Enhance adherence to oral anticoagulant therapy among patients with atrial fibrillation after an educational intervention in Nam Dinh provincial General Hospital

Nội dung text: Enhance adherence to oral anticoagulant therapy among patients with atrial fibrillation after an educational intervention in Nam Dinh provincial General Hospital

1. RESEARCH ARTICLE ENHANCE ADHERENCE TO ORAL ANTICOAGULANT THERAPY AMONG PATIENTS WITH ATRIAL FIBRILLATION AFTER AN EDUCATIONAL INTERVENTION IN NAM DINH PROVINCIAL GENERAL HOSPITAL Ngo Huy Hoang1, Tong Thi Anh2, 1Nam Dinh University of Nursing, 2Nam Dinh General Hospital ABSTRACT Objective: To assess the current before the intervention. There were 40.2% practice and changes in adherence to Anti- of patients who achieved the target IRN vitamin K anticoagulants therapy among before the intervention then this number cardiovascular patients with atrial fibrillation also increased markedly to 70.6% at the after the educational intervention at Nam point of one month later the intervention (p Dinh Provincial General Hospital. Method: values of 0.01). The percentage of patients The one group pre-test and post-test who had experienced the behaviors those educational intervention was conducted related to inadequate use of anticoagulants among 102 cardiovascular outpatients with also decreased clearly after the intervention. atrial fibrillation who were under Anti-vitamin Conclusion: The study results showed the K anticoagulant therapy at least one month. poor practice in adherence to Anti-vitamin The Morisky Medication Adherence Scale K anticoagulant, and the significantly (MMAS-8) was applied to evaluate the improvements after the educational outcomes before and after the education. intervention. The study revealed the real Results: Before the intervention, the need to educate patients on adherence percentage of patients achieved the overall to Anti-vitamin K anticoagulant therapy as adherence to Antivitamin K anticoagulant a supplement added to routine guidelines therapy was only 32.4% of patients. One when patients receive a prescription. month after completing the intervention, Keywords: adherence, atrial fibrillation, this rate increased significantly at 63.7%, an-tivitamin K, anticoagulants nearly double in comparision with this 1. INTRODUCTION Atrial fibrillation has been affecting in particular. According to statistics, millions of people worldwide, increasing cardiovascular diseases requiring the risk and severity of strokes, heart anticoagulant therapy are increasing [2,3]. failures, and deaths [1]. Viet Nam is a Anti-vitamin K (AVK) anticoagulants has country with a high rate of cardiovascular been widely used, especially in low-income diseases in general and valvular diseases countries, for the prevention and treatment of thromboembolism in conditions such as atrial fibrillation, venous thrombosis and pulmonary embolism, valvular heart Cor. author: Ngo Huy Hoang diseases [4]. AVK anticoagulant therapies Email: ngohoang64@ndun.edu.vn are facing two main obstacles including Received: Feb 17, 2021 the wide range of pharmacological effects Revised: Feb 23, 2021 and the therapeutic effectiveness of Accepted: Mar 05, 2021 AVK anticoagulants that is influenced 124 Journal of Nursing Science - Vol. 04 - No. 01
2. RESEARCH ARTICLE by many factors such as the sensitivity practically a serious knowledge gap in to medication of each patient, patient’s patients using anticoagulants [9], and diet, drug interactions, internal medical showed interventions through health comorbidities (liver failure, kidney failure...), education improving adherence to and especially depended on the patient’s anticoagulation therapies, increasing adherence to AVK anticoagulants [5,6]. treatment efficiency, and contributing to The International Normalized Ratio (INR) reducing mortality from cardiovascular test is the most reliable indicator of the disease [10]. In Viet Nam, descriptive therapeutic efficacy of AVK anticoagulants. studies by Nguyen Ngoc Phuoc in 2013 [11] The goal of treatment is to ensure the INR and Le Thi Thuy in 2014 [12] also revealed threshold of 2-3 or 3-4 depended on each poor practice in adherence to Anti-vitamin K patient, if the IRN test result below the target anticoagulant and influential factors among treatment threshold (INR < 2.0) this will put study samples of patients. However, there the patient at high risk of thrombosis, high was no educational intervention in order INR More than the treatment target (INR to solve this problem. Aiming to improve > 3.5), the patient is at risk for bleeding patients’ adherence to AVK anticoagulant