Audit, antithrombotics and atrial fibrillation--going full circle

Clinical audit is a cyclical activity that includes setting standards of practice, comparing actual practice with the standards, changing practice that does not meet the standards set and looking again at actual practice [1]. The expectation is that as discrepancies are found and corrected, practice will be standardised. But clinicians, like most people, tend to resist change [2]. Changing practice is best achieved by an approach that combines two or more methods [3]. In this issue of Age and Ageing, Elliott and colleagues report an audit that improved the appropriate prescription of warfarin and aspirin to older hospital inpatients with atrial fibrillation (AF ) [4]. Multidisciplinary educational meetings, feedback of audit data and reminders were used to change practice. This approach was more successful in increasing aspirin prescription than warfarin. One reason for the underuse of warfarin is concern about its safety in older patients [5]. Evidence from studies of warfarin use in clinical practice published since the audit was carried out may help allay this concern [6]. But it will not be dispelled, as there still seemed to be a higher risk of minor bleeding with warfarin. This could affect compliance and has cost implications in terms of use of services by patients with this complication and the need for closer monitoring. Also, although the patients in clinical practice were older than those in randomized controlled trials, those over 80 were in the minority and these are the people most likely to be in AF and at greatest risk of stroke.