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SummaryThe aims of this study were to investigate trends in the incidence of diagnosed atrial fibrillation (AF), and to identify factors associated with the prescription of antithrombotics (ATs) and to identify the persistence of patients with oral anticoagulant (OAC) treatment in primary care. Data were obtained from 400 Italian primary care physicians providing information to the Health Search/Thales Database from 2001 to 2004. The age-standardised incidence of AF was: 3.9–3.0 cases, and 3.6–3.0 cases per 1,000 person-years in males and females, respectively. During the study period, 2,016 (37.2%) patients had no prescription, 1,663 (30.7%) were prescribed an antiplatelet (AP) agent, 1,440 (26.6%) were prescribed an OAC and 301 (5.5%) had both prescriptions. The date of diagnosis (p = 0.0001) affected the likelihood of receiving an OAC. AP, but not OAC, use significantly increased with a worsening stroke risk profile using the CHADS2 risk score. Older age increased the probability (p < 0.0001) of receiving an AP, but not an OAC. Approximately 42% and 24% of patients persisted with OAC treatment at one and two years, respectively, the remainder interrupted or discontinued their treatment. Underuse and discontinuation of OAC treatment is common in incident AF patients. Risk stratification only partially influences AT management.

A comprehensive literature search identified seven instruments, of which three had psychometric data available. These were the 'Sawicki instrument', the Duke Anticoagulation Satisfaction Scale (DASS) and Deep Vein Thrombosis Quality of Life (DVTQoL). Sawicki assessed five domains with acceptable internal reliability. The six DVTQoL domains had good internal consistency, construct validity and reliability, although test-retest reliability and responsiveness have not been published. The DASS instrument covers three dimensions: limitations, burdens (i.e., negative impacts) and positive impacts. The burdens dimension correlated with short form-36 generic scales. The DASS had good internal consistency and item variability, and acceptable test-retest reliability and scale structure. DASS has the potential to help identify reasons for dissatisfaction and poor compliance across multiple models of care. Oral anticoagulation with vitamin K antagonists affects patients' quality of life, and is further complicated by variations in compliance and ability to self-manage anticoagulation. This paper reviews instruments designed specifically to assess treatment satisfaction in patients receiving oral anticoagulation.

OBJECTIVE: To assess the impact on burden reported by caregivers of patients with mild to moderate Alzheimer's disease (AD) who were treated with metrifonate during a randomized double blind clinical trial. DESIGN: Randomized clinical trial, with a 2-week screening period and a 26-week double blind, placebo controlled, treatment phase. Caregivers were assessed at baseline, at 12 weeks, and at end of trial. SETTING: Caregivers were interviewed at clinics as part of the assessment of the patients. PARTICIPANTS: Six hundred and three caregivers of AD patients who were enrolled in the MALT trial; 591 (98%) provided data suitable for analysis at baseline, and 546 (91%) provided data allowing for inclusion in the analysis of change scores. MEASUREMENTS: The Caregiver Burden Assessment consisted of the Screen for Caregiver Burden, including both subjective (SCB-subj) and objective (SCB-obj) scores; the cognitive subscale of Poulshock and Deimling (PD); an abridged version of the Relatives Stress Scale (aRSS); assessments of time spent in providing care, including the Caregiver Activity Time Scale (CATS); and demographic and background variables on both the patient and caregiver. RESULTS: Treatment of mild to moderate AD patients with metrifonate for a duration of 26 weeks significantly reduced the psychological burden of care to the caregivers, as measured by the SCB-subj, the PD, and the aRSS. There were no statistically significant differences on the measures assessing the time spent in caregiving, except for the caregiver's subjective impression of the change in time spent providing care during the trial. When comparing individual dose groups, most of the measures of burden showed the largest benefits in burden for the 60/80 mg group, followed by the 40/50 mg group, and then the placebo group. However, there was no statistically significant dose effect. CONCLUSIONS: This study provides the first evidence from a randomized clinical trial of any acetylcholinesterase inhibitor used in the treatment of AD demonstrating a positive impact on the patient's caregiver as well as benefits to the patient. These results were shown consistently across several measurement scales and were observed after six months of treatment. These findings reinforce the clinical significance of research that has shown that metrifonate has beneficial impacts on the cognitive, behavioral, and functional abilities of AD patients. Because caregiver burden is a leading factor in the decision for institutional care placement, the ability to favorably impact that burden through pharmacological treatment of the patient is important. J Am Geriatr Soc 48: 268–274, 2000.

