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AAFP/ACOG Educational and Practice Guidelines

PATRICK B. HARR, M.D.
Maryville, Missouri

THOMAS F. PURDON, M.D.
University of Arizona Health Science Center,
Tucson, Arizona

The recommended core educational guidelines for family practice residents in maternity and gynecologic care appear in this issue of American Family Physician,¹ as well as a joint statement on cooperative practice and hospital privileges,² both created by a joint task force of the American Academy of Family Physicians (AAFP) and the American College of Obstetricians and Gynecologists (ACOG). These two documents revise and update those first published in 1980.³

Originally published as AAFP Reprint No. 261, the core educational guidelines, then in obstetrics and gynecology, have served family medicine well. Family practice residency directors have been able to successfully negotiate curricula for their residents, and graduates of family practice residency programs have been able to successfully obtain privileges in practice based on the recommendations found in Reprint No. 261.

See "Core Educational Guidelines"

The current documents are the products of a year of face-to-face, open, good faith negotiation. Having succeeded in coming to agreement on the important issues of training and privileges, the task force continues to meet, highlighting the importance of interspecialty communication. While in the field there may be competition, the leaders of the specialties of family medicine and obstetrics and gynecology have demonstrated that they can work together for the good of patients.

In the spirit of cooperation, the document calls for curricula for family practice residents to be jointly crafted by family physicians and obstetricians, as well as taught by appropriately experienced physicians in both specialties. It calls on obstetricians to provide consultation and backup for family physicians who provide maternity care, while simultaneously calling for family physicians to exercise judgment to determine when timely consultation and/or referral may be appropriate.

The core educational guidelines outline a series of core skills that all family practice residents should experience. Advanced skills, such as loop electrosurgical excision procedures, ultrasound-guided amniocentesis, management of multiple gestation and performance of cesarean delivery, are outlined in the curriculum for family practice residents who are planning to practice in communities without readily available obstetric/gynecologic consultation and require special training. Importantly, advanced skills may be learned within the three-year family practice residency.

There are family practice residency programs awaiting the publication of these core educational guidelines so that they may successfully negotiate curricula and collaborative teaching relationships in maternity and gynecologic care for their family practice residents. There are individual family physicians awaiting the publication of the joint statement on cooperative practice and hospital privileges so that they may obtain privileges in maternity and gynecologic care with the support of the local departments of both family medicine and obstetrics and gynecology.

The original 1980 Reprint No. 261 has acquired an anecdotal reputation as the most powerful of the more than two dozen core educational guidelines, many also jointly developed, that have been published by the AAFP. Given the success of the joint AAFP/ ACOG task force in revising, updating and publishing agreed-on educational and practice guidelines, it can be anticipated that the relationship between departments of family medicine and obstetrics and gynecology, and indeed individual family physicians and obstetricians/gynecologists, should reflect the collaborative relationship of physicians practicing together for the benefit of the nation's population.

Dr. Harr is immediate past president and current chair of the AAFP Board of Directors and practices family medicine in Maryville, Mo. Dr. Purdon is vice president of ACOG and is associate professor of clinical obstetrics and gynecology at the University of Arizona Health Science Center in Tucson.

Drs. Harr and Purdon co-chair the Joint AAFP/ACOG Task Force, whose members include Robert C. Cefalo, M.D.; Vivian M. Dickerson, M.D.; Fredric D. Frigoletto, Jr., M.D.; Kenneth L. Noller, M.D.; Stanley Zinberg, M.D., and Debra Hawks, M.P.H., representing ACOG; and Bruce Bagley, M.D.; Daniel J. Ostergaard, M.D.; Rosemarie Sweeney and Norman B. Kahn, Jr., M.D., representing AAFP.

REFERENCES

1. Joint Task Force of the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. Maternity and gynecologic care: Recommended core educational guidelines for family practice residents [AAFP Core Educational Guidelines]. Am Fam Physician 1998; 58:275-7.
2. Joint Task Force of the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. AAFP-ACOG joint statement on cooperative practice and hospital privileges [AAFP Core Educational Guidelines]. Am Fam Physician 1998;58:277-8.
3. American Academy of Family Physicians, American College of Obstetricians and Gynecologists, Council on Resident Education in Obstetrics and Gynecology and the Association of Professors of Gynecology and Obstetrics. ACOG-AAFP recommended core curriculum and hospital practice privileges in obstetrics-gynecology for family physicians. Kansas City, Mo., AAFP, 1980. AAFP Reprint No. 261.

