Abstract
BackgroundGeneral practitioners (GPs) are ideally placed to bridge the widely noted evidence-practice gap between current management of NVAF and the need to increase anticoagulant use to reduce the risk of fatal and disabling stroke in NVAF. We aimed to identify gaps in current care, and asked GPs to identify potentially useful strategies to overcome barriers to best practice.MethodsWe obtained contact details for a random sample of 1000 GPs from a national commercial data-base. Randomly selected GPs were mailed a questionnaire after an advance letter. Standardised reminders were administered to enhance response rates. As part of a larger survey assessing GP management of NVAF, we included questions to explore GPs' risk assessment, estimates of stroke risk and GPs' perceptions of the risks and benefits of anticoagulation with warfarin. In addition, we explored GPs' perceived barriers to the wider uptake of anticoagulation, quality control of anticoagulation and their assessment of strategies to assist in managing NVAF.Results596 out of 924 eligible GPs responded (64.4% response rate). The majority of GPs recognised that the benefits of warfarin outweighed the risks for three case scenarios in which warfarin is recommended according to Australian guidelines. In response to a hypothetical case scenario describing a patient with a supratherapeutic INR level of 5, 41.4% of the 596 GPs (n = 247) and 22.0% (n = 131) would be "highly likely" or "likely", respectively, to cease warfarin therapy and resume at a lower dose when INR levels are within therapeutic range. Only 27.9% (n = 166/596) would reassess the patient's INR levels within one day of recording the supratherapeutic INR. Patient contraindications to warfarin was reported to "usually" or "always" apply to the patients of 40.6% (n = 242/596) of GPs when considering whether or not to prescribe warfarin. Patient refusal to take warfarin "usually" or "always" applied to the patients of 22.3% (n = 133/596) of GPs. When asked to indicate the usefulness of strategies to assist in managing NVAF, the majority of GPs (89.1%, n = 531/596) reported that they would find patient educational resources outlining the benefits and risks of available treatments "quite useful" or "very useful". Just under two-thirds (65.2%; n = 389/596) reported that they would find point of care INR testing "quite" or "very" useful. An outreach specialist service and training to enable GPs to practice stroke medicine as a special interest were also considered to be "quite" or "very useful" by 61.9% (n = 369/596) GPs.ConclusionThis survey identified gaps, based on GP self-report, in the current care of NVAF. GPs themselves have provided guidance on the selection of implementation strategies to bridge these gaps. These results may inform future initiatives designed to reduce the risk of fatal and disabling stroke in NVAF.
Highlights
General practitioners (GPs) are ideally placed to bridge the widely noted evidencepractice gap between current management of Non-valvular atrial fibrillation (NVAF) and the need to increase anticoagulant use to reduce the risk of fatal and disabling stroke in NVAF
The annual risk of stroke for people with NVAF at "high risk" ranges from 8.5% to 18.2% [5]. This risk can be reduced to approximately 3% to 6.6% per year. International guidelines, such as those conjointly published by the American College of Cardiology, the American Heart Association and the European Society of Cardiology [6], recommend warfarin for NVAF, for patients who have more than one moderate risk factor or who have "high risk" factors
Survey items As part of a larger survey [17], we explored issues relevant to the diagnosis and management of NVAF as follows: To our knowledge, GPs have rarely been engaged in the identification of barriers to managing NVAF, nor have they been invited to comment on potentially useful strategies to overcome barriers
Summary
General practitioners (GPs) are ideally placed to bridge the widely noted evidencepractice gap between current management of NVAF and the need to increase anticoagulant use to reduce the risk of fatal and disabling stroke in NVAF. The annual risk of stroke for people with NVAF at "high risk" ranges from 8.5% to 18.2% [5]. With warfarin, this risk can be reduced to approximately 3% to 6.6% per year. This risk can be reduced to approximately 3% to 6.6% per year International guidelines, such as those conjointly published by the American College of Cardiology, the American Heart Association and the European Society of Cardiology [6], recommend warfarin for NVAF, for patients who have more than one moderate risk factor (eg congestive heart failure, hypertension, age greater than 75 years) or who have "high risk" factors (previous stroke, TIA or embolism)
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