Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events

Outcomes of pharmacist-led patient education on oral anticoagulant therapy: A scoping review

BACKGROUND

Oral anticoagulants (OACs) are commonly used to prevent and treat thromboembolism and stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). Vitamin K antagonist (VKAs) and direct oral anticoagulant (DOACs) therapies are challenging because of the possible risk of bleeding. Patient education by pharmacists could be beneficial for reducing the risk of adverse effects and improving therapeutic outcomes.

OBJECTIVE

This scoping review aimed to investigate the outcomes of pharmacist-led patient education interventions regarding VKAs and DOACs therapies.

METHOD

Three databases (PubMed, Web of Science, and Scopus) were used following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines to identify articles published between January 1, 2008, and December 31, 2024. The data were synthesized using Rayyan AI.

RESULTS

A total of 1102 records were identified. After title and abstract screening, 77 studies were selected for full-text review, and 57 articles were ultimately included. The percentages of studies that examined VKAs, DOACs, and both (OACs) were 66.7 %, 19.3 %, and 14.0 %, respectively. At least one statistically significant outcome was detected in 81.6 % (31 out of 38) of the studies on VKAs, 36.4 % (4 out of 11) of the studies on DOACs and 50 % (4 out of 8) of the studies on OACs.

CONCLUSION

This review revealed that pharmacist-led patient education was particularly effective in cases of VKAs, while the outcomes in cases of DOACs were modest. Moreover, while the role of pharmacists in patient education on VKAs has been widely studied, limited research has focused on the effect of pharmacist-led education on DOACs.

Assessment of Awareness Levels About Anticoagulants in Patients With Atrial Fibrillation Presenting to Emergency Department

Atrial fibrillation (AF) is a rhythm disorder observed mostly amongst adults. AF has been regarded as one of the most important medical problems because it leads to thromboembolism and paralysis risks. Although warfarin has been used in the past to cope with this health problem, new oral anticoagulant medicines have replaced it in the last few years. The new oral anticoagulants, namely, dabigatran etexilate, rivaroxaban, and apixaban, are currently being used in daily clinical practice and treatment guidelines. Since AF patients are supposed to receive long-term oral anticoagulant therapy, it is extremely important to provide them with accurate information and appropriate training regarding the treatment to decrease oncoming complications. This is a prospective study involving 168 patients who were admitted to the emergency department with AF and who were using oral anticoagulants. Findings indicate a lack of awareness in the patients regarding the effects and side effects of the drugs they take despite having been informed by the prescribing physician. We believe that informed action by patients with regard to the oral anticoagulants and their side effects will have an impact on the reduction in hospitalization observed. It will also make a substantial contribution to the quality of life of AF patients and to their use of medical services.

An Analysis of Perceived and Actual Anticoagulant Knowledge among Independent Pharmacy Patients

Background:

Deficits in knowledge of parameters surrounding anticoagulant therapy administration carry substantial risks for patient harm. Patients prescribed anticoagulants may overestimate their knowledge of anticoagulant use principles. The purpose of this study was to analyze independent pharmacy patients’ perceived versus actual knowledge of their anticoagulation therapies.

Methods:

A 15-item survey across a dual-site pharmacy location evaluated patients’ confidence in their understanding of anticoagulant prescribing parameters and their awareness of measures to take to safeguard anticoagulant therapy routines. A pharmacist reviewed patient responses to survey items referencing actual understanding of anticoagulant therapies at the conclusion of the survey. Data analyses occurred by gender, age, ethnicity, location, living situation, self-management of anticoagulants, patient perception of anticoagulant safety, and reported receipt of anticoagulant education. Linear regressions were used for statistical analyses, with significance set at p<.05.

Results:

During the span of three months, 45 patients, 20 females and 25 males, completed the survey. Perceived anticoagulant knowledge did not differ significantly by demographics. Actual anticoagulant knowledge declined by over 20% between age groups 60-69 and 80-89 years old. African Americans displayed 10% lower actual anticoagulant knowledge than Caucasian Americans.

Conclusions:

This study revealed gaps in knowledge of anticoagulants among patients at an independent pharmacy. An appeal remains for more strategies to assist with knowledge of anticoagulant regimens. Healthcare institutions should continue to incorporate programs geared towards ongoing anticoagulant education, such as question and answer sessions, along with peer support mediums that foster optimal outcomes.

