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Improving the outcomes of anticoagulation


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Jackson, Shane L 2004 , 'Improving the outcomes of anticoagulation', PhD thesis, University of Tasmania.

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A number of studies have indicated that adverse events from anticoagulants are
significant contributors to health care system expenditure. Adverse events
comprise three groups: under-use, over-use and misuse. In Australia, it was
estimated in 1992 that adverse events from warfarin cost $100 million in direct
hospital costs alone.
Part one of this thesis gives an overview of atrial fibrillation (AF) and the
use of antithrombotics. This part provides comprehensive background on the
significance of AF and its contribution to stroke and details the extensive
evidence of antithrombotic drug efficacy in the prevention of stroke in AF. Despite overwhelming evidence that antithrombotics are effective in
reducing the risk of stroke in AF, they remain under-utilised. Studies conducted
internationally and nationally have shown that, in general, less than half of
eligible patients receive anticoagulants. Described in part two of this thesis is two
studies aimed at improving the use of antithrombotics for stroke prevention in AF.
A nationwide survey of a random sample of general practitioners (GPs),
cardiologists and other specialists was undertaken assessing barriers to the use of
anticoagulants for stroke prevention in AF. This survey identified a number of
key barriers to the use of anticoagulants and identified a number of key
interventions to improve the prescribing of anticoagulants. Targeting the
identified barriers to the use of anticoagulants, an educational intervention
directed at GPs was initiated, aimed at improving the prescribing of
antithrombotics in AF. The educational intervention utilised mailed guidelines
and the process of academic detailing. The effect of the intervention was analysed
using a controlled before and after study design. The educational intervention significantly improved the use of anticoagulants, but recognised that there is still
significant room for more improvement.
Findings of the nationwide survey of doctors identified portable
International Normalised Ratio (INR) monitors as a key intervention to improve
the prescribing of anticoagulants in AF, and improve the management of existing
patients on anticoagulants. Part three of this thesis evaluated the use of portable
INR monitors in three practice settings: an outpatient hospital anticoagulant
clinic, rural general practices and rural community pharmacies. The portable INR
monitors performed well in these three settings. They were found to give accurate
and reproducible results when compared to pathology testing and the use of the
monitors was well received by GPs, community pharmacists and patients.
Findings from these three studies show that the use of portable INR monitors has
the potential to significantly reduce health care expenditure associated with
anticoagulant therapy, and provides a number of alternative models for
anticoagulant management in the community setting. The final part of the thesis was an intervention aimed at reducing the
incidence of bleeding complications amongst patients commenced on warfarin in
hospital and discharged to GP care. Patients were randomised to a control or
intervention group, where the control group received standard care from their GP
and the intervention group received education after discharge and alternate day
INR monitoring using a portable INR monitor for four visits after discharge. The
intervention significantly reduced the incidence of bleeding complications
assessed 90 days after initial discharge, and provided a reproducible model of care
for patients commenced on warfarin in hospital and discharged to the community. The body of work conducted in this thesis provides a number of system
solutions aimed at reducing the incidence of anticoagulant-related misadventure
and under-use. It is clear that while this thesis provides preliminary evidence that
adverse events associated with warfarin can be reduced, more work targeting the
use of portable INR monitors in the initiation of warfarin therapy and transfer to
the community setting, and education for stroke prevention in AF should

Item Type: Thesis - PhD
Authors/Creators:Jackson, Shane L
Keywords: Atrial fibrillation, Anticoagulants (Medicine)
Copyright Holders: The Author
Copyright Information:

Copyright 2004 the Author - The University is continuing to endeavour to trace the copyright
owner(s) and in the meantime this item has been reproduced here in good faith. We
would be pleased to hear from the copyright owner(s).

Additional Information:

Thesis (Ph.D.)--University of Tasmania, 2004. Includes bibliographical references

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