Medicine & Health

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  • (2006) Gattellari, Melina; Worthington, John; Zwar, N; Leung, Dominic; Gelder, James; Ukoumunne, O; Anderson, Craig
    Conference Paper
    Background: Warfarin reduces stroke risk associated with non-valvular atrial fibrillation (NVAF) yet is underutilised. Wider use of warfarin is advocated to reduce the risk of mortality and disability. Aims: We have funding to: 1) develop an innovative intervention (Stop-Stroke) to optimise General Practitioners' (GPs) management of NVAF; 2) evaluate Stop-Stroke using a rigorous, clustered RCT; 3) determine the incremental cost per life year saved due to Stop-Stroke. Methods: Random allocation of 110 GPs from across Australia to control or the Stop-Stroke intervention. Stop-Stroke will comprise patient identification and recall, management plans, peer coaching, specialist support and decision tools. Data will be collected from over 2500 patients. Primary Outcome: The proportion of patients with NVAF over 65 who are on 'appropriate' antithrombotic treatment (judged against standardised criteria) will be compared. 'Appropriate treatment' will be determined using standardised medical record audits and blinded expert review. Results and Analysis: Outcomes will be compared, adjusting for clustered randomisation. Analysis will be by intention to treat. Implications: There is no proven implementation strategy for enhancing the prevention of stroke in patients with NVAF. If effective, Stop-Stroke will bridge evidence-practice gaps in managing NVAF and reduce the risk of stroke and disability in the Australian community.

  • (2007) Gattellari, Melina; Worthington, John; Zwar, N; Middleton, S
    Conference Paper
    Background: Optimising the management of NVAF is proving difficult and the potential to reduce stroke risk is yet to be fully realised. Barriers to using anticoagulants need to be addressed. Aims: To describe GP management of NVAF and barriers to the use of warfarin. Methods: Representative survey of Australian GPs. b: Of the 593 GP participants (response = 64.3%), 46.2% reported the experience of an ischaemic stroke in their NVAF patients without anticoagulation. When asked to select treatment for a hypothetical NVAF patient at 'high' risk of stroke, 71.0% appropriately selected warfarin. In the presence of a minor falls risk, 45.4% of GPs selected warfarin. Only 28.8% would anticoagulate the patient at high risk of stroke with a history of recurrent nosebleeds and 16.9% would anti-coagulate such a patient with a treated peptic ulcer bleed. 37.9% agreed that 'it is hard to decide whether the benefits of warfarin outweigh the risks', while only 54.3% agreed they fully understood their patients' views on both the benefits and risks of warfarin. Conclusion: Any strategy to improve the evidence based management of NVAF must address the excessive concerns clinicians have about anticoagulation. We need to reduce anxiety about 'acts of commission' in the management of NVAF.

  • (2006) Gattellari, Melina; Zwar, N; Worthington, John; Middleton, Susan
    Journal Article
    Background and Purpose: Anticoagulation reduces the risk of stroke in nonvalvular atrial fibrillation yet remains underused. We explored barriers to the use of anticoagulants among Australian family physicians. Methods: The authors conducted a representative, national survey. Results: Of the 596 (64.4%) eligible family physicians who participated, 15.8% reported having a patient with nonvalvular atrial fibrillation experience an intracranial hemorrhage with anticoagulation and 45.8% had a patient with known nonvalvular atrial fibrillation experience a stroke without anticoagulation. When presented with a patient at "very high risk" of stroke, only 45.6% of family physicians selected warfarin in the presence of a minor falls risk and 17.1% would anticoagulate if the patient had a treated peptic ulcer. Family physicians with less decisional conflict and longer-standing practices were more likely to endorse anticoagulation. Conclusion: Strategies to optimize the management of nonvalvular atrial fibrillation should address psychological barriers to using anticoagulation.