Patient-focused interventions to support vulnerable people using oral anticoagulants: a narrative review

The aim of this review was to identify patient-focused interventions that have been trialed to support vulnerable patient populations taking oral anticoagulants (warfarin and the direct-acting oral anticoagulants (DOACs)) such as older persons (65 years and over), those with limited health literacy, and those from culturally and linguistically diverse (CALD) backgrounds. This review also aimed to report on the effects of these interventions on outcomes relevant to the use of anticoagulant therapy. Original articles published between 1 January 1995 and 30 June 2017 were identified using several electronic databases such as Medline, Ovid, Embase, Scopus, Cochrane, and Google Scholar. The following terms were used for the three-tiered search: Tier 1, elderly, aged, older adult, geriatrics; Tier 2, health literacy, literacy, low health literacy, low English proficiency, patient literacy; and Tier 3, ethnicity, ethnic, ethnic groups, CALD, culturally and linguistically diverse, NESB, non-English speaking background, race, racial groups, religion, religious groups, and minority groups. The terms for each tier were combined with the following terms: anticoagulants, anticoagulation, warfarin, apixaban, dabigatran, rivaroxaban, DOACS, new oral anticoagulants, novel oral anticoagulants, patient care, patient knowledge, comprehension, patient education, patient participation, and communication. A total of 41 studies were identified. Most of the interventions identified included older persons taking warfarin who were monitored using the international normalized ratio (INR) and who received patient education. Many interventions reported a significant positive impact on patients' knowledge, reduction in the number of adverse events caused by hemorrhage, and better INR control. More research on patient-focused interventions is needed that includes patients with limited health literacy, those from CALD backgrounds, and family members and caregivers of patients taking oral anticoagulants.

Physicians' Practice of Dispensing Medicines: A Qualitative Study

OBJECTIVES

The physical act of giving medication to patients to administer away from a health care setting, dispensing, is normally performed by pharmacists. Dispensing of medication by physicians is a neglected patient safety issue, and having observed considerable variation in practice, the lead author sought to explore this issue further. A literature review yielded zero articles pertaining to this, so an exploratory study was commenced. The qualitative arm, relating to junior physicians' experience of, and training in, dispensing, is reported here.

METHODS

Focus groups were conducted to explore the beliefs, ideas, and experiences of physicians-in-training pertaining to dispensing of medication. These were recorded and transcribed. The transcriptions were thematically analyzed using the grounded theory.

RESULTS

The emergency department was the most common site of dispensing. No formal training in dispensing had been received. Informal training was variable in content and utility. The physicians felt that dispensing was part of their role.

CONCLUSIONS

Despite being expected to dispense, and the patient safety issues involved in giving drugs to patients to use at home, physicians do not feel that they have been trained to undertake this task. These findings from 1 hospital raise questions about the wider quality and safety of this practice.

Cognition and Health Literacy in Older Adults' Recall of Self-Care Information

Purpose of the Study

Health literacy is associated with health outcomes presumably because it influences the understanding of information needed for self-care. However, little is known about the language comprehension mechanisms that underpin health literacy.

Design and Methods

We explored the relationship between a commonly used measure of health literacy (Short Test of Functional Health Literacy in Adults [STOFHLA]) and comprehension of health information among 145 older adults.

Results

Results showed that performance on the STOFHLA was associated with recall of health information. Consistent with the Process-Knowledge Model of Health Literacy, mediation analysis showed that both processing capacity and knowledge mediated the association between health literacy and recall of health information. In addition, knowledge moderated the effects of processing capacity limits, such that processing capacity was less likely to be associated with recall for older adults with higher levels of knowledge.

Implications

These findings suggest that knowledge contributes to health literacy and can compensate for deficits in processing capacity to support comprehension of health information among older adults. The implications of these findings for improving patient education materials for older adults with inadequate health literacy are discussed.

An efficacy trial of an electronic health record-based strategy to inform patients on safe medication use: The role of written and spoken communication

OBJECTIVE

We tested the feasibility and efficacy of an electronic health record (EHR) strategy that automated the delivery of print medication information at the time of prescribing.

METHODS

Patients (N=141) receiving a new prescription at one internal medicine clinic were recruited into a 2-arm physician-randomized study. We leveraged an EHR platform to automatically deliver 1-page educational 'MedSheets' to patients after medical encounters. We also assessed if physicians counseled patients via patient self-report immediately following visits. Patients' understanding was objectively measured via phone interview.

