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Mann HK, Streiff M, Schultz KC, Halpern DV, Ferry D, Johnson AE, Magnani JW. Rurality and Atrial Fibrillation: Patient Perceptions of Barriers and Facilitators to Care. J Am Heart Assoc 2023; 12:e031152. [PMID: 37889198 PMCID: PMC10727401 DOI: 10.1161/jaha.123.031152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/03/2023] [Indexed: 10/28/2023]
Abstract
Background Patients experience atrial fibrillation (AF) as a complex disease given its adversity, chronicity, and necessity for long-term treatments. Few studies have examined the experience of rural individuals with AF. We conducted qualitative assessments of patients with AF residing in rural, western Pennsylvania to identify barriers and facilitators to care. Methods and Results We conducted 8 semistructured virtual focus groups with 42 individuals living in rural western Pennsylvania using contextually tailored questions to assess participant perspectives. We inductively analyzed focus group transcripts using paragraph-by-paragraph and focused coding to identify themes with the qualitative description approach. We used Krippendorff α scoring to determine interreviewer reliability. We harnessed investigator triangulation to augment the reliability of our findings. We reached thematic saturation after coding 8 focus groups. Participants were 52.4% women, with a median age of 70.9 years (range, 54.5-82.0 years), and most were White race (92.9%). Participants identified medication costliness, invisibility of AF to others, and lack of emergent transportation as barriers to care. Participants described interpersonal support and use of technology as important for AF self-care, and expressed ambivalence about how relationships with health care providers affected AF care. Conclusions Focus group participants described multiple social and structural barriers to care for AF. Our findings highlight the complexity of the experience of individuals with AF residing in rural western Pennsylvania. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04076020.
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Affiliation(s)
| | - Meg Streiff
- University Center for Social and Urban ResearchUniversity of PittsburghPA
| | - Kevan C. Schultz
- University Center for Social and Urban ResearchUniversity of PittsburghPA
| | - David V. Halpern
- University Center for Social and Urban ResearchUniversity of PittsburghPA
| | - Danielle Ferry
- Center for Research on Health Care, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPA
| | - Amber E. Johnson
- Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPA
| | - Jared W. Magnani
- Center for Research on Health Care, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPA
- Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPA
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Yiu A, Bajorek B. Patient-focused interventions to support vulnerable people using oral anticoagulants: a narrative review. Ther Adv Drug Saf 2019; 10:2042098619847423. [PMID: 31205676 PMCID: PMC6535713 DOI: 10.1177/2042098619847423] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 04/01/2019] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Angela Yiu
- Graduate School of Health – Pharmacy, University Technology of Sydney, Level 4, Building 7, 67 Thomas Street, Ultimo, NSW 2007, Australia
| | - Beata Bajorek
- Graduate School of Health – Pharmacy, University of Technology Sydney and Pharmacy Department, Royal North Shore Hospital, Australia
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Obamiro KO, Chalmers L, Lee K, Bereznicki BJ, Bereznicki LR. Adherence to Oral Anticoagulants in Atrial Fibrillation: An Australian Survey. J Cardiovasc Pharmacol Ther 2018; 23:337-343. [DOI: 10.1177/1074248418770201] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: The aim of this study was to investigate the proportion of patients who have suboptimal adherence to oral anticoagulant (OAC), identify the predictors of adherence, and determine whether patient-related factors vary across adherence levels in Australia. Methods: Respondents were recruited for an online survey using Facebook. Survey instruments included the Morisky Medication Adherence Scale, the Anticoagulation Knowledge Tool, the Perception of Anticoagulant Treatment Questionnaires, and a modified Cancer Information Overload scale. Predictors of medication adherence were identified using ordinal regression analysis. Results: Of the 386 responses eligible for analysis, only 54.9% reported a high level of adherence. Participants aged 65 years or younger were less likely to have high adherence compared to older participants (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.33-0.88; P = .013), while females were more likely to be highly adherent compared to males (OR, 1.69; 95% CI, 1.08-2.64; P = .023). The analyses showed that age, gender, treatment satisfaction, information overload, concerns about making mistake when taking OACs, and cost of medication were significant predictors of adherence. Conclusion: Self-reported suboptimal adherence to OAC is common among patients with atrial fibrillation. A focus on supporting people who are at higher risk of suboptimal adherence is needed to maximize the benefit of OAC therapy in this population.