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Anticoagulation in Elderly Persons: A Call for Wider Use

VALERY A. PORTNOI, M.D.
Albert Einstein College of Medicine
of Yeshiva University
Beth Israel Medical Center
New York, New York

THOMAS F. PURDON, M.D.
University of Arizona Health Science Center,
Tucson, Arizona

The decision to initiate anticoagulation treatment is one of the most difficult in the practice of geriatrics. The difficulty stems from concern about the adverse effects of bleeding complications, particularly intracranial hemorrhage. Warfarin is most commonly prescribed for the prevention of stroke in patients with atrial fibrillation and for long-term treatment of deep venous thrombosis, as discussed in the article by Ahktar and colleagues in this issue of AFP.¹ Although anticoagulation treatment for deep venous thrombosis is widely used in elderly patients, warfarin therapy is underused for stroke prevention in geriatric practice. Physicians and patients do not place similar values on the importance of the measures for stroke prevention.²

The prevalence of atrial fibrillation sharply increases with age (i.e., from 2 percent in persons younger than 50 years to 16 percent in persons 75 years of age and 22 percent among nursing home residents aged 91 to 103 years). The rate of embolic stroke complications from atrial fibrillation also increases with age. It is estimated that about 36 percent of all strokes in patients 80 years or older may be attributed to atrial fibrillation.³ Strokes associated with atrial fibrillation usually cause more profound neurologic deficits than do other types of strokes. This is ascribed to lack of a compensatory mechanism provided by collateral circulation in these patients, unlike patients with other types of strokes. Seventy-one percent of strokes associated with atrial fibrillation are fatal or result in dependency requiring extensive rehabilitation and restorative nursing home care.⁴

Elderly patients are very apprehensive about the prospect of becoming disabled because of a stroke. When asked about choosing between the risk of bleeding complications and the inconvenience caused by treatment with warfarin compared with the risk of stroke from untreated atrial fibrillation, they overwhelmingly prefer treatment. For many elderly patients, the prospect of stroke-related disability is "worse than death."²

Nonetheless, physicians appear reluctant to initiate this treatment in elderly persons. For example, one study⁵ showed that only 25 percent of elderly hospitalized patients at high risk of stroke were found to be receiving warfarin therapy, while as many as 50 to 70 percent could potentially benefit.⁵ The reasons cited in the literature for underuse of treatment with warfarin in the elderly are the following: lack of information on the treatment effectiveness in stroke prevention, exaggerated perception of the high risk of major bleeding complications and inconvenience caused by this treatment in elderly patients.⁶

The effectiveness of treatment with warfarin for stroke prevention is well documented in patients of any age with atrial fibrillation. For patients older than 75 years, treatment with warfarin reduces the rate of stroke associated with atrial fibrillation by about 70 percent (84 percent in women). According to an analysis of pooled data from five major randomized controlled studies,⁷ this benefit was 23 times greater than the rate of drug-induced complications in the elderly. Also, the most recent studies on the safety of warfarin treatment in the elderly cast doubt on the notion that the risk of bleeding is inherently higher in the elderly. The risk is only increased when the intensity of warfarin therapy exceeds the therapeutic need (i.e., when the International Normalized Ratio [INR]--the most appropriate means of monitoring anticoagulation treatment--is above the therapeutic level of 2.0 to 3.0). When the INR is above 3.0, and particularly when it is 4.5 or higher, the risk for intracranial hemorrhage complications in the elderly increases.

In one frequently cited study--the Stroke Prevention in Atrial Fibrillation II Study⁸--a high rate of intracranial hemorrhages was observed. However, in this study, the intensity of anticoagulation was set to yield an INR of up to 4.5. In a more recent study,⁹ the risk of warfarin-related bleeding was found to be no higher in elderly patients than in younger patients receiving warfarin therapy at therapeutic intensity. When the intensity of treatment is controlled and is therapeutic, the treatment is both effective and safe for the elderly. In addition, the study dispels another myth surrounding the issue of anticoagulant treatment in the elderly--that the management of therapy is more difficult in that population. At least up to the age of 80 years, elderly patients receiving treatment with warfarin require no more frequent monitoring or dosage adjustment than do younger patients.

Another recent study¹⁰ addressed the practice of physicians who prescribe anticoagulation therapy in nursing homes. It was found that although only 19 percent of physicians think that risks "outweigh benefits," the rest believe that the benefits do not "greatly outweigh the risks" (47 percent) or only "slightly outweigh the risks" (34 percent). In fact, nursing home patients have a potential to benefit the most from stroke prevention since they are burdened by the highest rate of risk factors for stroke. Denial of effective stroke prevention measures for this group of patients would be a grave mistake. The study cites that the excessive risk of falling (71 percent) and a history of gastrointestinal bleeding (71 percent) are the most common reasons for not using warfarin therapy. Neither of these conditons, however, represents an absolute contraindication to anticoagulation. The absolute contraindications are few--active bleeding and noncompliance. There are many relative contraindications to anticoagulation, and these are more likely to be found in the nursing home population. Examples include severe liver disease, uncontrolled hypertension, aortic aneurysm, recent neurosurgery or neurologic hemorrhage within the past two years.

