Overall, the committee concluded that this change is one that is worth making. One potential concern discussed by the committee is that ORBIT does not include all of the modifiable risk factors included in HAS-BLED so does not serve as a reminder of these to clinicians. However, the committee considered that fully investigating modifiable risk factors is established clinical practice, regardless of the tool used. Another potential challenge is that ORBIT is not the recommended bleeding risk tool for other conditions (such as venous thromboembolism). Therefore, an initial transition period may be needed for training and education in both primary and secondary care while healthcare professionals become familiar with the tool. This will have a resource impact, although it will be time limited. The committee also noted that use of the ORBIT tool, and access to online versions, is straightforward. Finally, the committee also discussed that, unlike HAS-BLED, ORBIT is not embedded in GP systems, which may cause some initial practical difficulties. However, because this will involve changes to centralised software, it is thought that it will be straightforward to implement and ORBIT will quickly be included in GP systems. Neither tool is included in hospital systems although both are widely available on smartphone apps. Return to recommendations Stroke prevention Why the committee made the recommendations Evidence from an analysis of several studies showed that direct-acting oral anticoagulants are more effective than warfarin for a number of outcomes. An economic model also showed that they offered a better balance of benefits to costs than warfarin. There were no studies directly comparing the direct-acting anticoagulants head-to-head but indirect comparisons based on the clinical evidence showed that the different direct-acting oral anticoagulants offered different benefits depending on the outcome considered. 