Background: Many patients with atrial fibrillation who are at moderate to high risk of stroke do not receive anticoagulation with vitamin K antagonists (VKAs) in accordance with recommendations. Objective: To determine (1) why Canadian patients with atrial fibrillation who are potentially eligible for VKA do not receive this therapy, (2) why Canadian primary care physicians discontinue VKA therapy, and (3) why VKA therapy is perceived as difficult to manage. Methods: The study involved a chart review of 3 cohorts of patients with nonvalvular atrial fibrillation at moderate to high risk of stroke: patients who had never received VKA treatment (VKA-naive), those whose treatment had been discontinued, and those whose VKA treatment was considered difficult to manage. Results: Charts for 187 patients (mean age 78.4 years, standard deviation 8.9 years) treated at 39 primary care sites were reviewed (62 treatment-naive, 42 with therapy discontinued, and 83 whose therapy was considered difficult to manage). Atrial fibrillation was paroxysmal in 82 (44%) of the patients, persistent in 47 patients (25%), and permanent in 58 (31%). One patient in each of the 3 cohorts had experienced a stroke during the 6 months before study participation. Bleeding events were more frequent among patients who had discontinued VKA therapy than in the other 2 groups. Among those whose therapy was discontinued and those whose therapy was difficult to manage, the mean time in the therapeutic range was 46.3% and 56.4%, respectively. The most common reason for not initiating VKA therapy in treatment-naive patients was the transient nature of atrial fibrillation (25/62 [40%]). The most common reason for discontinuation of VKA therapy was a bleeding event (10/42 [24%]). The presence of a concomitant chronic disease was the most common reason that a patient’s therapy was considered difficult to manage (46/83 [55%]). Conclusions: VKA therapy was not initiated or was discontinued for various reasons. Multiple comorbid conditions made management of VKA therapy more difficult. These findings reflect the challenges that primary care physicians experience in managing the care of patients with atrial fibrillation. RESUME Contexte : De nombreux patients atteints d’une fibrillation auriculaire (FA) et presentant un risque d’accident vasculaire cerebral (AVC) modere ou eleve ne recoivent pas d’anticoagulotherapie par un antagoniste de la vitamine K, conformement aux recommandations. Objectif : Determiner 1) pourquoi les patients canadiens atteints d’une FA et qui sont des candidats potentiels a l’anticoagulotherapie par un antagoniste de la vitamine K ne recoivent pas ce traitement, 2) pourquoi les medecins canadiens de soins primaires interrompent l’anticoagulotherapie par un antagoniste de la vitamine K, et 3) pourquoi la prise en charge d’un tel traitement est consideree comme difficile. Methodes: Cette etude comportait une analyse des dossiers medicaux des patients de trois cohortes atteints d’une FA non valvulaire et consideres comme presentant un risque modere ou eleve d’AVC : patients qui n’avaient jamais recu d’anticoagulotherapie par un antagoniste de la vitamine K, patients chez qui ce traitement avait ete interrompu et patients chez qui la prise en charge de ce traitement etait consideree comme difficile. Resultats : Les dossiers medicaux de 187 patients (âge moyen de 78,4 ans, ecart-type de 8,9 ans) traites dans 39 etablissements de soins primaires ont ete analyses (62 : jamais traites, 42 : traitement interrompu et 83 : prise en charge consideree comme difficile). On a repertorie 82 (44 %) cas de FA paroxystique, 47 (25 %) cas de FA persistante et 58 (31 %) cas de FA permanente. Un patient dans chacune des trois cohortes a eu un AVC durant les six mois precedant sa participation a cette etude. Les saignements etaient plus frequents parmi les patients chez qui on avait interrompu le traitement par l’antagoniste de la vitamine K que chez ceux des deux autres groupes. Parmi les patients chez qui le traitement avait ete interrompu ou sa prise en charge etait consideree comme difficile, le temps moyen dans l’ecart therapeutique etait respectivement de 46,3 % et de 56,4 %. La raison la plus souvent evoquee pour ne pas instaurer le traitement par un antagoniste de la vitamine K chez les patients n’ayant jamais recu un tel traitement etait la nature passagere de la FA (25/62 [40 %]). La raison la plus souvent evoquee pour interrompre ce traitement etait les saignements (10/42 [24%]). La presence d’une comorbidite chronique etait la raison la plus souvent evoquee pour expliquer la prise en charge difficile de ce traitement (46/83 [55 %]). Conclusions : L’anticoagulotherapie par un antagoniste de la vitamine K n’etait pas instauree ou etait interrompue pour diverses raisons. La presence de multiples comorbidites rendait sa prise en charge plus difficile. Ces resultats refletent les difficultes des medecins de soins primaires dans la prise en charge des patients atteints de fibrillation auriculaire.

Summary A cost-effectiveness model was developed on the basis of early clinical trial results from the US reporting sustained CD4+ cell response in patients receiving zalcitabine in addition to zidovudine. This model was then adapted and applied to 5 European countries to assess the comparative cost effectiveness of adding zaldtabine to antiviral treatment for AIDS patients. The countries included in the modelling effort were Switzerland, France, Italy, Germany and the UK. The model used a Markov state-transition process to estimate the rate of acute opportunistic disease episodes, li fetime medical treatment costs, and survival for pop. ulations of AIDS patients with baseline CD4+ counts of less than 300/]l1. Physic ian panels in each country developed standard treatment algorithms and adjusted the epidemiological data to renect the AIDS profile of each country. Economic consultants provided cost data. Results from this exploratory data analysis show that if CD4+ counts correlate with the incidence of opportunistic disease episodes as expected, the combined use of zalcitabine and zidovudinc for a 1-year period should be cost effective.

Objective To evaluate the frequency of and determine predictive factors for acute hospitalization in a prospective study of patients with Alzheimer's disease (AD). Design A one year prospective study. Participants 134 patients recruited from the memory clinic in Toulouse University Hospital, with AD diagnosed using the NINCDS-ADRDA criteria. Measures A comprehensive geriatric and neuropsychological assessment was conducted 6 monthly. Results Among the 134 patients included in this study, at one year follow up, 32 patients had at least one acute hospitalization. Patient-related variables predictive of acute hospitalization in the univariate analysis were: level of education, ADL-bathing, ADL-toileting, ADL-feeding, total ADL score, IADL A scale (daily upkeep), history of falls, and level of behavioural disorder as measured by the Cohen scale. In the multivariate regression model, two variables were associated with acute hospitalization: dependency for ADL-bathing [Odds Ratio (OR) = 5.65, 95% Confidence Intervals (CI): 2.3–14.4] and low level of education. Conclusion The results of this study demonstrate that acute hospitalization is frequent in AD patients resulting in considerable cost implications. Interventions that support patients and their cares to manage their loss of ADL may be a practical approach to reducing the need for acute hospital admissions. Copyright © 2002 John Wiley & Sons, Ltd.