RESULTS

122 patients completed the trial. Most intervention patients (70%) reported receiving MedSheets. Patients reported physicians frequently counseled on indication and directions for use, but less often for risks. In multivariable analysis, written information (OR 2.78, 95% CI 1.10-7.04) and physician counseling (OR 2.95, 95% CI 1.26-6.91) were independently associated with patient understanding of risk information. Receiving both was most beneficial; 87% of those receiving counseling and MedSheets correctly recalled medication risks compared to 40% receiving neither.

CONCLUSION

An EHR can be a reliable means to deliver tangible, print medication education to patients, but cannot replace the salience of physician-patient communication.

PRACTICE IMPLICATIONS

Offering both written and spoken modalities produced a synergistic effect for informing patients.

Use of an iPad to Provide Warfarin Video Education to Hospitalized Patients

OBJECTIVE

To evaluate the effectiveness of a warfarin educational video in the hospital setting and to determine patients' satisfaction with using an iPad to view a warfarin educational video.

METHODS

This prospective quality improvement project included adult (≥18 years of age) patients on warfarin in the hospital. All patients completed pre-video and post-video knowledge tests on the iPad before and after viewing the educational video on warfarin therapy. Patients also completed a patient satisfaction survey.

RESULTS

Forty hospitalized patients were educated using the warfarin video and included for analysis. The majority of patients were new to warfarin therapy (65%). Forty-three percent of patients passed the pre-video knowledge test, and 90% passed the post-video knowledge test (P < 0.001). No significant differences were observed among knowledge test scores when compared by age, sex, level of education, and use of central nervous system depressant medications. Most patients (82.5%) reported they liked using the iPad and found it easy to use. Patients who were younger (< 65 years) and female subjects reported they liked using the iPad more than older patients (P = 0.01) and male subjects (P = 0.02), respectively. Also, younger patients found the iPad easier to use compared with patients who were older (P = 0.01).

CONCLUSION

Educating hospitalized patients about warfarin by using a video on an iPad was effective. Video education on an iPad may be an alternative to traditional education in the hospital setting.

Living with Atrial Fibrillation: An Analysis of Patients' Perspectives

PURPOSE

The aim of this study was to determine the perceptions of patients with atrial fibrillation regarding the disease, to reveal their feelings, thoughts and wishes, and to investigate their perspectives and coping behaviors towards their condition.

METHODS

Phenomenological methodology was used. The study population consisted of a total of 225 patients treated by the cardiology department of a university hospital, while the study sample consisted of 32 patients who met the inclusion criteria. A semistructured interview addressed perceptions of patients with atrial fibrillation regarding the disease. Data were collected by asking the participants the three questions on the In-depth Individual Interview Form. Data were analyzed using the continuous comparative method of Colaizzi.

RESULTS

In the study sample, 50.0% of participants were female, 69.0% were married, and the mean age was 66.90 years (± 7.90 years). As a result of the content analysis, four main themes and 15 subthemes were identified: patient's mental status regarding the disease, patient's social status regarding the disease, patient's physical condition regarding the disease, and disease management and coping with the disease. The study found that individuals with atrial fibrillation faced major limitations in their daily living activities and social lives due to the disease symptoms and warfarin use.

CONCLUSIONS

Patients need to be provided with relevant individual training and counselling so that they lead more satisfactory lives. In addition, appropriate health appointment and monitoring systems should be developed for patients to reduce the problems associated with frequent follow-up appointments.

Early Medication Nonadherence After Acute Myocardial Infarction: Insights into Actionable Opportunities From the TReatment with ADP receptor iNhibitorS: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) Study

BACKGROUND

Nonadherence to prescribed evidence-based medications after acute myocardial infarction (MI) can contribute to worse outcomes and higher costs. We sought to better understand the modifiable factors contributing to early nonadherence of evidence-based medications after acute MI.

