Assessment of Web-based education resources informing patients about stroke prevention in atrial fibrillation.

WHAT IS KNOWN AND OBJECTIVE: The importance of 'shared decision-making' is much emphasized in recent clinical guidelines regarding stroke management in atrial fibrillation (AF), more so following the inclusion of non-vitamin K oral anticoagulants (NOACs) among the treatment options. It is important that patients are navigated through balanced and unbiased information about the available treatment options, so as to understand the risk and benefits associated with the therapies, and to enable them to accordingly communicate their concerns and views with their clinicians prior to therapy selection. Given the increasing popularity of the Internet as a source of health information, the specific objectives of this study were to identify what aspects of thromboprophylaxis (antithrombotic treatment options) were most commonly described in these resources, both in terms of content, that is to report the information provided (quantitative) and the underlying themes underpinning this content, and in terms of how this information might guide patient preferences (qualitative). METHOD: Resources for patients were identified via online search engines (Google, Yahoo, Ask, Bing), using the terms 'atrial fibrillation' and 'stroke' combined with patient/consumer information, patient/consumer resources and patient/consumer education. The researchers employed pragmatic (mix-method) approach to analyse the information presented within the resources using manual inductive coding, at two levels of analysis: manifest (reported surface theme or codes that are obvious and are countable) and latent (thematic, interpretative presentation of the content in the data set). RESULTS AND DISCUSSION: In total, 33 resources were reviewed. The 'manifest-level' analysis found that warfarin was the most frequently mentioned thromboprophylactic option among the anticoagulants, being cited in all resources, followed by the NOACs - dabigatran (82·3% of resources), rivaroxaban (73·5%) and apixaban (67·6%). Only one-third of resources discussed the role of stroke risk and/or bleeding risk within the decision-making. At the 'latent-level' analysis, three overarching themes emerged: (i) The practical ease of managing NOACs over warfarin; (ii) Unbalanced explanation about stroke risk versus bleeding risk; and (iii) Individualized antithrombotic therapy selection. In general, the benefit of stroke prevention with anticoagulant use was emphasized less compared to the risk of bleeding. Overall, one in four resources had an implied preference for either warfarin or the NOACs. WHAT IS NEW AND CONCLUSION: The implied inclination of some resources towards particular anticoagulant therapies and imbalanced information about the importance of anticoagulation in AF might misinform and confuse patients. Patients' engagement in shared decision-making and adherence to medicines may be undermined by the suboptimal quality of information provided in the resources. Health professionals have an important role to play in referring patients to appropriate resources to enable patient engagement in shared decision-making when selecting treatment.

Optimizing the management of acute ischaemic stroke: a review of the utilization of intravenous recombinant tissue plasminogen activator (tPA).

WHAT IS KNOWN AND OBJECTIVE: Thrombolysis using intravenous tissue plasminogen activator (tPA) is the only available evidence-based treatment for acute ischaemic stroke; however, its current utilization is very low. Therefore, the aim of this article is to review the literature regarding the use of intravenous tPA for the treatment of acute ischaemic stroke. The review will also compare utilization rates of thrombolysis in different centres across the world and identify key reasons for the underutilization of thrombolysis in stroke. METHODS: MEDLINE, EMBASE, International Pharmaceutical Abstracts (IPA) and Google Scholar were searched for relevant original articles, review papers and other publications over the publication period 1995-2012. RESULTS AND DISCUSSION: The National Institute of Neurological Disorders and Stroke (NINDS) (1995, N = 624 patients) and ECASS III (2008, N = 821 patients) are two pivotal randomized controlled trials providing evidence for the use of intravenous tPA within 3 h or 3-4.5 h from stroke onset, respectively. Both trials have shown that tPA administration decreases disability at 90 days from stroke. Furthermore, a recent pooled analysis of randomized controlled trials (2010, N = 3670 patients) supports these results, highlighting that early stroke treatment is associated with better outcomes, especially when treatment is started within 90 min of stroke onset (but suggesting that the benefit could be afforded within a 4.5-h time window). Three major observational trials, STARS (2000, N = 389 patients), CASES (2005, N = 1135 patients) and SITS-MOST (2007, N = 6483 patients), have reported acceptable safety and efficacy in clinical practice. However, only a small proportion of acute ischaemic stroke patients receive tPA in clinical practice, because of the limited availability of tPA-utilizing sites and suboptimal use of tPA in sites where it is available. WHAT IS NEW AND CONCLUSION: tPA reduces disability in stroke patients. Moreover, acceptable safety has been demonstrated in routine clinical practice. However, tPA is significantly underutilized, and specific efforts are needed to encourage appropriate implementation of the stroke treatment guidelines to optimize the use of this important therapy.

