Electronic Counselling for Oral Anticoagulant Patients

Abstract

Education is an essential part of care for patients taking oral anticoagulants. However, it may be time-consuming for health care providers and overwhelming for patients, and hence sometimes suboptimal. Technology-based education programs have the potential to overcome some of the problems relating to patient education and thus help to minimize therapy complications and improve clinical outcomes. The principal purposes of this study were to identify and evaluate research on electronic education interventions for warfarin patients, and to create and pilot electronic education programs for warfarin and DOAC patients. Chapter 1 provides general background information on coagulation, anticoagulants and patient education. Chapter 2 describes a systematic review, to our knowledge the first to evaluate technologybased educational interventions for warfarin patients. Searches were conducted of the Cochrane Library (CENTRAL), Ovid (MEDLINE), PubMed, CINAHL Plus (EBSCOhost), ERIC ProQuest, and Web of Science databases, as well as of US and EU clinical trials databases, for randomized controlled trials evaluating the effect of any electronic education intervention alone or in combination with other self-management techniques, in warfarin patients. The searches included studies published in English without date restrictions. Manual searches of reference lists in relevant publications were also conducted. All identified references were screened for inclusion within Endnote software. The Cochrane Collaboration?s Review Manager 5.3 (Rev Man 2014) software was then used for further data extraction and analysis. Risk of bias was assessed using the Cochrane ?Risk of bias? tool. Three randomized control trials and one ongoing study were identified. While they showed positive effects for electronic education of warfarin patients, the small size and heterogeneous nature of the identified studies mean the findings are limited in their value, and meta-analysis was not possible. More adequately powered, good quality, randomized, controlled studies are required in this area. Chapter 3 describes the development and piloting of an electronic tool to educate and assess patients? knowledge regarding their warfarin therapy. The tool was developed using Articulate 360 software and consisted of three main sections: a pre-education knowledge test (a previously validated anticoagulant knowledge test), an education section, and repetition of the knowledge test. It was piloted in the community pharmacy on English-speaking adult patients receiving warfarin who could use a suitable electronic device. A total of 56 patients participated in the pilot. 35/56 (62.5%) passed the knowledge test before the education program and this showed a statistically significant increase to 51/56 (91.1%) after the education program, demonstrating the utility of the tool in the short-term. Feedback to enhance the electronic tool was also received. The results of this pilot have laid the foundation for a future more comprehensive study incorporating long term follow up and a wider range of outcome measures. Chapter 4 concerns the development and piloting of an electronic education program for patients taking direct-acting oral anticoagulants (DOACs), which are increasingly being prescribed owing to their advantages over warfarin: They can be given in fixed doses, have fewer interactions with food or other drugs, a wide therapeutic window and do not require monitoring as closely as warfarin. As for the warfarin education tool, the DOAC program comprised educational material preceded and followed by knowledge tests. However, in this case the education component took the form of a dialogue between a pharmacist and patient, with points of interactivity where the patient selected material relevant to the DOAC he/she had been prescribed. Baseline adherence was established through the incorporation of the Morisky 8-item medication adherence scale (MMAS-8) into the program before the education component. The pre- and post-education knowledge test comprised relevant questions from the same anticoagulation knowledge test as that used in the warfarin education program. The program was evaluated in community pharmacies and by pharmacists in the pharmacistled outpatient anticoagulation clinic of a major Dublin hospital. Eligible patients were Englishspeaking adults who were capable of using appropriate electronic devices. A total of 53 patients enrolled in the pilot. 43/53 (81.1%) patients passed the test before the education program, and this showed a significant increase to 50/53 (94.3%) after education. In the MMAS-8 item questionnaire only 4 patients showed a low level of self-reported baseline adherence, 23 patients had a medium level of adherence, and 26 patients had a high adherence level. This pilot study confirmed that the tools were capable of being used in the workplace environment and of enhancing patient knowledge in the short term. Feedback was received on potential improvements, in particular to enhance the personalization of the education experience for individual patients, enabling future work to assess a refined intervention in a larger and longer duration randomized controlled trial with more comprehensive outcome measures. Chapter 5 explores the overall findings, and sets out the future work that can build upon the studies described here.