METHODS AND RESULTS

We assessed 7425 acute MI patients treated with percutaneous coronary intervention at 216 US hospitals participating in TReatment with ADP receptor iNhibitorS: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) between April 2010 and May 2012. Using the validated Morisky instrument to assess cardiovascular medication adherence at 6 weeks post MI, we stratified patients into self-reported high (score, 8), moderate (score, 6-7), and low (score, <6) adherence groups. Moderate and low adherence was reported in 25% and 4% of patients, respectively. One third of low adherence patients described missing doses of antiplatelet therapy at least twice a week after percutaneous coronary intervention. Signs of depression and patient-reported financial hardship because of medication expenses were independently associated with a higher likelihood of medication nonadherence. Patients were more likely to be adherent at 6 weeks if they had follow-up appointments made before discharge and had a provider explain potential side effects of their medications. Lower medication adherence may be associated with a higher risk of 3-month death/readmission (adjusted hazard ratio, 1.35; 95% confidence interval, 0.98-1.87) although this did not reach statistical significance.

CONCLUSIONS

Even early after MI, a substantial proportion of patients report suboptimal adherence to prescribed medications. Tailored patient education and pre discharge planning may represent actionable opportunities to optimize patient adherence and clinical outcomes.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01088503.

Risk of hemorrhage and treatment costs associated with warfarin drug interactions in patients with atrial fibrillation

BACKGROUND

Drug interactions with warfarin are common and may be responsible for increased patient morbidity and treatment costs.

OBJECTIVES

To assess the usage patterns of drugs that potentiate warfarin's anticoagulant activity and discuss their associated relationship with both risk of hemorrhage and treatment costs among warfarin users with atrial fibrillation (AF).

METHODS

A nested case-control study of long-term warfarin-treated AF patients was conducted using a health insurance claims database. Patients with a hemorrhagic event (cases) were matched to control patients using the incidence density sampling method. Drug-potentiating warfarin effects were identified within 30 days before the hemorrhagic event. Conditional logistic regression was used to calculate the association between use of potentiating drugs and hemorrhage risk. Mean treatment costs and CIs were calculated using the bootstrap method and tested using the t-test. Factors associated with treatment costs were determined using generalized linear models with the log-link function and γ distribution.

RESULTS

Approximately 80% of AF patients were prescribed at least 1 warfarin-potentiating medication while taking warfarin. Patients who used these medications had a 26% higher risk of hemorrhage compared with those who did not use these drugs. Likelihood of hemorrhagic events was significantly increased with the use of potentiating drugs from the following therapeutic classes: anticoagulants (odds ratio [OR] = 1.91), anti-infectives (OR = 1.76), antiplatelets (OR = 1.56), and analgesics (OR = 1.33). The risk also increased when patients took ≥3 therapeutic classes of interacting medications (OR = 1.62-1.85). Among patients with a hemorrhagic event, patients who were prescribed potentiating drugs had higher hemorrhage-related treatment costs ($1359) compared with those patients without prescriptions for warfarin-potentiating drugs ($691; P < 0.001).

CONCLUSIONS

Warfarin-potentiating drugs were commonly used among AF patients on warfarin. The use of potentiating drugs increased the risk of a hemorrhage, leading to higher treatment costs. More frequent monitoring or alternative anticoagulant therapies are needed to avoid frequent warfarin drug interactions.

The benefits of pharmacist-delivered warfarin education in the home

Objectives

Good warfarin knowledge is important for optimal patient outcomes, but barriers exist to effective education and warfarin knowledge is often poor. This study aimed to explore the educational outcomes of home-based warfarin education provided by trained pharmacists.

Methods

In a prospective, non-randomised, controlled cohort trial, patients received either usual community-based post-discharge care or a post-discharge warfarin management service, including warfarin education by trained pharmacists during two or three home visits. Patients’ warfarin knowledge was assessed at 8 and 90 days post-discharge using the Oral Anticoagulation Knowledge test.

Key findings

One hundred and thirty-nine patients were recruited into the usual care group between November 2008 and August 2009, and 129 into the intervention group between May and December 2009. Pharmacist-delivered warfarin education was associated with a significant difference between the intervention patients’ baseline and day 8 mean warfarin knowledge scores of 64.5% (95% confidence interval (CI) 61.0–68.5%) and 78.0% (95% CI 74.5–81.5%; P &lt; 0.001), respectively. The intervention patients also scored significantly higher than the usual care patients at day 8 (65.0%, 95% CI 61.5–68.0%; P &lt; 0.001), but not at day 90.

Conclusions

Use of an existing healthcare framework overcame several systemic barriers by facilitating warfarin education in patients’ homes. While the intervention was associated with better short-term warfarin knowledge, follow-up may be required to optimise its benefits. Widespread implementation of home-based warfarin education by pharmacists has the potential to contribute significantly to improved outcomes from warfarin therapy.