complications. Conversely, in case the therapy through patient education, the INR test result above the target treatment objectives of this study were to assess the threshold (INR > 3.5), it will put the patient current practice and changes in adherence at risk of bleeding complications. to Anti-vitamin K anticoagulants treatment among cardiovascular patients with atrial Thrombosis leading to thromboembolism fibrillation after the educational intervention caused by the inadequate use of at Nam Dinh Provincial General Hospital. anticoagulants that fails to reach preventing thrombosis or the use of substances 2. RESEARCH METHOD that reduce the anticoagulant effect of Study participants were out-patients, the AVK anticoagulants, and vice versa diagnosed with one of cardiovascular suffering from bleeding complications by diseases with atrial fibrillation and prescribed the overdose use are major consequences the AVK anticoagulant (Sintrom 4) and been associated with anticoagulants. Arcording managing by Nam Dinh provincial general to the final report from the early self- hospital. Inclusion criteria included patients management anticoagulation trial II aged full 18 years or older, had been taken published by the European Heart Journal, AVK anticoagulant for at least one month the rate of thrombosis was ranged from or longer up to the point of beginning of the 0.01 to 2.04 per 100 patients each year study, had ability to follow the educational and bleeding complications from 0.1 to 6.2 programs and consented to participate in per 100 patients each year [7]. According the study. Exclusion criteria were cases to the UK National Health Authority, AVK who did come for re-examination but his/her anticoagulants are one of the five drug condition had to be hospitalized; or patient groups related to fatal complications and who had participated in an educational should be considered about the safety of program with similar contents. Patients who patients [8]. did not participate fully in all activities of the Literature review of recent studies study and assessing times did not included regarding knowledge and practice of in the analysis of the results. adherence to anticoagulants revealed A before and after study was conducted Journal of Nursing Science - Vol. 04 - No. 01 125
3. RESEARCH ARTICLE from December 2019 to August 2020 at evaluate adherence practice. Any patient Nam Dinh Provincial General Hospital. who got ≥ 6 points by MMAS-8 scale was The research proposal was approved by counted as achieving the medication the Scientific Committee and the Boad adherence. The use of substances and for Research Ethics of Nam Dinh Nursing foods that reduce the therapeutic effects University as well as had the consent of Nam of AVK anticoagulants were assessed Dinh Provincial General Hospital. Followed with levels of use included 0; 1; 2; 3 points the accepted research proposal, the data equal to frequent; sometimes; rarely; never. collection and educational interventions Within a total of 12 points, any patient got ≥ began from February 1 to April 30, 2020. 8 points were reported met the adherence. According to the sample size formula for Achieving the alcohol / beer restriction an one group pre-test and post-test study if the amount of alcohol consumed less [13], the minimum sample size was 83 than 3 standardized drinks per day and participants. Convenient sampling method 14 standardized drinks per week for men; was applied and there were 102 patients less than 2 standardized drinks per day and who met the inclusion criteria of the study less than 9 standard drinks per week for during the period of data collection. With the women. The patient’s IRN result tests were desire to help as many patients who comply used to evaluate objectively the adherence with AVK anticoagulant therapy as possible, and patients who had the target IRN and all 102 of these patients were selected for no appear bleeding complications were the study. Therefore, the actual sample size counted as adherence to therapy. The study of this study was 102 participants. data set was analyzed by using SPSS 20.0 The educational intervention content was software. developed based on documents regarding 3.RESULTS guidelines for the use of AVK anticoagulants The mean age of 102 participated including ‘Oral anticoagulants’ of the Viet patients was 63.93±11.26 years, the Nam National Heart Institute 2020 [14], youngest was 33 years old and the oldest ‘Drug interactions and attention when is 89 years old. The number of female/ indicated’ by the Department of Health of male patients, resided in rural/urban areas Viet Nam 2015 [15] and ‘What to know and living with relatives/alone were 59/43, about the warfarin diet’ by the American 75/27 and 85/17, respectively. There were Heart Association 2019 [16]. Materials for only 4 of 102 patients trained at vocational education included handouts, illustrations, secondary and college levels after leaving flyers regarding adherence to AVK schools and no one of them earn a university anticoagulant therapy were provided for degree. patients in advance. The direct consulting The percentages of patients who of a three or four patient-group focused on adherenced to AVK anticoagulant use, the importance and patient’s benefits from diet, alcohol restriction and overall therapy adherence AVK anticoagulant therapy, (combined by adherence to all three specific behaviors, possible barriers and criteria) before and after the educational how to response and each session lasted intervention were demonstrates in Figure 1. average of 30 minutes. MMAS-8 [17] and Toolkit from Viet Nam National Heart Institute [11] were used to 126 Journal of Nursing Science - Vol. 04 - No. 01
4. RESEARCH ARTICLE Before the education After the education 100% 88.20% 90% 80% 70.60% 70% 80.40% 63.70% 60% 52.90% 50% 40% 30% 39.20% 35.30% 32.40% 20% 10% 0% Adherence to Adherence to diet Adherence to General adherence medication alcohol limiting to treatment Figure 1. Adherence to AVK anticoagulant therapy (n=102) Before the study, except the adherence to alcohol restriction that appeared already at high rate of patients (80.4%), the percentages of patients who adherence to AVK anticoagulant use, diet and overall therapy were all low at 39.2%, 35.3% and 32.4%, respectively. After the educational intervention, these percentages all increased at 70.6%, 52.9% and 63.7%. Table 1. IRN result tests of participated patients (n=102) Achieved the target IRN p value Time points for testing Number of (Chi square) % patients One month before the education (T0) 48 47.1 Right before the education (T1) 41 40.2 p (1-0) = 0.72 One month after the education (T2) 72 70.6 p (2-1) = 0.00 Table 1 showed the percentages of patients with IRN result tests met the target IRN values from one month before and right before the educational intervention were 47.1% and 40.5%, respectively. One month after completing the educational intervention, the percentage of patients with IRN values within the target IRN range considerably increased up to 70.6% in comparision with that before the intervention (p<0.01). Journal of Nursing Science - Vol. 04 - No. 01 127
5. RESEARCH ARTICLE Table 2. Hemorrhage signs of participated patients (n=102) Right before the One month after the education education Manifestations of hemorrhage Number of Number of % % patients patients Total 9 8.82 4 3.92 Natural petechiae under the skin 1 0.98 1 0.98 Prolonged bleeding after traumas such as shaving; cut hands; 8 7.84 3 2.94 brushing teeth or any minor wound At the time before participating the educational program, 9 of 102 patients had already manifestations of hemorrhage, among these patients, one was appeared natural hemorrhage under the skin. One month after completing the intervention, there were only four of these patients remained signs of hemorrhage including the patient who had had natural hemorrhage under the skin since the previous time. Before the education After the education 100% 85.30% 90% 80% 70% 62.70% 60% 50% 39.20% 34.30% 40% 32.40% 60.80% 30% 38.20% 20% 18.60% 10% 2.00% 20.60% 10.80% 0% 0.00% forgot a dose on forgot a dose in forgot a dose did not bring stopped taking felt troublesome the day before the past week during the past anticoagulant anticoagulant by having to take month while being away when felt anticoagulation from home uncomfortable every day Figure 2. Behaviors related to inadequate dosage of AVK anticoagulant (n=102) This figure showed that after the educational intervention, there was a clearly decreased trend in the proportion of patients who previously had behaviors related to inadequate use of AVK anticoagulants. 128 Journal of Nursing Science - Vol. 04 - No. 01
