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Optimizing the Use of Antithrombotic Therapy for Atrial Fibrillation in Older People: A Pharmacist-Led Multidisciplinary Intervention

Authors

  • Beata V. Bajorek BPharm, DipHospPharm, PhD,

    1. From the *Faculty of Pharmacy, University of Sydney, Sydney, Australia; Departments of Aged Care and Rehabilitation, Pharmacy, and §Clinical Pharmacology, Royal North Shore Hospital, New South Wales, Australia.
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  • Ines Krass BPharm, DipHospPharm, PhD,

    1. From the *Faculty of Pharmacy, University of Sydney, Sydney, Australia; Departments of Aged Care and Rehabilitation, Pharmacy, and §Clinical Pharmacology, Royal North Shore Hospital, New South Wales, Australia.
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  • Susan J. Ogle MBBS FRACP,

    1. From the *Faculty of Pharmacy, University of Sydney, Sydney, Australia; Departments of Aged Care and Rehabilitation, Pharmacy, and §Clinical Pharmacology, Royal North Shore Hospital, New South Wales, Australia.
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  • Margaret J. Duguid BPharm,

    1. From the *Faculty of Pharmacy, University of Sydney, Sydney, Australia; Departments of Aged Care and Rehabilitation, Pharmacy, and §Clinical Pharmacology, Royal North Shore Hospital, New South Wales, Australia.
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  • Gillian M. Shenfield DM

    1. From the *Faculty of Pharmacy, University of Sydney, Sydney, Australia; Departments of Aged Care and Rehabilitation, Pharmacy, and §Clinical Pharmacology, Royal North Shore Hospital, New South Wales, Australia.
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  • This project was funded by the Commonwealth Department of Health and Aging (Australia), Quality Use of Medicines Evaluation Program.

Address correspondence to Dr. Beata V. Bajorek, Faculty of Pharmacy (A15), Science Road, University of Sydney, NSW 2000 Australia. E-mail: beatab@pharm.usyd.edu.au

Abstract

Objectives: To develop, implement, and evaluate a pharmacist-led multidisciplinary intervention in a hospital setting that would optimize antithrombotic use in elderly atrial fibrillation patients. The hypothesis that there would be an increase in the proportion of patients receiving antithrombotic therapy at discharge was tested.

Design: Evidence-based algorithms were developed to define the criteria (stroke risk vs contraindications) by which an elderly patient's requirement for antithrombotic therapy was assessed.

Setting: A major Sydney teaching hospital.

Participants: Two hundred eighteen consecutively admitted elderly patients (mean age 85.2) were recruited over a 6-month period.

Intervention: A pharmacist-coordinated multidisciplinary review process was implemented to coordinate risk assessments and subsequently recommend appropriate antithrombotic therapy, as per the algorithms.

Measurements: The proportion of patients receiving antithrombotic therapy was assessed on admission (preintervention), at discharge (postintervention), and postdischarge (follow-up at 3 and 6 months).

Results: As a result of the intervention, 78 patients (35.8%) required changes to their existing antithrombotic therapy. Of these changes, 60 (76.9%) were “upgrades” to more-effective treatment options (e.g., from no therapy to any agent or from aspirin to warfarin). The remaining 18 (23.1%) changes were “downgrades” to less-effective, albeit safer, options. Despite a significant increase in anti thrombotic use overall (59.6% vs 81.2%, P<.001), fewer patients received warfarin postintervention, after having been assessed as inappropriate candidates (20.7% vs 17.4%, P=.39).

Conclusion: A pharmacist-led multidisciplinary process was successfully developed and implemented within the hospital setting to increase overall antithrombotic use. Having addressed some of the known barriers and limitations to warfarin use, these algorithms may allow allied health workers, patients, and clinicians to work collaboratively to achieve optimal and, importantly, appropriate (i.e., safe and effective) antithrombotic use in at-risk elderly patients.

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