Performance of an online translation tool when applied to patient educational material

BACKGROUND

Language barriers may prevent clinicians from tailoring patient educational material to the needs of individuals with limited English proficiency. Online translation tools could fill this gap, but their accuracy is unknown. We evaluated the accuracy of an online translation tool for patient educational material.

METHODS

We selected 45 sentences from a pamphlet available in both English and Spanish, and translated it into Spanish using GoogleTranslate™ (GT). Three bilingual Spanish speakers then performed a blinded evaluation on these 45 sentences, comparing GT-translated sentences to those translated professionally, along four domains: fluency (grammatical correctness), adequacy (information preservation), meaning (connotation maintenance), and severity (perceived dangerousness of an error if present). In addition, evaluators indicated whether they had a preference for either the GT-translated or professionally translated sentences.

RESULTS

The GT-translated sentences had significantly lower fluency scores compared to the professional translation (3.4 vs. 4.7, P < 0.001), but similar adequacy (4.2 vs. 4.5, P = 0.19) and meaning (4.5 vs. 4.8, P = 0.29) scores. The GT-translated sentences were more likely to have any error (39% vs. 22%, P = 0.05), but not statistically more likely to have a severe error (4% vs. 2%, P = 0.61). Evaluators preferred the professional translation for complex sentences, but not for simple ones.

DISCUSSION

When applied to patient educational material, GT performed comparably to professional human translation in terms of preserving information and meaning, though it was slightly worse in preserving grammar. In situations where professional human translations are unavailable or impractical, online translation may someday fill an important niche.

Are the risk factors listed in warfarin prescribing information associated with anticoagulation-related bleeding? A systematic literature review

Warfarin significantly reduces thromboembolic risk, but perceptions of associated bleeding risk limit its use. The evidence supporting the association between bleeding and individual patient risks factors is unclear. This systematic review aims to determine the strength of evidence supporting an accentuated bleeding risk when patients with risk factors listed in the warfarin prescribing information are prescribed the drug. A systematic literature search of MEDLINE and Cochrane CENTRAL was conducted to identify studies reporting multivariate relationships between prespecified covariates and the risk of bleeding in patients receiving warfarin. The prespecified covariates were identified based on patient characteristics for bleeding listed in the warfarin package insert. Each covariate was evaluated for its association with specific types of bleeding. The quality of individual evaluations was rated as 'good', 'fair' or 'poor' using methods consistent with those recommended by the Agency for Healthcare Research and Quality (AHRQ). Overall strength of evidence was determined using the Grading of Recommendations Assessment, Development (GRADE) criteria and categorised as 'insufficient', 'very low', 'low', 'moderate' or 'high'. Thirty-four studies, reporting 134 multivariate evaluations of the association between a covariate and bleeding risk were identified. The majority of evaluations had a low strength of evidence for the association between covariates and bleeding and none had a high strength of evidence. Malignancy and renal insufficiency were the only two covariates that had a moderate strength of evidence for their association with major and minor bleeding respectively. The associations between covariates listed in the warfarin prescribing information and increased bleeding risk are not well supported by the medical literature.

Association between CHADS₂risk factors and anticoagulation-related bleeding: a systematic literature review

OBJECTIVE

To determine the strength of evidence supporting an accentuated bleeding risk when patients with CHADS(2) risk factors (chronic heart failure, hypertension, advanced age, diabetes, and prior stroke/transient ischemic attack) receive warfarin.

METHODS

A systematic literature search of MEDLINE (January 1, 1950, through December 22, 2009) and Cochrane CENTRAL (through December 22, 2009) was conducted to identify studies that reported multivariate results on the association between CHADS(2) covariates and risk of bleeding in patients receiving warfarin. Each covariate was evaluated for its association with a specific type of bleeding. Individual evaluations were rated as good, fair, or poor using methods consistent with those recommended by the Agency for Healthcare Research and Quality. The strength of the associations between each CHADS(2) covariate and a specific type of bleeding was determined using Grading of Recommendations Assessment, Development and Evaluation criteria as insufficient, very low, low, moderate, or high for the entire body of evidence.

