Assessing the Appropriateness of Oral Anticoagulation for Atrial Fibrillation in Advanced Frailty: Use of Stroke and Bleeding Risk-Prediction Models.

BACKGROUND: Atrial fibrillation (AF) is common among frail older adults. Oral anticoagulation (OAC) is particularly challenging for these due to overlapping stroke and bleeding risk factor profiles. OBJECTIVE: To compare the utility of stroke and haemorrhage risk-prediction instruments in the treatment of AF among frail older adults. DESIGN: Cross-sectional study. SETTINGS AND PARTICIPANTS: Frail residents in four nursing homes with a Clinical Frailty Scale score ≥5 (median 7±0). MEASUREMENTS: The prevalence of AF was assessed by ECG and chart review. Stroke (CHADS2 and CHA2DS2-VASc) and bleeding (HASBLED and HEMORR2HAGES) risk-prediction scores were then applied. A validated, risk-based, colour-coded decision support tool, incorporating these instruments, was then used to create a risk matrix and assess the appropriateness of OAC. RESULTS: In total, 225 patients were included. The distribution of CFS scores was similar irrespective of AF status. In all, 86/225 (38%) had any history of AF. Of these, only 15/86 (17%) were prescribed OAC. All those in AF scored ≥2 on the CHA2DS2-VASc. One-third also scored high-risk of bleeding using HAS-BLED or HEMORR2HAGES. Risk-prediction scores were similar between those with 'known' (documented) and occult (only on ECG) AF. The colour-coded decision tree suggested that OAC would be recommended for the majority in AF when HAS-BLED (60/86, 70%) was used as the bleeding risk-prediction instrument. Despite this, only 12/60 (20%) were anticoagulated. When HEMORR2HAGES was incorporated instead, one patient was advised OAC, the remainder no treatment (57%) or an antiplatelet (42%). DISCUSSION: Stroke risk was high and bleeding risk levels comparatively low, suggesting that the balance of risk may favor OAC for AF in this cohort of patients with advanced frailty. Despite this and the high prevalence of AF, OAC prescription rates were low. The decision-support tool used showed mixed results, depending on the bleeding-risk score incorporated, suggesting that while useful, they should not replace clinical judgement.

A laboratory for testing the interoperability of telehealth systems.

Interoperability allows telehealth equipment to interact to achieve predictable results. To address the need for telehealth interoperability, the Alberta Research Council has been working with the Alberta Health and Wellness organization in Canada, and others, to create guidelines and a facility for testing telehealth equipment for compliance with technical interoperability standards. The laboratory consists of two rooms (7 m x 7 m) in a new building. The rooms are wired with easy-to-configure copper and fibre networks for telephone, Switch-56, ISDN, ATM, wireless and satellite services. One room specializes in teleconsultation and tele-education, while the other has facilities for teleradiology and telemonitoring. The rooms are interconnected in order to perform interoperability tests between realtime and store-and-forward equipment. The laboratory was piloted in the summer of 1999.

Telemedicine and security. Confidentiality, integrity, and availability: a Canadian perspective.

The health care system is undergoing major reform, characterized by organized delivery systems (regionalization, decentralization, devolution, etc); shifts in care delivery sites; changing health provider roles; increasing consumer responsibilities; and accountability. Rapid advances in information technology and telecommunications have led to a new type of information infrastructure which can play a major role in this reform. Compatible health information systems are now being integrated and connected across institutional, regional, and sectorial boundaries. In the near future, these information systems will readily be accessed and shared by health providers, researchers, policy makers, health consumers, and the public. SECURITY is a critical characteristic of any health information system. This paper will address three fields associated with SECURITY: confidentiality, integrity, and availability. These will be defined and examined as they relate to specific aspects of Telemedicine, such as electronic integrated records and clinical databases; electronic transfer of documents; as well as data storage and disposal. The guiding principles, standards, and safeguards being considered and put in place to ensure that telemedicine information intrastructures can protect and benefit all stakeholders' rights and needs in both primary and secondary uses of information will be reviewed. Implemented, proposed, and tested institutional, System, and Network solutions will be discussed; for example, encryption-decryption methods; data transfer standards; individual and terminal access and entry I.D. and password levels; smart card access and PIN number control; data loss prevention strategies; interference alerts; information access keys; algorithm safeguards; and active marketing to users of standards and principles. Issues such as policy, implementation, and ownership will be addressed.