Strengths and Limitations
This study has several strengths. It is a large and rigorously conducted pragmatic trial using mixed methods to maximize the intervention.This study also has limitations. Practices within the ACT and the decision support software evolved over the course of the trial. However, OR and ACT clinicians viewed these changes favorably, and there was no evidence of temporal heterogeneity. The trial was paused during an EHR transition period, which came with a learning curve for the ACT clinicians that included changing alerts, changing data availability, and new communication modalities. It is difficult to extrapolate the results beyond an academic center. There are multiple factors, including contamination and Hawthorne effects, which may have caused the study to underestimate the benefit of the ACT. A cluster-randomized study would be optimal to estimate the impact of the ACT on outcomes.