC) therapy management services associated with anticoagulation-related outcomes for patients with atrial fibrillation (AF) relative to usual care?FindingsThis cohort study evaluated 44 746 patients with AF initiating DOACs (managed using 2 different system-level care models or usual care) and warfarin therapy (managed by warfarin clinics). Patients receiving DOACs vs warfarin were less likely to experience adverse outcomes overall, but neither system-level DOAC management service was appreciably superior to usual DOAC care.MeaningRandomized trials are needed to confirm the findings of this study, which suggest that there is no effectiveness advantage to system-level DOAC therapy management services vs usual care for patients with AF.