Underutilization of antithrombotic therapy in elderly rural patients with atrial fibrillation.

BACKGROUND: Antithrombotic agents are underutilized in elderly patients with atrial fibrillation. In a peer-review audit of antithrombotic use in Missouri, rural patients were given antithrombotic therapy less often than rural patients for unclear reasons. METHODS AND RESULTS: The charts of 597 hospitalized Medicare patients discharged between October 1, 1993, and December 31, 1994, from urban and rural hospitals in Missouri were reviewed. In addition to antithrombotic therapy prescribed at the time of discharge, patient and physician information, relative contraindications to antithrombotic therapy, and risk factors for stroke were identified. Rural and urban patients were similar in terms of age, sex, and risk factors for stroke. At least one stroke risk factor was noted in 87% of rural patients and in 84% of urban patients. Urban patients were more likely to have a relative contraindication to antithrombotic therapy compared with rural patients (66% vs 54%, P =.04) but received antithrombotic therapy more often (58% vs 47%, P =.02). Cardiologists prescribed antithrombotic therapy significantly more often than noncardiologists (69% vs 52%, P =.003). CONCLUSIONS: Elderly rural patients with atrial fibrillation receive antithrombotic therapy less frequently than urban patients despite having a similar high-risk profile and fewer relative contraindications. Primary care physicians prescribe antithrombotic therapy less often than cardiologists, which is one of the reasons for this underutilization.

Assessment of the anti-G straining maneuver (AGSM) skill performance and reinforcement program.

Initial high-G centrifuge training of USAF fast jet pilots was instituted in 1985. Also, since the mid-1980's, pilot awareness of G-induced loss of consciousness (G-LOC) has been enhanced by briefings, videotapes, and safety articles. Aircraft accidents caused by an improperly performed anti-G straining maneuver (AGSM), however, continue to occur. Deficiencies in the AGSM of pilots in flight have not been systematically studied. A test program to reinforce the proper performance of the AGSM in flight was initiated in the United States Air Forces Europe (USAFE) in 1993. Head-up display videotapes (HUD tapes) were recorded during flight and critiqued during debrief by flight leads for AGSM technique and continuity. Questionnaires were completed by F-16, F-15C, and F-15E pilots assigned to USAFE: 78 surveys were completed out of 110 distributed (71%). There were 57 pilots (73%) who reported one or more problems with their AGSM: 33 noted that the timing of their breathing was too quick (< 2 s cycle), 11 that their breathing was too slow (> 4 s), 9 that inhalation was too long, 18 occasionally did not "get the jump on the Gs," and 34 frequently or occasionally talked during +Gz exposures. Of the 105 reported deficiencies, 67 (64%) were mostly or completely corrected: 30/33 (91%) if the timing of breathing was too quick, 8/11 (73%) if too slow, 5/9 (56%) if inhalation too long, 12/18 (67%) "jump on the Gs," and 12/34 (35%) if they talked. This program was most successful in remediating timing problems with the AGSM.