Opportunistic Screening for Atrial Fibrillation in the Pharmacies: A Population-Based Cross-Sectional Study.

INTRODUCTION: Opportunistic screening of atrial fibrillation is a valuable approach to the identification of subjects with unknown or non-symptomatic atrial fibrillation (AF) with the potential of reducing the burden of ischemic stroke in the population. AIM: To evaluate the feasibility of a large-scale screening for atrial fibrillation using a blood pressure monitor (MicrolifeAFIB) endowed with a validated algorithm able to detect AF calculating the irregularity of interval times between heartbeats. METHODS: In this cross-sectional study conducted in 74 pharmacies in Verona participated 3071 people aged 50 years or more. In 6 months, information about drugs, previous diagnoses of cardiovascular diseases, anthropometric and demographic data was recorded, together with the measurement of blood pressure and cardiac rhythm by using the MicrolifeAFIB device. Pharmacists also collected anthropometric and demographic data of the participants, along with information concerning their personal history of cardiovascular disease and the use of antihypertensive and antithrombotic agents. All those who were positive at the screening for atrial fibrillation were referred to their family doctor. RESULTS: The screening revealed 98 subjects (3.2%) positive for AF; 44 of these reported a previous diagnosis of AF and were treated with anticoagulants (77%) or with antiplatelet agents (7%). By logistic regression analysis, age, male sex and heart failure were independently associated with positivity for AF. Association between positive test and previous stroke/TIA was found in the 54 subjects without a previous diagnosis of AF (9% had a previous stroke/TIA). CONCLUSIONS: Opportunistic screening for atrial fibrillation in the pharmacies is feasible and allows to identify a number of subjects with silent, non-previously diagnosed AF, therefore is potentially useful in large-scale projects aimed at the prevention of cardiovascular morbidity and mortality.

The care for chronic heart failure by general practitioners. Results from a clinical audit in Italy.

BACKGROUND: In Italian primary care, chronic heart failure (CHF) patients are mainly managed by general practitioners (GPs). However, there are few studies analysing CHF management challenges in primary care and identifying opportunities for improvement. OBJECTIVES: To describe CHF care as implemented by GPs in the Veneto Region and to identify opportunities for improvement. METHODS: In 2008, using an audit process, 114 Venetian GPs analysed their electronic health records, identified CHF patients and collected clinical and care related information: prevalence, co-morbidity, caring conditions, diagnostic and therapeutic management, and hospitalization. After two training sessions, data on pharmacotherapy were analysed again in 2009. RESULTS: The prevalence of CHF was 1.2% (95% CI: 1.1-1.3%). Diagnostic echocardiography was used in 57% of cases. At baseline, the proportions of patients that used specific medication were: diuretics 88%; angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) 77%, beta-blockers 46% and anti-aldosterone agents 32%. After two training sessions, the use of ACE inhibitors/ARB and beta-blockers increased to 80% and 56%, respectively. Renal failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus and dementia were the most prevalent concomitant diseases, posing specific management problems. Half of the patients were generally visited at home; they were dependent on some kind of care given. CONCLUSION: In Veneto a large number of CHF patients are mainly managed by GPs. Further improvements are necessary to meet standards of care with regard to diagnosis, medication, follow-up and home care. The care situation affected hospitalization and the quality of follow-up visits.

Quality assessment of information about medications in primary care electronic patient record (EPR) systems.

BACKGROUND: Many different brands of primary care electronic patient record (EPR) software are available to general practitioners (GPs). Their ability to support GPs in improving prescribing varies greatly. OBJECTIVE: To assess, using a ten-item tool, the quality of drug information provided by EPR software to support the appropriateness of prescriptions and to propose a list of quality standards for this type of application. METHODS: The eight EPR programmes most used in general practice in Italy were assessed by a multidisciplinary team using the ten-item tool. The tool evaluated information on single drugs and drug safety and information on prescription rules in force. RESULTS: Out of eight EPR programmes assessed, none scored more than 55% of the maximum possible score. Two achieved scores higher than 50%, one scored 48%, four ranged from 32% to 39% and one obtained 22%. Information on drug safety, such as the ability to detect interactions, to monitor laboratory parameters or to get updated information on drug safety was particularly limited. None of the eight EPR programmes contained drug information for patients, but two of them contained drug advertising. CONCLUSIONS: This project highlighted the poor quality of drug information provided by these EPR programmes. The ten-item tool seems suitable for assessing their quality. Based on this analysis, we have proposed a set of ten quality standards for prescribing software.

[Nonvalvular atrial fibrillation: thromboembolic risk assessment and therapy in a general practice population]. / Fibrillazione atriale non valvolare: valutazione del rischio tromboembolico e del trattamento antitrombotico in una popolazione di pazienti in medicina generale.

BACKGROUND: Cardiologists may prescribe antithrombotic therapy to patients with atrial fibrillation (AF), but prescription application mostly depends on general practitioners. The present study aims to assess frequency and appropriateness of antithrombotic therapy in general practice, as a function of thromboembolic risk factors, using the CHADS2 score. METHODS: The computer records of 39 general practitioners were evaluated in order to identify patients with non-valvular AF; therapy and thromboembolic risk factors were recorded. RESULTS: AF was documented in 951 patients; 96 (10.1%) had contraindications to oral anticoagulants. Among the remaining 850 patients, 292 (34.4%) did not receive antithrombotic therapy according to guidelines. In particular, 102 (12.0%) did not receive any antithrombotic treatment. CONCLUSIONS: Among general practitioners of the Veneto region (Italy), the application of guidelines on antithrombotic therapy in non-valvular AF is comparable, or even slightly better than that reported in published cohort studies, but it deserves further improvement. There is a need for targeted educational interventions and a better coordination between cardiologists and general practitioners.

General practitioners' serum creatinine recording styles.

Opportunistic screening of serum creatinine records in the database of general practitioners (GPs) could be a very practical and inexpensive way to pinpoint chronic kidney disease. To get an idea of the consistency of such records, we retrospectively analyzed how 8 GPs recorded serum creatinine values for a total number of 11,711 adults over a 36-month period. While more than 1 test per patient was requested on average during the observation period, unfortunately only 27% of the numerical values tested were recorded; in more than 47% of cases, the GP simply recorded that the value was "normal." This style of data recording prevents any effective use of the serum creatinine values, impeding any estimation of the glomerular filtration rate or appreciation of temporal trends.