RESULTS

Forty-one studies were identified, reporting 127 multivariate evaluations of the association between a CHADS(2) covariate and bleeding risk. No CHADS(2) covariate had a high strength of evidence for association with any bleeding type. For the vast majority of evaluations, the strength of evidence between covariates and bleeding was low. Advanced age was the only covariate that had a moderate strength of evidence for association; this was the strongest independent positive predictor for major bleeding. Similar findings were observed regardless of whether all included studies, or only those evaluating patients with atrial fibrillation, were assessed.

CONCLUSION

The associations between CHADS(2) covariates and increased bleeding risk were weak, with the exception of age. Given the known association of the CHADS(2) score and stroke risk, the decision to prescribe warfarin should be driven more by patients' risk of stroke than by the risk of bleeding.

Tools used to evaluate written medicine and health information: document and user perspectives

This study aims to identify and review tools used to evaluate consumer-oriented written medicine (WMI) and health (WHI) information from a document and user perspective. Articles that met the following inclusion criteria were reviewed: studies evaluating readability, presentation, suitability, quality of WMI/WHI. A total of 152 articles were identified, of which 64 satisfied the inclusion criteria. Fifty-nine original studies used evaluation tools and 5 reviewed a specific group of tools. Sixteen detailed the development or validation of an instrument. Fifteen studies evaluated WMI and 28 evaluated WHI. Twenty-three evaluation instruments were identified. Of the seven readability tests, SMOG was predominantly used (12 of 43 studies). Eight tools measured health literacy, with REALM being the most popular instrument (7 of 43). SAM was the most commonly used presentation tool (12 of 43 studies). Many tools are available to evaluate WMI and WHI. However, the majority are researcher focused. Most evaluate readability and presentation, revealing a gap in valid and reliable tools for assessing quality of information, and those that can be used by consumers.

Creating an anticoagulant patient education class

A patient education workgroup was developed on a progressive care medical/vascular surgical unit. The workgroup identified patient education needs regarding discharge education for postsurgical patients and those discharging with oral anticoagulants (OAC). Staff surveys aided the workgroup in identifying a need for additional discharge education for patients and families. After various methods of patient education were explored, it was determined the workgroup could best meet the needs of the patient population through a class format providing group discussion and interaction. Logistical details and class formatting were configured to meet both the needs of the patients and the nursing staff. Current institutional patient education pamphlets were used to develop the content for the class. Physician review and input were obtained during the development of the content. A patient education specialist was also consulted to ensure proper literacy levels were used. To meet the Joint Commission National Patient Safety Goal regarding anticoagulant safety, the content focused on home management, which included the following: knowledge of INR goal range, dietary factors, when to call the provider and safety precautions. Other topics to promote self-efficacy in anticoagulation therapy were also included in the content. Postclass evaluations completed by patients and families provided useful feedback for continuous improvement and patient satisfaction. Preliminary survey results indicate high patient satisfaction with the class. Plans include a quality improvement project to evaluate the effectiveness of the patient education class on OAC.

Hospitalization costs associated with warfarin-related bleeding events among older community-dwelling adults

PURPOSE

A prior paper from this study demonstrated that patient report of receiving medication instructions from health care professionals is associated with reduced risk of warfarin-related bleeding hospitalizations. The objective of this analysis was to describe the hospitalization costs due to warfarin-related bleeding events in older community-dwelling adults and to estimate the hospitalization costs avoided due to the receipt of medication instruction from different sources.

METHODS

We estimated the expected hospitalization costs associated with four instruction sources based on the respective incidence rate of observed hospitalizations and mean hospitalization cost for warfarin-related bleeding episodes from a prospective cohort study of beneficiaries of the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE). We estimated hospitalization costs avoided due to each instruction source compared to no instructions using the payer's perspective. We conducted probabilistic sensitivity analysis to account for uncertainty in our parameters.

RESULTS

One hundred twenty-six warfarin-related bleeding hospitalizations occurred during the observation period with a mean cost of $10,819 (SD: $11,536). The mean expected hospitalization cost from a warfarin-related bleeding hospitalization without instruction was $835 per year per person. Hospitalization costs avoided with instruction from a health care professional ranged from $443 to $481 per year per person.

CONCLUSIONS

The costs per hospitalization associated with warfarin-related bleeding events are substantial. Instructions for warfarin management from a health care professional may reduce the number of warfarin-related bleeding hospitalizations and associated costs. Investments in interventions to improve communication regarding warfarin management may be justified economically based on the potential cost savings estimated in this study.