Stroke management: updated recommendations for treatment along the care continuum.

The Australian Clinical Guidelines for Stroke Management 2010 represents an update of the Clinical Guidelines for Stroke Rehabilitation and Recovery (2005) and the Clinical Guidelines for Acute Stroke Management (2007). For the first time, they cover the whole spectrum of stroke, from public awareness and prehospital response to stroke unit and stroke management strategies, acute treatment, secondary prevention, rehabilitation and community care. The guidelines also include recommendations on transient ischaemic attack. The most significant changes to previous guideline recommendations include the extension of the stroke thrombolysis window from 3 to 4.5 h and the change from positive to negative recommendations for the use of thigh-length antithrombotic stockings for deep venous thrombosis prevention and the routine use of prolonged positioning for contracture management.

Barriers to the utilization of thrombolysis for acute ischaemic stroke.

WHAT IS KNOWN AND OBJECTIVE: Thrombolysis is currently the only evidence-based pharmacological treatment available for acute ischaemic stroke (AIS); however, its current utilization is suboptimal (administered to <3% of AIS patients). The aim of this article was to identify the potential barriers to the use of thrombolysis via a review of the available literature. METHODS: Medline, Embase, International Pharmaceutical Abstracts and Google Scholar were searched to identify relevant original articles, review papers and other literature published in the period 1995-2011. RESULTS AND DISCUSSION: Several barriers to the utilization of thrombolysis in stroke have been identified in the literature and can be broadly classified as 'preadmission' barriers and 'post-admission' barriers. Preadmission barriers include patient and paramedic-related factors leading to late patient presentation for treatment (i.e. outside the therapeutic time window for the administration of thrombolysis). Post-admission barriers include in-hospital factors, such as suboptimal triage of stroke patients and inefficient in-hospital acute stroke care systems, a lack of appropriate infrastructure and expertise to administer thrombolysis, physician uncertainty in prescribing thrombolysis and difficulty in obtaining informed consent for thrombolysis. Suggested strategies to overcome these barriers include public awareness campaigns, prehospital triage by paramedics, hospital bypass protocols and prenotification systems, urgent stroke-unit admission, on-call multidisciplinary acute stroke teams, urgent neuroimaging protocols, telestroke interventions and risk-assessment tools to aid physicians when considering thrombolysis. Additionally, greater pharmacists' engagement is warranted to help identify the people at risk of stroke and support preventative strategies, and provide the public with information regarding the recognition of stroke, as well as facilitate the access and use of thrombolysis. WHAT IS NEW AND CONCLUSION: The most effective interventions appear to be those comprising several strategies and those that target more than one barrier simultaneously. Therefore, optimal utilization of thrombolysis requires a systematic, integrated multidisciplinary approach across the continuum of acute care.

Warfarin management after discharge from hospital: a qualitative analysis.

WHAT IS KNOWN AND OBJECTIVE: Warfarin is recognized as a high-risk medication for adverse events, and the risks are particularly heightened in the period immediately following a patient's discharge from hospital. This qualitative study aimed to explore the experiences of Australian patients and healthcare professionals of warfarin management in the post-discharge period and identify the benefits and deficiencies of existing systems, to inform the development of a model for a new collaborative post-discharge warfarin management service. METHODS: Healthcare professionals, professional organization representatives and patients recently discharged from hospital taking warfarin (consumers) were recruited via purposive, criterion-based sampling within two Australian states. Semi-structured telephone interviews were conducted between August and October 2008 using standard discussion guides. Data were manually analyzed to identify emergent themes using a phenomenological approach. RESULTS: Forty-seven participants were involved in the telephone interviews. Three major themes emerged: (i) appropriate warfarin education is integral to effective warfarin management, (ii) problems occur in communication along the continuum of care and (iii) home-delivered services are valuable to both patients and healthcare professionals. DISCUSSION: Although high-quality warfarin education and effective communication at the hospital-community interface were identified as important in post-discharge warfarin management, deficiencies were perceived within current systems. The role of home-delivered services in ensuring timely follow-up and promoting continuity of care was recognized. Previous studies exploring anticoagulation management in other settings have identified similar themes. Post-discharge management should therefore focus on providing patients with a solid foundation to minimize future problems. WHAT IS NEW AND CONCLUSION: Addressing the three identified facets of care within a new, collaborative post-discharge warfarin management service may address the perceived deficiencies in existing systems. Improvements may result in the short- and longer-term health outcomes of patients discharged from hospital taking warfarin, including a reduction in their risk of adverse events.

