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Interventions on Anticoagulation Patients Taking Warfarin With EducationResearch Paper

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Educational Intervention for Patients Taking Warfarin at the Anticoagulation Clinic

Patients with a trial fibrillation (Afib or AF) and high stroke risks are often administered the anticoagulant, warfarin. Warfarin's benefit, however, hinges on the time that is spent in their INR's (international normalized ratio, which is 2.0-3.0) target therapeutic range (TTR). Patients with AF don't have adequate knowledge regarding their condition and treatment by warfarin; this may influence their INR control. Educating patients with regard to their illness and therapy will lead to improved patient grasp of warfarin medication and factors contributing to INR control.

Methods/Design: RCT (randomized controlled clinical trial) of a rigorous educational intervention comprises group sessions (involving 2 to 8 AF patients) wherein enrolled patients will acquire standardized information concerning the advantages and risks linked to oral anticoagulant (OAC) treatment, significance of INR monitoring and management, and lifestyle interactions. Patients will be provided this information via a specialist-patient-centered DVD, patient worksheets and an updated educational handbook. Study sample will comprise 200 patients unaware of warfarin effects (and eligible for being administered the drug), who will be randomly assigned to usual care or intervention groups. AF guidelines laid down by the National Institute for Health and Care Excellence (NICE) will dictate which patients are eligible to be administered the medication; also, participants chosen for the study's purpose should have electrocardiogram-documented AF. Criteria for exclusion from the study are: patients below 18 years of age; warfarin contraindication(s); valvular heart problems; warfarin usage history; those who can't read or talk English; impaired cognition; and likelihood of death within a year due to a disease. The time a patient spends in TTR represents primary endpoint, whereas secondary endpoints are quality of life measures (AF-QoL-18), depression and anxiety (HADS), medication-related beliefs (BMQ), awareness of anticoagulation and AF, and disease representations (IPQ-R). The study will entail recording of clinical outcomes, such as bleeding, anticoagulation interruptions, and stroke. Each measure of outcome will be evaluated 5 times: at baseline, at 30 days, 60 days, half a year, and one year after completion of intervention.

1. Introduction

The most widespread form of arrhythmia observed by clinicians is AF or atrial fibrillation; for individuals over 40 years of age, there is a roughly 25% chance of developing the disease throughout their lifetime. AF constitutes a standalone risk element for stroke, presenting five times greater risks among AF patients than among people with normal rhythm. It is responsible for nearly 10% to 15% of total ischemic strokes; nearly 25% of strokes occur among the elderly individuals aged 80+ (Lip & Edwards, 2006). Moreover, in case of AF-related strokes, the patient will typically have considerably larger rates of morbidity and mortality, increased risks of disability and prolonged hospitalization (Smith, Xuere, Pattison, Lip & Lane, 2010).

Educational interventions informing families of ways to lower possibilities of bleeding prove extremely valuable. Warfarin-linked bleeding risks are intimately associated withwarfarin control adequacy. Better warfarin control has been noted among patients who are educated regarding warfarin -- through both verbal and written modes. Warfarin is associated with more drug and food interactions than all other prescription drugs; knowledge of these interactions will facilitate warfarin control among patients (Newall, Monagle & Johnston, 2005).

1.1. Statement of the Problem

There are several reasons behind non-compliance of OAT prescriptions by AF patients (Engelke, 2012; Deck, 2015). Numerous factors may be ascribed to INR failing to be within therapeutic range. AF patients might exhibit (a) poor knowledge regarding OAT, (b) low educational level, (c) no education in regard to OAT, and (d) non-adherence to therapy. One obstacle is OAT-connected health beliefs. OAT-prescribed patients do not completely grasp the concept of self-regulation theory that involves consistent medication, and food-and-drink intake; their problems are further aggravated by poor communication between physician and patient (Hu, Chow, Dao, Errett & Keith, 2006). Other factors that heighten patients' bleeding risks include: aging effects and multiple comorbidities (Hu et al., 2006; Deck, 2015).

1.2. Significance of the Study

In the U.S., one among the five medication categories posing greatest risk for patients is - anticoagulants (Engelke, 2012). In over 2% of OAT-consuming patients, cases of major bleeding are reported. OAT-related cerebral hemorrhage shows 22% recurrence rate, following resumption of OAT intake (Engelke, 2012; Kirsch, 2011). Among the elderly patients (aged 80+), risk elements in regard to major bleeding expand to include poly-pharmacy and inadequate patient education (Engelke, 2012). Not even half of OAT-consuming patients can maintain target INR's stability (Kirsch, 2011). Departure from therapeutic range places warfarin users at risks, either for embolism or for bleeding (Deck, 2015).

