Is your doctor using this or a gut feel?
http://medicalxpress.com/news/2016-09-tool-incidence.html
A 102-year-old patient, lucid, intelligent
and still with things to accomplish in life, underlined the value of
hospital pharmacist Beata Bajorek's work in stroke prevention.
Associate Professor Bajorek had been paged to give her expert opinion on a recommendation the woman not be prescribed warfarin.
Without it, the patient was at high risk of stroke; with it, she was at high risk of bleeding and other complications.
"She asked all the right questions and understood all my answers and
all the risks. After I'd left the ward, my pager went off again and I
was called back to answer more questions, but in the end the warfarin
was prescribed and dispensed. I was satisfied she knew what she was
doing," says Associate Professor Bajorek, of the Graduate School of
Health at UTS.
Years later, the memory has stayed with A/Prof Bajorek as she continues her research on a web-based tool to help decide the best treatment for people with atrial fibrillation (AF) or heart arrhythmia.
The Computerised Antithrombotic Risk Assessment Tool, or CARAT, uses three measures to assess a patient's suitability for anticoagulant therapy. Importantly, it takes age out of the equation.
Under old prescribing practices, in a time when the pharmaceutical
options for AF came down to warfarin versus aspirin, the centenarian's
age would have disqualified her from receiving warfarin. Warfarin is now
one of a suite of anti-coagulant drugs while aspirin has been proved to
be of no use in stroke prevention for people with AF.
"The older you are the more likely it is that you'll need
anticoagulant therapy. But the older you are, the more difficult it is
for you to use such medicines," she says.
"But just because you're old doesn't automatically mean you should never take warfarin."
The CARAT provides separate checklists for a person's likelihood of
stroke; their risk of having a bleed, internally or externally; and a
medication safety assessment, including a range of factors such as risk
of a fall, cognitive impairment, drug interactions and kidney and liver
function.
"The tool doesn't presume that warfarin or another anticoagulant is
the ideal outcome. The aim is to work out who should be taking such
medicines and who shouldn't be."
When the clinician has entered information for all three assessments,
the CARAT will provide a recommendation on a person's eligibility for
drug therapy and what dose they should take.
A/Prof Bajorek and her collaborators are now working with the second
iteration of the tool, and have done a pilot trial at a Sydney hospital.
Data from that trial showed that, after the application of the tool,
two-thirds of patients were recommended a change to their therapy. That
led to a significant increase in the number of patients prescribed
anti-coagulants (89.2% of study patients).
The majority of health professionals who used CARAT version 2
believed it would help to improve medicine use and thereby help to
reduce the incidence of stroke.
Next steps, pending funding, include a randomised controlled trial
and an expansion of the tool to engage patients in the decision-making
process.
A/Prof Bajorek says she foresees a day when specialist pharmacists
and nurse practitioners as well as GPs would use the tool routinely in
ongoing risk-benefit assessment for medication prescribing in stroke prevention.
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