Characteristics of ambulatory anticoagulant adverse drug events: a descriptive study

BACKGROUND

Despite the high frequency with which adverse drug events (ADEs) occur in outpatient settings, detailed information regarding these events remains limited. Anticoagulant drugs are associated with increased safety concerns and are commonly involved in outpatient ADEs. We therefore sought to evaluate ambulatory anticoagulation ADEs and the patient population in which they occurred within the Duke University Health System (Durham, NC, USA).

METHODS

A retrospective chart review of ambulatory warfarin-related ADEs was conducted. An automated trigger surveillance system identified eligible events in ambulatory patients admitted with an International Normalized Ratio (INR) >3 and administration of vitamin K. Event and patient characteristics were evaluated, and quality/process improvement strategies for ambulatory anticoagulation management are described.

RESULTS

A total of 169 events in 167 patients were identified from December 1, 2006-June 30, 2008 and included in the study. A median supratherapeutic INR of 6.1 was noted, and roughly half of all events (52.1%) were associated with a bleed. Nearly 74% of events resulted in a need for fresh frozen plasma; 64.8% of bleeds were classified as major. A total of 59.2% of events were at least partially responsible for hospital admission. Median patient age was 68 y (range 36-95 y) with 24.9% initiating therapy within 3 months prior to the event. Of events with a prior documented patient visit (n = 157), 73.2% were seen at a Duke clinic or hospital within the previous month. Almost 80% of these patients had anticoagulation therapy addressed, but only 60.0% had a follow-up plan documented in the electronic note.

CONCLUSIONS

Ambulatory warfarin-related ADEs have significant patient and healthcare utilization consequences in the form of bleeding events and associated hospital admissions. Recommendations for improvement in anticoagulation management include use of information technology to assist monitoring and follow-up documentation, avoid drug interactions, and engage patients in their care.

Drug interaction presenting as acute abdomen

Warfarin is the most common oral anticoagulant prescribed around the world. Adverse drug interactions with warfarin are a huge problem especially in the elderly and in patients who take multiple medications. Most adverse drug interactions involve concomitantly prescribed oral or intravenous medications. Occasionally, topical or mucosally absorbed drugs can interact, leading to fluctuations in warfarin levels with adverse consequences. In this case report, we describe a case of intestinal intramural hematoma, a rare but known consequence of a supra therapeutic international normalized ratio (INR). The supra therapeutic INR was a consequence of mucosally absorbed miconazole, prescribed for vaginal candidiasis. We wish to highlight this rare and potentially fatal drug interaction, along with the need for frequent INR monitoring when new drugs are added or removed in patients taking warfarin.

Continuity of Health Care and the Pharmacist: Let's Keep It Simple

Pharmacists are a cornerstone of quality medication management. High-quality continuity of care involves patient-centered medication therapy management, which could be bolstered for 26 million Part D Medicare beneficiaries. Yet, many patients do not receive sufficient instruction about their prescription medications. Patient-centered aspects are important because of the heterogeneity in patient types and severity of disease, varying treatment requirements, lifestyle factors, and differences in health literacy. Although time constraints for all health professionals are apparent, a simple but crucial contribution by pharmacists to the continuity of care is to increase the emphasis on patient-centered medication instruction.

Factors associated with exacerbation of heart failure include treatment adherence and health literacy skills

We determined the factors associated with exacerbation of heart failure, using a cohort (n = 192) nested within a randomized trial at a university-affiliated ambulatory practice. Factors associated with emergency or hospital care included left ventricular ejection fraction, hematocrit and serum sodium levels, refill adherence, and the ability to read a prescription label. Refill adherence of <40% was associated with a threefold higher incidence of hospitalization for heart failure than a refill adherence of >or=80% (P = 0.002). In multivariable analysis, prescription label reading skills were associated with a lower incidence of heart failure-specific emergency care (incidence rate ratio, 0.76; 95% confidence interval (CI), 0.19-0.69), and participants with adequate health literacy had a lower risk of hospitalization for heart failure (incidence rate ratio, 0.34; 95% CI, 0.15-0.76). We conclude that inadequate treatment adherence and health literacy skills are key factors in the exacerbation of heart failure. These findings emphasize the need for careful instruction of patients about their medications.