Anticoagulant usage for primary stroke prevention: a general practitioner survey in local areas of metropolitan Sydney.

We assessed the hypothesis that having a non-English-speaking background (NESB), being very elderly, living alone, and having cognitive impairment were contributing factors to anticoagulant under-utilisation for atrial fibrillation in our local community. A questionnaire was mailed to 532 general practitioners (GPs) in three areas of metropolitan Sydney, Australia. The questionnaire included five case scenarios, regarding either an English-speaking background (ESB) patient, or an NESB patient, each characterised by potential barrier(s) for anticoagulant usage: being (1) elderly; (2) elderly with mild dementia; (3) elderly with mild dementia and living alone; (4) elderly with severe dementia; and (5) very elderly. The overall response rate was 34%. The percentage of GPs recommending anticoagulation was 57%, 50%, 6%, 25% and 23%, respectively, for the ESB scenario, and 48%, 32%, 4%, 14% and 18%, respectively, for the NESB scenario. Eighty-eight percent of GPs rated 'adherence to International Normalized Ration monitoring' as 'very important' in their decision. In conclusion, the factors proposed in our hypothesis were associated with a lower likelihood for anticoagulant prescription for atrial fibrillation.

Evaluation of a medication education program for elderly hospital in-patients.

To improve elderly patients' understanding and safe usage of their medications. English-speaking hospital inpatients aged > or =65 years were recruited. They were self-medicating at home with at least 1 regular medication and had a Mini-Mental State Examination (MMSE) score of at least 20 out of 30. The patients were taught medication details on 3 consecutive days. The patients' medication knowledge was recorded before education and again at a home visit after discharge from hospital. Patient medication knowledge before education showed that participants knew 50% of brand names, dosage and times, 55% of medication purpose, and 15% of major side effects. At follow-up home visits, the relevant figures improved significantly to 90%, 85%, and 25%, respectively (P < or = .05). Similar improvement occurred in the 2 patient groups with an MMSE score of 20 to 24 and 25 to 30 (P = .03). This simple, practical, nursing-staff-conducted program worked well in a hospital setting and resulted in improved medication knowledge, even in patients with mild cognitive impairment.

Safety and low molecular weight heparin in older people in a hospital with ambulatory care.

UNLABELLED: To examine major bleeding and mortality rates of low molecular weight heparin (LMWH) and unfractionated heparin (UFH) for patients with pulmonary embolism (PE) and/or deep vein thrombosis (DVT), a retrospective review of the medical records for 286 patients who presented at a local hospital with PE and/or DVT during the period November 2002-August 2003 was performed. DATA COLLECTED: presence of co-morbidities, concurrent medications, presence, site and severity of bleeding, outcome. Of all the patients, 50.7% received LMWH plus warfarin, 21.0% received UFH plus LMWH plus warfarin, 14.0% received UFH and warfarin, and 9.8% received LMWH only. There were nine minor bleeds and six major bleeds, which resulted in four deaths. Being a hospitalized patient and being age > or =70 years were associated with a major bleed (p<0.05). For hospital inpatients age > or =70 years on UFH and LMWH the number of major bleeds/1000 patient days was 18.9 and 9.2, respectively. The major bleeding rate is comparable if not better than that reported in the literature in our hospital setting where nearly half of the anticoagulation services were provided as ambulatory care. The increased rate of bleeding in the elderly we found is consistent with the findings of previous studies.

Management of pulmonary embolism in the home.

AIM: To describe the characteristics, outcomes and treatment complications of patients with pulmonary embolism (PE) who were treated at home and as outpatients in an ambulatory care program. METHODS: Retrospective descriptive study of patients with PE who were treated in the ambulatory care unit during 2003. Ambulatory care unit data and medical record information were reviewed. Data collected included demographic and clinical data, standard clinical indicators of unplanned admission during treatment program, incidence of major bleeding, recurrent venous thromboembolism (VTE), and death within 3 months of admission into the ambulatory care program. RESULTS: 130 patients with PE were treated: 46% were treated totally as outpatients and 54% as early discharge patients. Mean age was 66.4 years; 61% were women. The program was successfully completed for 89% of patients; one patient was lost to follow-up. There were three episodes of major bleeding (2%; 95% CI, 0.5%-7%), all in patients aged > 70 years. Four patients died (3%; 95% CI, 0.8%-8%) within 3 months of admission into the program, but none in the first week, no death being directly attributable to PE. There were seven episodes of recurrent VTE (5%; 95% CI, 2%-11%). CONCLUSION: Appropriately selected patients with sub-massive PE can be treated as outpatients and in the home. Although the outcome is good in most patients, a significant proportion will require admission, emphasising the need for a well defined protocol and close medical supervision. Further study will more closely define at-risk patients and refine the care pathways.