Pharmacist-led intervention for older people with atrial fibrillation in long-term care (PIVOTALL study): a randomised pilot and feasibility study.

BackgroundOlder care home residents are a vulnerable group of people with atrial fibrillation (AF) at high risk of adverse health events. The Atrial Fibrillation Better Care (ABC: Avoid stroke; Better symptom management; Cardiovascular and other comorbidity management) pathway is the gold-standard approach toward integrated AF care, and pharmacists are a potential resource with regards to its' implementation. The aim of this study was to determine the feasibility of pharmacist-led medicines optimisation in care home residents, based on the ABC pathway compared to usual care.MethodsIndividually randomised, prospective pilot and feasibility study of older (aged ≥ 65 years) care home residents with AF (ISRCTN14747952); residents randomised to ABC pathway optimised care versus usual care. The primary outcome was a description of study feasibility (resident and care home recruitment and retention). Secondary outcomes included the number and type of pharmacist medication recommendations and general practitioner (GP) implementation.ResultsTwenty-one residents were recruited and 11 (mean age [standard deviation] 85.0 [6.5] years, 63.6% female) were randomised to receive pharmacist-led medicines optimisation. Only 3/11 residents were adherent to all three components of the ABC pathway. Adherence was higher to 'A' (9/11 residents) and 'B' (9/11 residents) components compared to 'C' (3/11 residents). Four ABC-specific medicines recommendations were made for three residents, and two were implemented by residents' GPs. Overall ABC adherence rates did not change after pharmacist medication review, but adherence to 'A' increased (from 9/11 to 10/11 residents). Other ABC recommendations were inappropriate given residents' co-morbidities and risk of medication-related adverse effects.ConclusionsThe ABC pathway as a framework was feasible to implement for pharmacist medication review, but most residents' medications were already optimised. Low rates of adherence to guideline-recommended therapy were a result of active decisions not to treat after assessment of the net risk-benefit

Prevalence and outcomes of atrial fibrillation in older people living in care homes in Wales:a routine data linkage study 2003-2018

OBJECTIVE: To determine atrial fibrillation (AF) prevalence and temporal trends, and examine associations between AF and risk of adverse health outcomes in older care home residents. METHODS: Retrospective cohort study using anonymised linked data from the Secure Anonymised Information Linkage Databank on CARE home residents in Wales with AF (SAIL CARE-AF) between 2003 and 2018. Fine-Gray competing risk models were used to estimate the risk of health outcomes with mortality as a competing risk. Cox regression analyses were used to estimate the risk of mortality. RESULTS: There were 86,602 older care home residents (median age 86.0 years [interquartile range 80.8–90.6]) who entered a care home between 2003 and 2018. When the pre-care home entry data extraction was standardised, the overall prevalence of AF was 17.4% (95% confidence interval 17.1–17.8) between 2010 and 2018. There was no significant change in the age- and sex-standardised prevalence of AF from 16.8% (15.9–17.9) in 2010 to 17.0% (16.1–18.0) in 2018. Residents with AF had a significantly higher risk of cardiovascular mortality (adjusted hazard ratio [HR] 1.27 [1.17–1.37], P < 0.001), all-cause mortality (adjusted HR 1.14 [1.11–1.17], P < 0.001), ischaemic stroke (adjusted sub-distribution HR 1.55 [1.36–1.76], P < 0.001) and cardiovascular hospitalisation (adjusted sub-distribution HR 1.28 [1.22–1.34], P < 0.001). CONCLUSIONS: Older care home residents with AF have an increased risk of adverse health outcomes, even when higher mortality rates and other confounders are accounted for. This re-iterates the need for appropriate oral anticoagulant prescription and optimal management of cardiovascular co-morbidities, irrespective of frailty status and predicted life expectancy

Stop and Go: Barriers and Facilitators to Care Home Research

Barriers to care home research have always existed, but have been thrown into sharp relief by the COVID-19 pandemic. Existing infrastructure failed to deliver the research, or outcomes, which care home residents deserved and we need to look, again, at how these barriers can be taken down. Barriers can be categorised as procedural (encountered before research starts), system (encountered during research) or resident-specific. To tackle these, research regulatory bodies need to adopt a standardised approach to how care home research is developed and designed, reviewed and regulated, and how such approaches can enable recruitment of as wide a range of residents and their representatives as possible, including those without the mental capacity to consent for research. Establishment of local, inter-disciplinary collaborations between universities, general practices, health and social care providers and care homes is another priority. This should be based on pre-existing models such as the 'Living lab' model developed in The Netherlands and now being implemented in the UK and Austria. These changes are critical to develop a sustainable research model. If well designed this will deliver better outcomes for residents and align with the individual and organisational priorities of those who care for them

Integrated care for atrial fibrillation management: The role of the pharmacist.

