Over 15% of atrial fibrillation patients are not prescribed any antithrombotic agent for stroke prevention by GPsBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4467 (Published 26 September 2017) Cite this as: BMJ 2017;358:j4467
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Similar findings from an audit in a district general hospital, and the importance of opportunistic prescribing.
While it is a relief to see more patients with atrial fibrillation (AF) are being prescribed appropriate anticoagulation year on year, the pattern of this improvement raises some questions. For instance, why are the improvements in prescribing for the newly diagnosed not mirrored in groups of patients with longstanding AF?
An audit I conducted in a district general hospital in Northwest England found similar results to this study: 1/5 patients with AF seen in cardiology outpatient clinics in May 2017 had inappropriately not been offered oral anticoagulation by their GP. Interestingly, closer to 1/3 patients with AF had no anticoagulation, the difference being made up by those with recognised contraindications. Those patients receiving anticoagulation were universally taking appropriate therapies, and were stable on them too.
These last two pieces of information (plus the markedly improved rates of prescription in newly diagnosed patients) suggest to me that not only are GPs aware of the immense importance of appropriate anticoagulation, but also that they are becoming increasingly skilled in identifying who would and who would not benefit from particular therapies. The issue, it seems, is in recovering patients who have long known of their diagnosis but had decisions regarding their prescription made before the importance of anticoagulation was fully understood, or before novel agents offered a choice of medicines to suit different situations. In the case of the audit, these were not patients who rarely saw their GP – in fact they had been seen and referred to cardiology clinics for one reason or another, without the omission being spotted or acted on.
The answer, perhaps, is to remember Stott and Davis’ advice and strive to find time in ever busier days to realise ‘The Exceptional Potential in Each Primary Care Consultation’(1). While making that time is easier said than done, cutting the rate of avoidable stroke should be all the incentive we need to make management of on-going health problems a priority equal to today’s presenting complaint.
(1) Stott NCH, Davis RH (1979).The exceptional potential of each primary care consultation. JRCGP,(29), 201-5.
Competing interests: No competing interests