| dc.description.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. | en |