Utilization of evidence-based therapy for the secondary prevention of acute coronary syndromes in Australian practice.

AIM: To review and document the current utilization of pharmacotherapy for the secondary prevention of acute coronary syndromes (ACS) in patients discharged from an Australian hospital. METHODS: A retrospective cross-sectional study was conducted at a major Sydney teaching hospital. Patients with either a primary or secondary diagnosis of acute coronary syndrome were identified from medical records over a 4-month period (January-April 2007). A range of clinical data was extracted from medical records, including medical history, clinical presentation and pharmacotherapy both on admission and at discharge. This audit focussed on the use of four guideline-recommended therapies: aspirin +/- clopidogrel, beta blockers, statins and ACE-inhibitors (ACE-I), as well as the utilization of multiple antithrombotics. RESULTS: Data pertaining to a total of 169 patients was extracted and reviewed. The mean age of the study population was 65.9 years and 71% of the population was male. Non-ST-segment elevation myocardial infarction (Non-STEMI) accounted for 42% of the admissions, whereas 33.7% and 24.3% of the patients were respectively admitted for ST-segment elevation myocardial infarction (STEMI) or unstable angina. After accounting for reported contra-indications, overall, 96% of the eligible patients received antithrombotics comprising of at least aspirin, and 79% of eligible patients received aspirin plus clopidogrel. Furthermore, 82% of eligible patients received a beta-blocker at discharge, 86% a statin and 79% received either an ACE-I or angiotensin-II receptor antagonist. Compared with patients who presented with myocardial infarction (with or without ST-segment elevation), those presenting with unstable angina were less likely to receive a beta-blocker (OR = 0.19, 95%-CI: 0.08-0.48) or an ACE-agent (OR = 0.15, 95%-CI: 0.06-0.39) at discharge. Patients over 65 years of age were also less likely to receive a beta-blocker (OR = 0.35, 95%-CI: 0.14-0.89) or an ACE-agent (OR = 0.28 95%-CI: 0.11-0.70) at discharge, but were also less likely to receive the combination of aspirin plus clopidogrel (OR = 0.19, 95%-CI: 0.07-0.54) at discharge, compared with younger patients. Men were more likely to be discharged on a statin (OR = 3.36, 95%-CI: 1.11-10.15), compared with women. Only six patients (4%) received three or more antithrombotics at discharge; five of these received the triple combination of aspirin, clopidogrel and warfarin. CONCLUSIONS: There is a good adherence to evidence-based guidelines for the secondary prevention of ACS in this local setting. However, there is some potential underutilization in the older population and patients presenting with unstable angina. Variability in the use of oral anticoagulants alongside dual antiplatelet therapy indicates there is potentially a need for further guidance regarding the prescription of antithrombotics in those requiring poly-therapy.

Failure to weigh patients in hospital: a medication safety risk.

Often patients are not weighed in hospital. Failure to weigh patients prescribed renally excreted drugs may correlate to adverse drug events. We carried out a cross-sectional study of patients prescribed common renally excreted drugs (heparin, enoxaparin and gentamicin), admitted to two wards at Royal North Shore Hospital, Sydney over 3 months. Of all patients surveyed, 28% (22/78) in the orthopaedic ward and 22% (27/124) in the medical ward were weighed. Among those prescribed therapeutic doses of the study drugs, 25% (3/12) in the orthopaedic ward and 27% (7/26) in the medical ward were weighed. Patients prescribed therapeutic anticoagulation who were not weighed experienced more haemorrhagic complications than patients who were weighed (P = 0.03). Patients prescribed renally excreted drugs in hospital are frequently not weighed. This is associated with reduced medication safety.