Basia Diug

Clinical Outcomes Associated with Medication Regimen Complexity in Older People: A Systematic Review

To systematically review clinical outcomes associated with medication regimen complexity in older people.

The Unrecognized Psychosocial Factors Contributing to Bleeding Risk in Warfarin Therapy

Background and Purpose— Warfarin is an effective drug for the prevention of thromboembolism in the elderly. The major risk for patients taking warfarin is bleeding. We aimed to assess the impact of psychosocial factors, including mood, cognition, social isolation, and health literacy on warfarin instability among community-based elderly patients. Methods— A case–control study was conducted between March 2008 and June 2009 in a community-based setting. Cases were patients previously stabilized on warfarin who recorded an international normalized ratio ≥6.0. Control subjects were patients whose international normalized ratio measurement was maintained within the therapeutic range. Patient interviews investigated potential predisposing factors to elevated International Normalized Ratio levels. Results— A total of 486 patients were interviewed: 157 cases and 329 control subjects, with an approximate mean age of 75 years. Atrial fibrillation was the most common primary indication. Adjusted multivariate logistic regression revealed impaired cognition (OR, 1.9; 95% CI, 1.0 to 3.6), depressed mood (OR, 2.2; 95% CI, 1.2 to 3.9), and inadequate health literacy (OR, 4.0;95% CI, 2.1 to 7.4) were associated with increased risk of an elevated International Normalized Ratio. Conclusions— This study identified impaired cognition, depressed mood, and inadequate health literacy as risk factors for warfarin instability. These had a similar impact to well-recognized demographic, clinical, and medication-related factors and are prevalent among the elderly. These findings suggest that elderly patients prescribed warfarin should be reviewed regularly for psychosocial deficits.

Evaluating the use of twitter as a tool to increase engagement in medical education

Background: Social media is regularly used by undergraduate students. Twitter has a constant feed to the most current research, news and opinions of experts as well as organisations. Limited evidence exists that examines how to use social media platforms, such as Twitter, effectively in medical education. Furthermore, there is limited evidence to inform educators regarding social medias potential to increase student interaction and engagement. Aim: To evaluate whether social media, in particular Twitter, can be successfully used as a pedagogical tool in an assessment to increase student engagement with staff, peers and course content. Methods: First year biomedical science students at Monash University completing a core public health unit were recruited into the study. Twitter-related activities were incorporated into the semester long unit and aligned with both formative and summative assessments. Students completed a structured questionnaire detailing previous use of social media and attitudes towards its use in education post engagement in the Twitter-specific activities. Likert scale responses compared those who participated in the Twitter activities with those who did not using students t-test. Results: A total of 236 (79.4%) of invited students participated in the study. Among 90% of students who reported previous use of social media, 87.2% reported using Facebook, while only 13.1% reported previous use of Twitter. Social media was accessed most commonly through a mobile device (49.1%). Students actively engaging in Twitter activities had significantly higher end-of-semester grades compared with those who did not [Mean Difference (MD) = 3.98, 95% CI 0.40, 7.55]. Students perceived that the use of Twitter enabled greater accessibility to staff, was a unique method of promoting public health, and facilitated collaboration with peers. Discussion: Use of social media as an additional, or alternate, teaching intervention is positively supported by students. Specific use of micro-blogs such as Twitter can promote greater student-staff engagement by developing an ongoing academic conversation.

Spontaneously reported haemorrhagic adverse events associated with rivaroxaban and dabigatran in Australia.