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Affiliation(s)
- Kehinde O. Obamiro
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Leanne Chalmers
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Kenneth Lee
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Bonnie J. Bereznicki
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Luke R. Bereznicki
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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Lim SL, Chan SP, Lee KY, Ching A, Holden RJ, Miller KF, Storrow AB, Lam CS, Collins SP. An East-West comparison of self-care barriers in heart failure. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 8:615-622. [PMID: 29283270 DOI: 10.1177/2048872617744352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Barriers in heart failure self-care contribute to heart failure hospitalizations, but geographic differences have not been well-studied. We aimed to compare self-care barriers in heart failure patients managed at tertiary centers in an Eastern (Singapore) versus a Western (USA) nation. METHODS Acute heart failure patients were prospectively assessed with a standardized instrument comprising of 47 distinct self-care barriers. The multi-equation generalized structural equation model was used to evaluate for geographic differences in barriers experienced, and association of barriers with outcomes. RESULTS Patient-related factors accounted for six out of 10 most prevalent self-care barriers among the 90 patients, with a median number of 11 barriers reported per patient. The Western patients reported a higher level of barriers when compared with their Eastern counterparts (median (interquartile range) 15 (9-24) versus 9 (4-16), p=0.001), after adjusting for demographics and co-morbidities. Many of these differences could be explained by geographic differences between the countries. There was no significant difference identified in all-cause mortality (19.4% versus 10.2%) and heart failure re-hospitalization (41.9% versus 45.8%) at six months between the groups. CONCLUSIONS Self-care barriers are highly prevalent among acute heart failure patients, and differ substantially between East and West, but were not associated with geographic differences in outcomes.
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Affiliation(s)
- Shir Lynn Lim
- Department of Cardiology, National University Heart Center, Singapore
| | - Siew Pang Chan
- Department of Medicine, National University of Singapore, Singapore.,Cardiovascular Research Institute, National University Heart Center, Singapore
| | - Kim Yee Lee
- Department of Cardiology, National University Heart Center, Singapore
| | - Anne Ching
- Department of Cardiology, National University Heart Center, Singapore
| | - Richard J Holden
- Department of BioHealth Informatics, Indiana University School of Informatics and Computing, USA.,Indiana University Center for Aging Research, USA
| | | | | | - Carolyn Sp Lam
- Department of Cardiology, National Heart Center, Singapore.,Duke-NUS Graduate Medical School, Singapore
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Mohamed S, Abdul Razak T, Hashim R, Mohd Ali Z. Knowledge of Atrial Fibrillation and Stroke Prevention. J Pharm Technol 2016. [DOI: 10.1177/8755122516681820] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Bacground: Atrial fibrillation (AF) patients are 5 times more likely to have stroke than non-AF patients. Stroke prevention (SP) using anticoagulation therapy was recommended in AF patients. Knowledge about AF and SP (KAFSP) is one of the essential factors that can improve patients’ adherence. Yet no established studies were found to determine patients’ KAFSP among AF patients. Objectives: To develop and validate the questionnaire used to measure KAFSP. Methods: A cross-sectional survey was conducted in 4 hospitals in Malaysia. The psychometric of the KAFSP Questionnaire (KAFSP-Q) were performed using content validity index (CVI), internal consistency, test-retest, exploratory factor analysis (EFA), and sensitivity test. Results: A total of 304 patients completed a face-to-face interview to answer the KAFSP-Q. Content and face validity was assessed by 6 experts who are knowledgeable in this field and 15 AF patients, respectively. The KAFSP-Q had good CVI and were well understood by AF patients. The KAFSP-Q also had good reliability and stability with Cronbach’s α of .83 and intraclass correlation coefficient values in test-retest for stability of .9. The EFA results indicated that there were 6 factors with factor loadings above .30. The low correlations between subscales ranged between .01 and .48, which indicated that good discriminant and construct validity were achieved. The scale was able to differentiate between patients’ knowledge levels before and after counseling given. Conclusions: The KAFSP-Q is reliable and valid to measure patients’ KAFSP. Further validation studies are recommended to validate the KAFSP-Q in different contexts and in other languages.
