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Management of warfarin in atrial fibrillation: views of health professionals, older patients and their carers

Beata V Bajorek, Susan J Ogle, Margaret J Duguid, Gillian M Shenfield and Ines Krass
Med J Aust 2007; 186 (4): 175-180. || doi: 10.5694/j.1326-5377.2007.tb00856.x
Published online: 19 February 2007

Abstract

Objective: To identify the views of health professionals, patients and their carers on strategies to improve the use and management of warfarin in older patients with atrial fibrillation.

Design: Qualitative study based on analysis of group interviews.

Setting: A major metropolitan teaching hospital, from 1 March to 30 April 2003.

Participants: 14 patients (≥ 65 years) with established atrial fibrillation and taking warfarin, three carers, 12 specialists, eight general practitioners, six community pharmacists, nine hospital pharmacists, and 11 nurses volunteered in response to flyers promoting the study.

Results: Suggested strategies to improve warfarin management targeted support services for GPs and patients. Hospital-based clinicians felt that dissemination of trial evidence to GPs to support treatment recommendations is required, and that GPs need to enlist allied health professionals in the management of patients taking warfarin. GPs preferred access to practical advice from expert colleagues on the day-to-day management. Patients requested more information about warfarin therapy, as access to information is inadequate, particularly from primary sources (GPs, community pharmacists). Verbal and written information are equally important, but a single counselling session or supply of a booklet was viewed as inadequate. Participants identified various interventions for all levels of warfarin management; from the collective input, a framework for management strategies was developed.

Conclusions: Health professionals and patients require more customised information to support warfarin use and management.

Despite evidence to support its use in atrial fibrillation,1,2 several Australian studies have shown that warfarin therapy remains underutilised, particularly in older patients,3,4 where the day-to-day management is perceived by clinicians to be more difficult.5,6 In prescribing warfarin, current practice often involves initiation of therapy in the acute care setting (hospital), with long-term management provided in the community by the general practitioner. For the patient, this usually translates to routine visits to the pathology service for blood tests, regular follow-up by doctors for warfarin dose adjustment, and lifestyle changes (eg, diet).

Previous research has focused on identifying the barriers to warfarin use and preferences for treatment options.5,7,8 Widespread consultation with key prescribers and patients on how to improve warfarin use and its day-to-day management is lacking. Furthermore, to our knowledge, no studies have explored the broader perspectives of patients’ carers or other health professionals. We aimed to explore the attitudes of doctors, other health professionals, patients and carers, to identify ways to improve the management of warfarin in older patients.

Methods

A series of group interviews, involving health professionals, patients and carers, was conducted at Royal North Shore Hospital, Sydney between 1 March and 30 April 2003. Each interview involved an independent facilitator experienced in conducting focus groups and unknown to the participants, a co-facilitator, and a scribe. Discussion was facilitated using a brief topic guide, listing open-ended questions such as:

Data analysis

The audiotaped discussions were transcribed verbatim then thematically analysed, using a phenomenological approach,10,11 by inductively coding significant statements within the transcripts into themes, followed by re-review of the data for verification.12 Validity was attained by investigator triangulation and respondent validation; the co-facilitator and scribe independently analysed the transcripts before reaching a consensus,13,14 then compared this against the scribe’s supplementary notes. Finally, after review by the main facilitator, the findings were fed back to volunteer participants from each group to ensure the accuracy of the interpretation.14

Results

From eight group interviews (n = 63, Box 1), four core themes arose: day-to-day experiences with warfarin therapy; dependence on the GP in warfarin therapy; barriers to warfarin use; and strategies to improve warfarin use. The last theme is the subject of this article, and comprised four sub-themes:

Need for information to support warfarin use

Across all of the groups, an overarching theme was the perceived paucity of information to support warfarin therapy across the continuum of care.

Information for decision making

GPs and hospital-based doctors felt that there is insufficient information to support the decision to initiate warfarin therapy. GPs were perplexed about the decisions made in hospital to begin warfarin therapy, and wanted a wider dissemination of clinical trial evidence to provide a rationale. They requested that specialists be more proactive in offering this information, similar to the way that industry representatives promote their products.

Patients likewise needed more information on the role and relative importance of warfarin therapy, as this affects their decision to accept, and hence continue with, warfarin.

Health professionals, particularly nurses, collectively expressed a need to document and communicate information on the decisions to initiate warfarin therapy, expressing uncertainty as to whether patients’ cognitive, functional and social status are considered in these decisions. Geriatricians focused on the risks of therapy, asking prescribers to justify their decisions, and cardiologists felt that GPs particularly need to engage in this process, recommending specific “prompts” (decision aids) to help assess and document a patient’s suitability for warfarin therapy. Hospital pharmacists suggested explicit, objective and practical measures to routinely obtain patient-specific information for decision making, as a risk-reduction strategy.

Information for ongoing management

To support ongoing management in the community, there was widespread need for more information, particularly among GPs, who wanted practical and interactive advice, rather than position statements, for dealing with acute situations (eg, high international normalised ratios [INRs], bleeds).