Objectives: The objective of our study was to describe spontaneously reported haemorrhagic adverse events associated with rivaroxaban and dabigatran in Australia. Methods: Data were sourced from the Australian Therapeutic Goods Administration (TGA) Database of Adverse Event Notifications between June 2009 and May 2014. Records of haemorrhagic adverse events in which rivaroxaban or dabigatran was considered as a potential cause were analysed. Results: There were 240 haemorrhagic adverse events associated with rivaroxaban and 504 associated with dabigatran. Age was specified for 164 (68%) haemorrhages associated with rivaroxaban, of which 101 occurred in people aged ⩾75 years. Age was specified for 437 (87%) haemorrhages associated with dabigatran, of which 300 occurred in people aged ⩾75 years. Time from treatment initiation to haemorrhage was specified for 122 (51%) haemorrhages associated with rivaroxaban, with 69 (57%) haemorrhages occurring within 30 days of rivaroxaban initiation. Time from treatment initiation to haemorrhage was specified for 253 (50%) haemorrhages associated with dabigatran, with 123 (49%) haemorrhages occurring within 30 days of dabigatran initiation. Gastrointestinal (GI) haemorrhages were the most frequent type of haemorrhages associated with both rivaroxaban (n = 105, 44%) and dabigatran (n = 302, 60%). Data were available on the severity of haemorrhage for 101 (42%) haemorrhages associated with rivaroxaban, with haemorrhage leading to death in 17 people. The severity of haemorrhage was specified for 384 (76%) haemorrhages associated with dabigatran, with haemorrhage leading to death in 61 people. Conclusions: Our study highlights the need for research on the haemorrhagic complications of anticoagulation in clinical care. A considerable proportion of reported haemorrhagic events occurred within 30 days of rivaroxaban and dabigatran initiation. This highlights the importance of considering bleeding risk at the time of treatment initiation.

Patient Safety in Primary Care: Are General Practice Nurses the Answer to Improving Warfarin Safety? An Australian Perspective

Primary health care plays a pivotal role in health systems. The ageing population and mounting prevalence of chronic disease will place increasing demands on primary care. Currently, 30% of general practice patients in Australia are aged 65 and over (Australian Institute of Health and Welfare 2009) and almost half of general practice consultations involve a chronic condition (Knox et al. 2008). Older patients with chronic conditions often have multiple co-morbidities and medications, requiring general practitioners (GPs) to coordinate and case manage their care. Managing such complex patients poses challenges for GPs who are often time poor (Jacobsen et al. 2003), which results in an increasing reliance on shared care and patient self-management. This potentially increases the risk of patient safety incidents such as medication-related adverse events. Patient safety, which refers to “the reduction of risk of unnecessary harm associated with health care to an acceptable minimum,” (Runciman et al, 2009, p. 19) is a fundamental principle of health care influenced by a number of interrelated factors, related to individual patients, health professionals, policies, guidelines, and regulatory procedures. In this paper, we present the example of warfarin management to illustrate safety and quality issues in the Australian primary care setting.

Replacing warfarin for better or worse: identifying patient factors and future directions.

doi: 10.5694/mja12.11863 In Australia, atrial fi brillation (AF) affects 1%–2% of the population, placing them at a fi vefold increased risk of stroke.1 The prevalence of AF increases sharply with age, with 50% of patients aged 75 years or over.2 Warfarin has been used clinically for more than 70 years and is the mainstay anticoagulant for prophylaxis of stroke as well as for the management of AF. However, in recent years, the novel oral anticoagulants (NOACs) dabigatran, rivaroxaban and apixaban have been developed. These promise more effi cacy than warfarin in stroke prevention, while being safer and easier to use.3 A recent review by the Australian Government Department of Health and Ageing provided perspectives on current and future options for improving the use of anticoagulation therapies in managing patients with AF.2 In this article, we focus on strategies to improve anticoagulation management in patients with AF in light of the increasing utility of NOACs.

The impact of clinical maturity on competency in evidence-based medicine: a mixed-methods study

