Antithrombotic prescribing in atrial fibrillation: application of a prescribing indicator and multidisciplinary feedback to improve prescribing.
BACKGROUND
Atrial fibrillation is common in older people, and is associated with an increased risk of ischaemic stroke. Antithrombotic therapy reduces stroke-risk, but is known to be under-prescribed.


OBJECTIVE
To use an evidence-based indicator to audit antithrombotic prescribing for older hospital inpatients with atrial fibrillation, and to assess whether feedback of audit results to hospital staff increases antithrombotic use.


METHODS
Cross-sectional notes-based audits, before and after feedback.


METHODS
Six Aged Care and three General Medicine units at nine Australian public teaching hospitals between September 1998 and May 1999.


METHODS
1416 hospital inpatients aged 65 years and over (median age 81).


METHODS
Medication charts were reviewed to identify patients prescribed digoxin or amiodarone. Presence of atrial fibrillation was confirmed by review of the patients' medical notes. To be considered appropriate, patients with atrial fibrillation had to be receiving either warfarin or aspirin (or both), or have documented contraindications to both agents. Feedback of audit results was provided to medical, pharmacy and nursing staff at multidisciplinary meetings. Changes in antithrombotic prescribing 4-8 weeks and 6 months after feedback were assessed. Prescribing 8 weeks prior to feedback was assessed retrospectively.


RESULTS
Appropriateness of the decision to prescribe (or not prescribe) antithrombotic therapy increased from 81/112 (72%) immediately prior to feedback to 97/105 (92%) 4-8 weeks later (P<0.0001). Six months after feedback, appropriateness of prescribing declined slightly, to 85% (p=0.36). Over the 8 weeks prior to feedback, appropriateness of prescribing did not change (74% versus 77%, p=0.80). Increased aspirin prescribing accounted for most of the improvement in antithrombotic use after feedback, while warfarin continued to be under-used.


CONCLUSIONS
Antithrombotics were under-prescribed for older patients with atrial fibrillation. Audit and multidisciplinary feedback resulted in increased antithrombotic prescribing. The intervention had a greater impact on aspirin prescribing compared with warfarin.
Elliott
Rohan A
RA
Centre for Applied Gerontology, Bundoora Extended Care Centre, Bundoora VIC 3083, Australia. rohan.elliott@armc.org.au
Woodward
Michael C
MC
Oborne
C Alice
CA
D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D001241:Aspirin / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D001315:Australia; D054869:Clinical Audit / Q000592:standards*; D003430:Cross-Sectional Studies; D019317:Evidence-Based Medicine; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006784:Hospitals, Teaching; D006801:Humans; D033183:Interdisciplinary Communication; D017410:Practice Guidelines as Topic / Q000592:standards; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D014859:Warfarin / Q000627:therapeutic use
D000925:Anticoagulants; D005343:Fibrinolytic Agents; D014859:Warfarin; D001241:Aspirin