title: Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention.
abstract: OBJECTIVE
  To develop, implement, and evaluate a pharmacist-led multidisciplinary intervention in a hospital setting that would optimize antithrombotic use in elderly atrial fibrillation patients. The hypothesis that there would be an increase in the proportion of patients receiving antithrombotic therapy at discharge was tested.
  
  
  METHODS
  Evidence-based algorithms were developed to define the criteria (stroke risk vs contraindications) by which an elderly patient's requirement for antithrombotic therapy was assessed.
  
  
  METHODS
  A major Sydney teaching hospital.
  
  
  METHODS
  Two hundred eighteen consecutively admitted elderly patients (mean age 85.2) were recruited over a 6-month period.
  
  
  METHODS
  A pharmacist-coordinated multidisciplinary review process was implemented to coordinate risk assessments and subsequently recommend appropriate antithrombotic therapy, as per the algorithms.
  
  
  METHODS
  The proportion of patients receiving antithrombotic therapy was assessed on admission (preintervention), at discharge (postintervention), and postdischarge (follow-up at 3 and 6 months).
  
  
  RESULTS
  As a result of the intervention, 78 patients (35.8%) required changes to their existing antithrombotic therapy. Of these changes, 60 (76.9%) were "upgrades" to more-effective treatment options (e.g., from no therapy to any agent or from aspirin to warfarin). The remaining 18 (23.1%) changes were "downgrades" to less-effective, albeit safer, options. Despite a significant increase in anti thrombotic use overall (59.6% vs 81.2%, P<.001), fewer patients received warfarin postintervention, after having been assessed as inappropriate candidates (20.7% vs 17.4%, P=.39).
  
  
  CONCLUSIONS
  A pharmacist-led multidisciplinary process was successfully developed and implemented within the hospital setting to increase overall antithrombotic use. Having addressed some of the known barriers and limitations to warfarin use, these algorithms may allow allied health workers, patients, and clinicians to work collaboratively to achieve optimal and, importantly, appropriate (i.e., safe and effective) antithrombotic use in at-risk elderly patients.
authors.affiliation: Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia. beatab@pharm.usyd.edu.au
authors.forename: Beata V
authors.initials: BV
authors.lastname: Bajorek
authors.forename: Ines
authors.initials: I
authors.lastname: Krass
authors.forename: Susan J
authors.initials: SJ
authors.lastname: Ogle
authors.forename: Margaret J
authors.initials: MJ
authors.lastname: Duguid
authors.forename: Gillian M
authors.initials: GM
authors.lastname: Shenfield
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000097:blood / Q000150:complications / Q000188:drug therapy*; D000075202:Contraindications; D003299:Cooperative Behavior; D019317:Evidence-Based Medicine; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006784:Hospitals, Teaching; D006801:Humans; D020766:Intracranial Embolism / Q000097:blood / Q000517:prevention & control; D008297:Male; D009517:New South Wales; D010348:Patient Care Team; D010351:Patient Discharge; D010595:Pharmacists; D012306:Risk; D018570:Risk Assessment; D014859:Warfarin / Q000009:adverse effects / Q000627:therapeutic use
chemical_list: D005343:Fibrinolytic Agents; D014859:Warfarin; D001241:Aspirin