Cardiologists and hospital pharmacists supported this, but varied in their approaches. Cardiologists focused on practical, simply formatted, written information for managing day-to-day situations, as continuing education seminars were of limited benefit, whereas pharmacists felt that written methods would be ineffective.

Among all of the health professionals, community pharmacists felt that they have least opportunity to assist patients and GPs, as they often lack access to both specific information on the patient’s warfarin regimen and appropriate resources, and are unable to track blood test results because they are not linked into the reporting system between the patient, pathologist and GP.

Hospital-based pharmacists acknow-ledged this problem, and suggested that community pharmacists could make better use of their computer software to help manage patients.

Deficiencies in the provision of information to patients

The participants universally agreed that the provision of information to patients is inadequate, including poor use of existing resources. The supply of the standard “little blue warfarin booklet” (manufacturer-produced) is insufficient as a stand-alone measure, as patients need to practically engage with its contents to achieve adherence. Patients and carers felt that verbal and written information are equally important, but need to be provided in a paced manner with an opportunity to verify the patient’s understanding at a later time.

Access to dedicated services in the community setting
Patient surveillance

Community-based surveillance and support of older patients was proposed by hospital pharmacists and nurses, who recognised that education alone would not guarantee risk-free warfarin use. Mobile community-based services were recommended, as hospital-based anticoagulant clinics were considered of limited assistance to the at-risk older population. GPs suggested specialised community liaison services, including home visits, using qualified pharmacists to improve the surveillance of patients, but were opposed to a greater role for the general community pharmacist, as they were perceived to be underqualified to provide higher level cognitive services (eg, patient education, counselling, and therapeutic drug monitoring).

Access to information and resources

There was general agreement that access to information and resources within the community setting needs improvement, as education in the hospital setting was perceived as ineffective. Even patients who received comprehensive education in hospital stated that they found it difficult to apply the knowledge once discharged, as there is no ongoing reinforcement. Face-to-face accessible support and advisory services in the community setting are necessary, but patients did not feel that GPs alone could offer this.

Although community pharmacists are ideally placed and trained to contribute to ongoing patient education, hospital pharmacists were disappointed that their community peers contributed minimally to warfarin education, but GPs were worried about increasing their involvement. Patients reported variable experiences at community pharmacies, and were most satisfied when information was provided in a caring atmosphere.

Although community pharmacists agreed that they could be more involved in warfarin counselling, both initially and on follow-up, surveillance of patients was perceived as the role of nurses and GPs.

Discussion

To our knowledge, this is the first study to have concurrently examined the perspectives of clinicians, allied health professionals and patients regarding appropriate strategies to improve warfarin use and management in Australia. Although studies have previously explored prescriber and patient preferences for selecting treatment options,5,7,8 or have identified interspecialty differences in prescribing,5,15,16 none have concurrently gauged opinions on how to enhance therapeutic management.

Several important issues emerged from our study. First, despite a relative paucity of evidence about the risk versus benefit of warfarin therapy in older patients, there is room for improvement in decision-making processes, particularly in the documentation and communication of decisions. Before initiation of therapy, risk assessments need to be performed and documented more carefully, as there is uncertainty as to how rigorously clinicians consider various factors. Interventions involving comprehensive assessment, with systematic documentation and communication, can assist in selection of appropriate antithrombotic therapy for individual patients,17 and may help clarify the perceived underutilisation of warfarin in older patients.

It was widely acknowledged that GPs need practical information on how to apply evidence from clinical trials to individual patients. However, while GPs preferred face-to-face contact with clinicians to discuss issues and ask questions, hospital-based clinicians and allied health professionals preferred paper-based resources. The value of live contact is highlighted by an Australian study reporting an improvement in GPs’ knowledge and confidence in prescribing warfarin following face-to-face academic-detailing visits.18 Although a multitude of guidelines have been developed, ranging from small practice-based protocols to consensus statements,19 their utility is dependent on the evidence and the process by which they are developed,20 and is limited by clinicians’ beliefs that guidelines are inapplicable to their patients.21-23

Previous studies examining patient preferences for using warfarin versus other therapies have not sought to identify patients’ needs for resources to support the therapy.7 Patients in our study felt somewhat abandoned in their management of warfarin, and felt that they have no option other than to undertake independent research because of the limited accessibility of the GP, lack of information from community pharmacists, and non-availability of services for ongoing support, advice, and education. These findings are concerning, given that patient knowledge regarding warfarin is generally poor,24,25 and this influences anticoagulation control.24 Yet our findings suggest there is limited effort toward rectifying this problem, perhaps reflecting an assumption by health professionals that other colleagues are educating patients. Our findings highlight that additional counselling at every opportunity, from all involved, is warranted and must cater to individual patient needs rather than relying on suboptimally formatted mass-produced written information.26,27

Internationally, support services to monitor and educate patients on warfarin therapy are coordinated by allied health professionals,28,29 and in our study, participants, particularly cardiologists, felt that GPs could make greater use of allied health services (eg, pharmacists and nurses) in the community. However, community pharmacists did not see a need for their own greater involvement, and GPs perceived such services to be of limited value, preferring practical advice from consultants. The responses of both GPs and pharmacists highlight an important issue: the entire, significant responsibility for the management of warfarin therapy has been defaulted to the GP. Allied health professionals must recognise their contributions to and responsibilities in warfarin therapy, as this itself may be a major step forward in improving its management in the community setting.

