Patient education and advocacy form the backbone to patient safety. Continued education has particular importance for those with AF who are anticoagulated. Poor outcomes, such as hospital readmissions, link to patients’ lack of knowledge about their care and treatment.1 Various patient care models for managing anticoagulation therapy associate with improved outcomes. These models include management by specialized staff at anticoagulation clinics along with patient self-testing and self-management of international normalized ratio (INR). Healthcare providers including nurses, pharmacists, and physicians have the responsibility of educating patients and advocating for appropriate placement of each individual into the optimal patient care model.
Anticoagulation therapy with warfarin is a safe and effective treatment, but can be cumbersome for both clinicians and patients to manage. Initial education at the hospital or physician’s office and continued education at home help patients to remain well-informed about their disease state and become proactive in their care. Warfarin causes the most adverse drug events that lead to emergency department visits.2 Studies have shown that patient education improves time spent in therapeutic range with warfarin and decrease rates of hemorrhagic and thrombotic events.3,4 The Joint Commission’s National Patient Safety Goals require a patient education component for anticoagulation.5 Clinicians should not only initiate education, but they should also be prepared to recommend resources to patients for continued education at home.
A 2013 report showed that more than 80% of adults use the internet, and almost 60% of them had looked online for health related information in the previous 12 months. Some clinicians remain concerned about the quality of the information on the web and the difficulty patients have evaluating the credibility of information. Directing patients to authoritative, commercial-free, patient-oriented medical information may help mitigate some of these concerns. An abundance of advocacy groups offer quality, up to date information for patients, especially those sponsored by governments, academic medical centers, and major professional organizations. Clinicians should recognize the added value in having conversations with well-informed patients. A motivated patient can discover more details on a specific health topic from the internet than is feasible for a clinician to provide during a single office visit. When managed correctly, continued lay education using the internet may result in a more productive patient-provider relationship and can facilitate shared decision making.
Whenever feasible, patients taking warfarin should be referred to an Anticoagulation Management Service (clinic) for specialized care. In this setting, well-informed patients can enroll in programs for self-testing or self-management of INR. Self-testing allows patients to monitor their INR in the convenience of their own home. Self-testing increases time spent in therapeutic range (TTR), quality of life, and patient satisfaction.6 Patient self-management of warfarin also has proven to be a safe and effective method for well-informed and highly motivated patients. Previous studies report this model of care to be superior to management by general practitioners or anticoagulation clinics in terms of quality of INR control and rates of thromboembolic and hemorrhagic events.7-10 Suitable patients should have such management strategies implemented. There is considerable interest in adapting Anticoagulation Management Services to provide counseling, education, and follow-up for patients anticoagulated with the NOACs in addition to their continued services that provide important value to warfarin patients.
Initial education by a clinician and continued education by the patient is the key for successful anticoagulation. Clinicians should aid their patients to acquire the tools to be proactive in their care, and patients should be directed toward quality healthcare information from the internet, books, magazines, newsletters, newspapers, or other patient preferred media.
1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital.Ann Intern Med.2003;138(3):161-167.
2. Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults.Ann Intern Med.2007;147(11):755-765.
3. Pernod G, Labarere J, Yver J, et al. EDUC'AVK: reduction of oral anticoagulant-related adverse events after patient education: a prospective multicenter open randomized study.J Gen Intern Med.2008;23(9):1441-1446.
4. Wilhelm SM, Petrovitch EA. Implementation of an inpatient anticoagulation teaching service: expanding the role of pharmacy students and residents in patient education.Am J Health Syst Pharm.2011;68(21):2086-2093.
5. Joint Commission. Anticoagulation therapy, NPSG 03.05.01. www.jointcommission.org/assets/1/6/2011_NPSGs_HAP.pdf. Accessed 27 June, 2011.
6. Matchar DB, Jacobson A, Dolor R, et al. Effect of home testing of international normalized ratio on clinical events.N Engl J Med.2010;363(17):1608-1620.
7. Kortke H, Korfer R. International normalized ratio self-management after mechanical heart valve replacement: is an early start advantageous?Ann Thorac Surg.2001;72(1):44-48.
8. Voller H, Glatz J, Taborski U, Bernardo A, Dovifat C, Heidinger K. Self-management of oral anticoagulation in nonvalvular atrial fibrillation (SMAAF study).Z Kardiol.2005;94(3):182-186.
9. Watzke HH, Forberg E, Svolba G, Jimenez-Boj E, Krinninger B. A prospective controlled trial comparing weekly self-testing and self-dosing with the standard management of patients on stable oral anticoagulation.Thromb Haemost.2000;83(5):661-665.
10. Khan TI, Kamali F, Kesteven P, Avery P, Wynne H. The value of education and self-monitoring in the management of warfarin therapy in older patients with unstable control of anticoagulation.Br J Haematol.2004;126(4):557-564.
Hear Dr. Greg Piazza discuss patient advocacy and education:
View Dr. Ruff's Patient Page here:
Christian T. Ruff, MD, MPh. Stroke Prevention in Atrial Fibrillation. Circulation: Journal of the American Heart Association. 2012, 125:e588-e590
View a lecture on Stroke Prevention in Atrial Fibriallation from Julie Shea, a Nurse Practitioner at Brigham and Women's Hospital.
Patient Education for Stroke Prevention in Atrial Fibrillation
Julie Shea, MS, RNCS, FHRS, CCDS