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Affiliation(s)
- Sahimi Mohamed
- International Islamic University Malaysia, Kuantan Campus, Kuantan, Pahang, Malaysia
| | - Tariq Abdul Razak
- International Islamic University Malaysia, Kuantan Campus, Kuantan, Pahang, Malaysia
| | - Rosnani Hashim
- Cyberjaya University College of Medical Sciences, Selangor, Malaysia
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Factors Affecting Warfarin-Related Knowledge and INR Control of Patients Attending Physician- and Pharmacist-Managed Anticoagulation Clinics. J Pharm Pract 2011; 24:485-93. [DOI: 10.1177/0897190011415684] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives: To assess the anticoagulation knowledge and international normalized ratio (INR) control among patients on warfarin. Methods: A cross-sectional study with 156 randomly sampled patients from physician- (non-medication therapy adherence clinic [non-MTAC]) and pharmacist (MTAC)-run anticoagulation clinics using a validated interviewer-administered questionnaire. Patients' INR readings from 2008 to 2010 were recorded. Results: Patients on warfarin scored an average of 66.5% ± 36.0% for their knowledge on how warfarin works, 42.9% ± 44.9% for interaction between warfarin and alcohol, and 49.2% ± 21.1% for adverse effects. No significant differences were found between MTAC and non-MTAC patients on their knowledge. There was a negative correlation between patients' knowledge and age ( P = .001, rs = −.293) and a positive correlation between patients' knowledge and education level ( P = .001, rs = .365). MTAC patients were found to have better INR control than non-MTAC when compared for mean percentage days in range (63.4% ± 18.9% vs 52.5% ± 18.2%; P = .006) and mean percentage visits in range (58.8% ± 17.9% vs 46.8% ± 18.6%; P = .001). Conclusions: MTAC patients were found to have better INR control compared to non-MTAC patients. A joint cooperation between physicians, pharmacists, and nurses should exist to achieve desired therapeutic outcomes.
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Nasser S, Mullan J, Bajorek B. Challenges of Older Patients’ Knowledge About Warfarin Therapy. J Prim Care Community Health 2011; 3:65-74. [DOI: 10.1177/2150131911416365] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To review the challenges of warfarin education for older patients (aged 65 years or older) in terms of knowledge, access to warfarin education, and education resources. Methods: A quasi-systematic review of the literature was performed via electronic database searches (eg, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, Meditext, and Google Scholar) from 1990 to May 2011. Results: The 62 articles reviewed found that improved patient knowledge results in better anticoagulation control. The review also found that between 50% and 80% of older patients have inadequate knowledge about the basic aspects of warfarin therapy (eg, action, benefits and risks, interactions with other drugs or foods, international normalized ratio management). Demographic factors, such as advancing age, lower family income, and limited health literacy, were found to inversely affect patients’ warfarin knowledge, and access to warfarin education and information resources were often suboptimal in different practice settings. Finally, a number of educational strategies and resources that could be readily incorporated to improve the effectiveness of current warfarin education programs were extracted from the review. Conclusion: This comprehensive review highlights that education about warfarin in older patients is currently suboptimal and may in part contribute to poor therapeutic outcomes. This review article also acknowledges the need to identify, target, and develop educational strategies and resources to further improve older patients’ knowledge about their warfarin therapy.
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Davis NJ, Billett HH, Cohen HW, Arnsten JH. Impact of adherence, knowledge, and quality of life on anticoagulation control. Ann Pharmacother 2005; 39:632-6. [PMID: 15713790 DOI: 10.1345/aph.1e464] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Patients receiving chronic warfarin therapy who have poor anticoagulation control are at increased risk for adverse events. However, it is unknown how adherence to warfarin, patient demographics, patient knowledge about therapy, and perceived impact of warfarin therapy on quality of life are associated with anticoagulation control. OBJECTIVE To determine the association between these patient factors and anticoagulation control in patients attending 2 anticoagulation clinics in the Bronx, New York City. METHODS A cross-sectional survey of 52 patients was conducted. The 4-item Morisky survey was used to assess self-reported adherence. Patient knowledge about warfarin therapy and the perceived impact of warfarin therapy on quality of life were determined by self-administered questionnaires. Associations between adherence, patient knowledge, impact of warfarin therapy on quality of life, and anticoagulation control were determined with t-tests, chi(2) analysis, and logistic regression. RESULTS Only 14% of patients had good anticoagulation control. Adequate adherence was reported by 50% of patients and was significantly associated with good anticoagulation control (p = 0.01). Thirty-seven percent of participants had good knowledge of anticoagulation, and 19% of participants reported that warfarin negatively impacted their quality of life. Knowledge about warfarin therapy and impact of warfarin on quality of life were not significantly associated with anticoagulation control. CONCLUSIONS Adherence is one of many factors that contribute to anticoagulation control. Adequate adherence, as determined by the Morisky survey, was significantly associated with anticoagulation control. Patient demographic characteristics, knowledge about warfarin therapy, and perceived impact of warfarin on quality of life were not associated with anticoagulation control.
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Affiliation(s)
- Nichola J Davis
- Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10461-2601, USA.
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