Objective To identify whether the clinical maturity of medical trainees impacts upon the level of trainee competency in evidence-based medicine (EBM). Materials and methods Undergraduate and graduate-entry medical trainees entering their first year of training in the clinical environment were recruited for this study. Competency in EBM was measured using a psychometrically validated instrument. EBM competency scores were analysed using Students t tests, in order to differentiate between undergraduate and graduate-entry trainee performance. Ten focus group discussions were conducted with undergraduate and graduate-entry trainees. Audio transcripts were thematically analysed. Results Data on a total of 885 medical trainees were collected over a 5-year period. Undergraduate trainees had significantly higher EBM competency scores during years in which the programme was presented in a didactic format (mean difference (MD)=1.24 (95% CI)CI 0.21 to 2.26; 1.78 (0.39 to 3.17); 2.13 (1.16 to 3.09)). Graduate trainee EBM competency scores increased when a blended learning approach to EBM was adopted, demonstrating no significant difference in EBM competency scores between undergraduate and graduate cohorts (−0.27 (−1.38 to 0.85); −0.39 (−1.57 to 0.79). Qualitative findings indicated that differences in learning and teaching preference among undergraduate and graduate-entry trainees influenced the level of competency obtained in EBM. Conclusions Clinical maturity is the only one factor that may influence medical trainees’ competency in EBM. Other predictors of EBM competency may include previous training and exposure to epidemiology, biostatistics and information literacy. While graduate-entry medical students may have more ‘life’ experience, or maturity, it does not necessarily translate into clinical maturity and integration into the clinical environment.

What are the attributes of a good health educator

Objectives The purpose of this study was to examine the attributes that students and educators believe are important to being a good health educator in a non-clinical setting. Methods A cross-sectional survey of first-year health science students and educators involved with a Health Science course in Melbourne, Australia was performed. A convenience sampling approach was implemented, with participants were required to rate the importance of teaching attributes on a previously developed 15-item written questionnaire. Descriptive statistics were generated, with Pearson’s chi-square statistics used to examine differences between groups. In total 94/147 (63.9%) of students and 15/15 (100%) of educators participated in the study. Results Of the 15 attributes, only ‘scholarly activity’ was not deemed to be not as an important attribute to define a good educator. Knowledge base (50% vs. 13.3%) and feedback skills (22.3% vs. 0%) were rated as important attributes by students in comparison to educators. Professionalism (20% vs. 5.3%), scholarly activity (20% vs. 3.2%) and role modelling (26.7% vs. 3.2%) were rated as the most important attributes by educators in comparison to students. Conclusions No single attribute makes a good health educator; rather health educators are required to have a rounded approach to teaching. Students have greater focus on the educator providing a transfer of knowledge. Educators are additionally focused on professionalism attributes, which may not be valued by students. Students and educators must enter into a clearer understanding of expectations, from both parties, to obtain optimal education outcomes.

Warfarin versus aspirin for stroke prevention (BAFTA)

Jonathan Mant and colleagues (Aug 11, p 493) should be commended on their study focusing on warfarin versus aspirin therapy in people older than 75 years. Although the study showed that those prescribed warfarin had fewer episodes of major bleeds than those taking aspirin, participant selection potentially aff ected the study outcome and generalisability of the fi ndings. In addition to excluding patients on the basis of risk factors outlined in the study protocol, primarycare physicians excluded patients if, on their own clinical judgment, patients were deemed at risk of stroke and haemorrhage. This criterion is not clearly defi ned or attributed to any specifi c set of guidelines. The complexities associated with man aging warfarin require close monitoring by the treating clinician, with additional reliance on patients’ com petencies. In exercising clinical judgment when prescribing warfarin, responsible physicians should not only exclude patients on the basis of risk factors outlined in the study, but should also assess patients for other well recog nised risk factors for stroke and haem orrhage in those taking warfarin, including impaired cognitive function, inadequate health literacy, and a history of poor compliance. The lack of detail on these important risk factors in this study is concerning, particularly when the study design allows for discretionary exclusion of patients by their physician. The results of this study might therefore provide an illusion of safety for indiscriminate prescription of anticoagulants.

The value of food fortification as a public health intervention

Monash University, Melbourne, VIC odine is a micronutrient essential for thyroid hormone synthesis. I Inadequate dietary intake is associated with preventable iodine deficiency disorders, including neurological impairment, goitre, and hypothyroidism. The effectiveness of iodised salt for improving population iodine levels and of urine iodine assessment for detecting deficits have led to iodine deficiency being eliminated in many countries where it was once a problem.