Within Europe and the Asia-Pacific, the Atrial Fibrillation Better Care (ABC) pathway is the gold standard integrated care strategy for atrial fibrillation management. Atrial fibrillation diagnosis should be Confirmed and Characterized (CC) before implementation of ABC pathway components: (1) 'A'- Anticoagulation/Avoid stroke; (2) 'B'- Better symptom management and (3) 'C'- Cardiovascular and other co-morbidity optimization. Pharmacists have the potential to expedite integrated care for atrial fibrillation across the healthcare continuum -hospital, community pharmacy and general practice. This review summarizes the available evidence base for pharmacist-led implementation of the 'CC to ABC' model

Effectiveness and Safety of Antithrombotic Medication in Patients With Atrial Fibrillation and Intracranial Hemorrhage: Systematic Review and Meta-Analysis

BackgroundFor patients with atrial fibrillation who survive an intracranial hemorrhage (ICrH), the decision to offer oral anticoagulation (OAC) is challenging and necessitates balancing risk of thromboembolic events with risk of recurrent ICrH.MethodsThis systematic review assesses the effectiveness and safety of OAC and/or antiplatelets in patients with atrial fibrillation with nontraumatic ICrH. Bibliographic databases CENTRAL, MEDLINE, EMBASE, and CINAHL were searched. Articles on adults with atrial fibrillation with spontaneous ICrH (intracerebral, subdural, and subarachnoid), receiving antithrombotic therapy for stroke prevention were eligible for inclusion.ResultsTwenty articles (50 470 participants) included 2 randomized controlled trials (n=304)' 8 observational studies, 8 cohort studies, and 2 studies that meta-analyzed individual-level data from observational studies. OAC therapy was associated with a significant reduction in thromboembolic events (summary relative risk [sRR], 0.51 [95% CI, 0.30-0.86], heterogeneity I2=2%; P=0.39, n=5 studies) and all-cause mortality (sRR, 0.52 [95% CI, 0.38-0.71], heterogeneity I2=0; P=0.44, n=3 studies). OAC therapy was not associated with an increased risk of recurrent ICrH (sRR, 1.44 [95% CI, 0.38-5.46], heterogeneity I2=70%, P=0.02, n=5 studies). Nonvitamin K antagonist OACs were more effective at reducing the risk of thromboembolic events (sRR, 0.65 [95% CI, 0.44-0.97], heterogeneity I2=72%, P=0.03, n=3 studies) and were associated with a lower risk of recurrent ICrH (sRR, 0.52 [95% CI, 0.40-0.67], heterogeneity I2=0%, P=0.43, n=3 studies) than warfarin.ConclusionsIn nontraumatic ICrH survivors with atrial fibrillation, OAC therapy is associated with a reduced risk of thromboembolic events and all-cause mortality without significantly increasing risk of recurrent ICrH. This finding is primarily based on observational data, and further larger randomized controlled trials are needed to corroborate or refute these findings

Prevalence of atrial fibrillation and outcomes in older long-term care residents: a systematic review.

Backgroundanticoagulation is integral to stroke prevention for atrial fibrillation (AF), but there is evidence of under-treatment in older people in long-term care (LTC).Objectiveto synthesise evidence on the prevalence and outcomes (stroke, mortality or bleeding) of AF in LTC and the factors associated with the prescription of anticoagulation.Methodsstudies were identified from Medline, CINAHL, PsycINFO, Scopus and Web of Science from inception to 31 October 2019. Two reviewers independently applied the selection criteria and assessed the quality of studies using the Newcastle Ottawa Scale.Resultstwenty-nine studies were included. Prevalence of AF was reported in 21 studies, ranging from 7 to 38%. Two studies reported on outcomes based on the prescription of anticoagulation or not; one reported a reduction in the ischaemic stroke event rate associated with anticoagulant (AC) prescription (2.84 per 100 person years, 95% confidence interval [CI]: 1.98-7.25 versus 3.95, 95% CI: 2.85-10.08) and a non-significant increase in intracranial haemorrhage rate (0.71 per 100 person years, 95% CI: 0.29-2.15 versus 0.65, 95% CI: 0.29-1.93). The second study reported a 76% lower chance of ischaemic stroke with AC prescription and a low incidence of bleeding (n = 4 events). Older age, dementia/cognitive impairment and falls/falls risk were independently associated with the non-prescription of anticoagulation. Conversely, previous stroke/transient ischaemic attack and thromboembolism were independently associated with an increased prescription of anticoagulation.Conclusionestimates of AF prevalence and factors associated with AC prescription varied extensively. Limited data on outcomes prevent the drawing of definitive conclusions. We recommend panel data collection and systems for linkage to create longitudinal cohorts to provide more robust evidence