The decision to treat with warfarin should be based on careful consideration of the individual's benefit and risk from therapy, rather than on age itself. Nonetheless, almost one third of physicians surveyed in this study¹⁰ believed that a 94-year-old nursing home resident with atrial fibrillation, ischemic heart disease and compensated congestive heart failure should not be offered warfarin treatment because of the patient's "advanced age." A minority of physicians thought that despite the lack of evidence of falls in the past and the patient's independence in activities of daily living, the mere potential risk of falling should contraindicate treatment with warfarin.

An approach to patient care that minimizes the risk of falling and maximizes safety precautions against injury related to gait disturbances can be much more effectively implemented in nursing homes than within the community-dwelling elderly. Nursing homes may offer an environment that allows close monitoring of a patient's status and intensity of therapy. It is much easier to make sure, for example, that no over-the-counter medications, particularly aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), are taken. When use of an NSAID is unavoidable, misoprostol can be added to the medical regimen. These measures likely diminish the risk of gastrointestinal bleeding in patients treated with warfarin, even if they have a history of bleeding.¹¹

Finally, warfarin treatment should be discussed with patients and their families. Advanced age should no longer be considered a contraindication for anticoagulation. In addition, the fact that the patient is residing in a nursing home also should not adversely influence the decision to use anticoagulation.

Dr. Portnoi has recently joined the faculty of the Division of Geriatric Medicine at Albert Einstein College of Medicine of Yeshiva University, Beth Israel Medical Center, New York. He was formerly clinical associate professor of medicine at Georgetown University Medical Center, Washington, D.C.See article on page 130.

REFERENCES

1. Ahktar W, Reeves WC, Movahed A. Indications for anticoagulation in atrial fibrillation. Am Fam Physician 1998;57:130-6.
2. Man-Son-Hing M, Laupacis A, O'Connor A, Wells G, Lemelin J, Wood W, et al. Warfarin for atrial fibrillation. The patient's perspective. Arch Intern Med 1996;156:1841-8.
3. Aronow WS, Ahn C, Gutstein H. Prevalence of atrial fibrillation and association of atrial fibrillation with prior and new thromboembolic stroke in older patients. J Am Geriatr Soc 1996;44:521-3.
4. Fisher CM. Reducing risks of cerebral embolism. Geriatrics 1997;34:49-66.
5. Stafford RS, Singer DE. National patterns of warfarin use in atrial fibrillation. Arch Intern Med 1996;156:2537-41.
6. McCrory DC, Matchar DB, Samsa G, Sanders LL, Pritchett EL. Physician attitudes about anticoagulation for nonvalvular atrial fibrillation in the elderly. Arch Intern Med 1995;155:277-81.
7. Stroke Prevention in Fibrillation Investigators. Risk factors for stroke and efficacy of antithrombolic therapy in atrial fibrillation in the elderly. Arch Intern Med 1994;154:1449-57.
8. Stroke Prevention in Atrial Fibrillation Investigators. Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II Study. Lancet 1994;343:687-91.
9. Stroke Prevention in Atrial Fibrillation Investigators. Bleeding during antithrombotic therapy with atrial fibrillation. Arch Intern Med 1996;156:409-16.
10. Monette J, Gurwitz JH, Rochon PA, Avorn J. Physician attitudes concerning warfarin for stroke prevention in atrial fibrillation: results of a survey of long-term care practitioners. J Am Geriatr Soc 1997;45:1060-5.
11. White RH, McKittrick T, Takakuwa J, Callahan C, McDonell M, Fihn S. Management and prognosis of life-threatening bleeding during warfarin therapy. Arch Intern Med 1996;156:1197-201.

The authors would like to acknowledge the assistance of Norman B. Kahn Jr., M.D., and Stanley Zinberg, M.D., in preparation of the manuscript.

The 1998 Recommended Core Educational Guidelines for Family Pratice Residents: Maternity and Gynecologic Care (AAFP Reprint No. 261) and the AAFP­ACOG Joint Statement on Cooperative Practice and Hospital Privileges (AAFP Reprint No. 261A) are also available from the AAFP by calling Tresa Lee at 800-274-2237, ext. 5208; e-mail: tlee@aafp.org.

Copyright © 1998 by the American Academy of Family Physicians.
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