Study limitations

In conducting group interviews, bias may be introduced though the facilitation of the discussions, dominance of individuals, and in the interpretation of the results. However, the main facilitator and the study investigators functioned independently, were not involved in a dependency relationship with any of the participants, and necessarily set aside all prejudgements about the topic in data analysis.12 Because recruitment was voluntary, the sample may have been biased toward those wanting to express a particular viewpoint, especially grievances, and may not be generalisable to most key players in warfarin management. However, the sample represents a diversity of experiences and perspectives on this issue.

Resource limitations precluded a larger sample size, and although each discussion was facilitated until no new issues emerged, we were unable to hold multiple sessions to ensure theme saturation,12 nor ascertain additional views (eg, junior medical officers). Because of the small number of carers, it was not fully elucidated whether their perspectives differ from those of patients; however, the perspectives of both patient and carer groups, as a whole, were similar. Because the analysis involved anonymised transcripts, we were unable to correlate perspectives with participants’ age, sex, location, or therapeutic regimen.

Our study suggests that very simple measures, such as disseminating information to patients and GPs, and the participation of allied health professionals, may have some far-reaching effects in terms of improving the use and management of warfarin. Much more intervention by all health professionals is required, and further research should explore the development, implementation and evaluation of new resources and strategies, given the opportunities to adopt newer technologies.

1 Characteristics of the participants in the eight focus groups

Number (Group composition)

Mean age in
years ± SD (range)

Mean years with warfarin* ± SD (range)


Patients and carers I

7 (6 patients, 1 carer; 3 M, 4 F)

78.9 ± 4.1 (72–83)

11.0 ± 12.4 (1–29)

Patients and carers II

10 (8 patients, 2 carers; 5 M, 5 F)

76.0 ± 9.2 (65–91)

3.1 ± 4.6 (0.5–15)

Clinicians I: aged care

6 (5 consultants, 1 registrar; 2 M, 4 F)

42.0 ± 10.7 (32–57)

10.75 ± 10.1 (3–26)

Clinicians II: cardiology/general medicine

6 (3 consultants, 3 registrars; 4 M, 2 F)

41.0 ± 13.8 (28–57)

12.0 ± 10.7 (2–25)

General practitioners

8 (3 from small practices of ≤ 2 GPs, 5 from large practices of > 2 GPs/medical centre; 6 M, 2 F)

51.8 ± 11.1 (42–75)

20.9 ± 12.9 (10–49)

Aged care nurses

11 (3 aged care ward nurses, 2 aged care clinical nurse specialists/consultants, 4 home-nursing service or assessment nurse, 1 hospital-to-community liaison nurse, 1 hospital-to-community liaison pharmacist; 0 M, 11 F)

42.5 ± 10.4 (25–54)

18.9 ± 11.1 (3.5–33)

Hospital pharmacists

9 (4 specialist pharmacists [cardiology, aged care, neurology], 4 rotational/ward pharmacists, 1 outpatient pharmacist; 1 M, 8 F)

39.6 ± 11.8 (26–56)

17.9 ± 13.2 (3–36)

Community pharmacists

6 (5 senior community pharmacists, 1 graduate pharmacist; 5 M, 1 F)

50.5 ± 16.9 (23–67)

24.9 ± 17.3 (0.5–40)


* Years with warfarin means number of years practising in specialty, or number of years taking warfarin, or number of years caring for a warfarin user, for health care professionals, patients, and carers, respectively. M = male. F = female. Each group interview lasted an average of 1 hour (range, 45–80 minutes).

2 Potential strategies at different levels of intervention to improve long-term warfarin use and management

Hospital-based decision-making processes for the prescribing of warfarin by clinicians

Community-based decision-making processes for the prescribing of warfarin by GPs

Long-term patient monitoring in the community setting

Patient surveillance (pharmacovigilance) in the community setting

Patient and carer education and information services

Ongoing support services for patients and carers on a long-term basis


INR = international normalised ratio.

Received 13 February 2006, accepted 30 November 2006

  • Beata V Bajorek1,2
  • Susan J Ogle3
  • Margaret J Duguid3
  • Gillian M Shenfield3
  • Ines Krass1

  • 1 Faculty of Pharmacy, University of Sydney, Sydney, NSW.
  • 2 Northern Sydney Central Coast Health, Sydney, NSW.
  • 3 Royal North Shore Hospital, Sydney, NSW.


Correspondence: beatab@pharm.usyd.edu.au

Acknowledgements: 

A grateful thank-you is extended to Dr Peter Veitch for his involvement in, and support of, this study. This project was funded by the Australian Government Department of Health and Ageing.

Competing interests:

None identified.

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