Abstract
BackgroundAnticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation.MethodsWe carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations.ResultsOne hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86–1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97).ConclusionsSpecialist feed-back in addition to an educational session did not increase the uptake of anticoagulation in patients with AF.Trial registrationANZCTRN12611000076976 Retrospectively registered.
Highlights
Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability
We evaluated the impact of specialist communication about stroke prevention exclusively in atrial fibrillation (AF), providing General Practitioner (GP) with the opportunity to discuss specific patient cases and barriers to management with a medical peer, followed by expert decisional support to consolidate decision making
Recruitment Of 5601 randomly selected GPs located around Australia, we contacted 5578 of whom 948 (17.0%) expressed interest in receiving further information
Summary
Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. Affecting 1 in 20 people over the age of 65 and one in 10 people older than 75 years [1], atrial fibrillation (AF) is associated with a five-fold increased risk of ischaemic stroke [2]. Gattellari et al BMC Family Practice (2020) 21:102. Evidence from randomised controlled trials confirms anticoagulation as the most effective antithrombotic to prevent stroke in AF [11]. At least one-half of people with AF do not receive anticoagulation and up to 85% experiencing an acute ischaemic stroke are either not anticoagulated or have sub-therapeutic anticoagulation [5, 7, 8]. Around 2% of people with AF have an absolute contraindication to oral anticoagulants [10]
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