1.3. Study Objective

This study is aimed at assessing the success of an educational intervention (created in relation to warfarin) on knowledge of warfarin-consuming patients and side-effect frequency (Abd El-Naby, Hashem & Ismail, 2014).

1.4. Study Hypothesis

H1: Patients engaging in a planned warfarin educational intervention will score more on warfarin-medication-related knowledge than those who aren't enrolled in it.

H2: Patients engaging in a planned warfarin educational intervention will show lower occurrence of side-effects of warfarin compared to those who aren't a part of the program (Abd El-Naby et al., 2014).

2. Review of the Literature

Existing literature reveals that compliance can be promoted and complications can be avoided among OAT-consuming patients through patient education. This education, however, is usually absent or insufficient. A 2009 study interviewed forty OAT-administered patients and their corresponding healthcare providers. The providers comprised one specialist and thirty five GPs (general practitioners) -- of these, 12 healthcare providers (i.e. around one-third) didn't know of the fact that their OAT-using patients suffered multiple issues, like non-compliance to treatment and depression (Lowthian el al., 2009).

There are great variations in published reports, concerning warfarin-anticoagulation patient education, in terms of strategy, patient testing and content. The key to improving warfarin anticoagulation will be: prioritization of educational domains; more effective educational material delivery; and standardization of educational material. For enhancing safety as well as effectiveness of OAT, numerous strategies, including educational programs, have been formulated. But the precise effect of an OAT-centered patient education intervention is still questionable (Abd El-Naby et al., 2014).

Literature has shown that OAT-related patient knowhow is different among patients of different ages. Older patients (aged more than 75 years) typically exhibit poorer OAT knowledge (Clarkesmith, Pattison, Lip and Lane, 2013). Altered eating habits, which include lesser appetite, may elicita drop of INR below therapeutic amounts because of the absorption pathways of the body. Time devoted to discussions with patients and gauging their extent of knowledge in the course of patient visits may assist in improving their beliefs, practices and knowledge (Deck, 2015).

2.1. Theoretical Framework

The adaptation model of Sister Callista Roy is the abstract framework utilized for driving this study. Roy's theory has its roots in the days of her pediatric nursing career (Phillips, 2010). Her job enabled her to observe children's resiliency and capability of adapting to physical and psychological changes, under hospitalization. Later on, while pursuing higher studies, Roy employed adaptation as groundwork for her theory (Phillips, 2010). The study also employs the following additional models, namely: Self-Regulation Theory Model, Health Belief Model, and Patient-Provider Communication Theory.

2.1.1 Self-Regulation Theory Model

In the medical education context, this model outlines clinical and academic performance's cyclical control via numerous key processes, including goal-directed action, employment of specific goal attainment strategies, and alterations and revisions to strategies/behaviors for performance and learning optimization. The theory offers powerful potential for enhancing clinical and academic performance in the medical education context (Sandars & Cleary, 2011). People continually govern personal behaviors. Thus, they represent a major locus in creating and successfully maintaining health promotional habits. Other motivational/guiding factors are not very likely to induce long-term behavioral modifications unless people cultivate ways to personally control their health-linked actions and motivation. Karoly and Maes (2005) document the increasing shift from prescriptive regimens-centered medical management approach and adherence to them, to a self-management one that is collaborative in nature. Their conceptualization of self-regulation is with regard to a triadic system whereby individuals' influence has a bearing on health-linked habits. According to the authors' goal-guidance theory, goal adoption causes self-directed modification; implementation plans transform goals into fruitful behavior; and maintenance plans assist with sustaining acquired behavioral modifications. Several health-connected cognitions were reviewed, which can influence all three general self-regulatory processes. The authors define measurement scales, of which many are designed in terms of traits, and assess their predictive empirical evidence. Self-regulation paradigms have a common meta-theory basis, that cognitive determinants significantly influence health behaviors (Sandars & Cleary, 2011).

2.1.2 Patient-Provider Communication Theory

Reviews and theoretical works contending that patient-healthcare provider interaction can improve compliance via various mechanisms, thoroughly scrutinize the relationship of patient-health provider interaction with patient adherence. Communication facilitates patients' grasp of their health issue and the advantages and risks of medication. Every aspect of the patient-physician relationship, right from initial procuring of medical history of the patient to describing a treatment strategy, depends on proper and successful communication, both non-verbal and verbal. While most patient-doctor communication essentially entails information-sharing regarding diagnosis and treatment alternatives, a majority… [END OF PREVIEW]

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