6. RESEARCH ARTICLE 4.DISCUSSION did adhered to all three categories at approximately double in compared with Published studies, even mentioned that before the education as seen in the the same problem, still had different Figure 1. In our study, the patients’ IRN features. Literature review showed two values of one month before and right before descriptive studies regarding adherence the educational intervention were used as to AVK anticoagulant therapy by Nguyen an objectively to evaluate the effect of the Ngoc Phuoc in 2013 [11], and by Shehab intervention and Table 1 demonstrated a A et al in 2019 [18], those applied the clearly improvement in patients’ adherence same tool and criteria for measurement to AVK anticoagulant therapy after the and assessment as which were applied education by 70.6% of patients who had in this study, therefore they were used for IRN values within the target IRN range in discussion on assessing the situation of comparision with 40.5% right before the patients’ adherence to AVK anticoagulant intervention. This result confirmed that the therapy. There was currently no educational patients who participating in the education interventions available regarding enhance of this study had actually compliance to patients’ adherence to AVK anticoagulant, practical instructions provided from the so discussion on the effectiveness of education. In other words, this was a educational intervention based on a recent convincing evidence of the effectiveness of study regarding educational intervention the implemented educational intervention. to improve adherence to hypertension In addition, a reducing trend in the treatment by Nguyen Thi Thu Thuy in number of patients with manifestations 2018 that also used the same design and of hemorrhage seen in Table 2 as well as Morisky scale (MMAS-8) for measurement in the number of patients with behaviors of compliance [19]. related to inadequate medication use The results of our study (Figure 1) presented in Figure 2 also contributed to together with the results from the studies the effectiveness of the education of this mentioned above [11,18] reflected poor study. Along with the positive changes in the adherence to AVK anticoagulant therapy. improvements of adherence to hypertension In fact, all patients coming to hospital for treatment after the educational intervention medical treatment were instructed for in the study by Nguyen Thi Thu Thuy [20]. medication use when received a prescription. This study showed again the need of proper However, routine instructions were likely educational interventions for outpatients not enough to make patients be awared regarding the enhance to treatment of of the importance of adherence, to believe cardiovascular diseases in general. in the benefits and how to compliance as Although, the study showed positive well as key factors that help patients to be changes in the patients’ adherence to confident and follow instructions [20]. This AVK anticoagulant therapy it was also indicated a real need for more appropriate inevitable limitations that were no control interventional programs. group to be compared with and the time After completing the educational interval for evaluation was not long enough intervention, there were significantly to confirm the sustainability of adherence increased percentages of patients who [21,22]. However, to some extent, this study Journal of Nursing Science - Vol. 04 - No. 01 129
7. RESEARCH ARTICLE contributed to increased effectiveness 5. Ansell J, Hirsh J, Hylek E et al of using AVK anticoagulants. Naturally, (2008). Pharmacology and management adherence to specific therapies is likely of the vitamin K antagonists: American to be reduced over time, it is suggested College of Chest Physicians evidence- that appropriate educational programs based clinical practice guidelines. Chest. on adherence for target patients should 2008;133(6):160S-98S. be developed and regularly implemented 6. Rubboli A, Becattini C, Verheugt FW in order to reinforce, strengthen and (2011). Incidence, clinical impact and risk of maintain patients’ adherence practice, bleeding during oral anticoagulation therapy. online educating methods should be also World journal of cardiology; 3(11):351. considered. 7. Koertke H, Zittermann A, Tenderich G 5. CONCLUSION AND RECOMMENDATION et al (2007). Low-dose oral anticoagulation Poor practice of adherence to AVK in patients with mechanical heart valve anticoagulants was seen in the participated prostheses: final report from the early patients within this study and there self-management anticoagulation trial II. were significantly improvements after European heart journal; 28(20):2479-84. the educational intervention. This study 8. Keeling D, Baglin T, Tait C et al (2011). showed the need to provide patients with Guidelines on oral anticoagulation with atrial fibrillation an adequate education to warfarin-fourth edition. British journal of enhance their adherence to anticoagulant haematology; 154(3):311-24. therapy in addition to the routine counseling 9. Chenot J-F, Hua TD, Abed MA et that they receive during their re-examination. al (2014). Safety relevant knowledge of REFERENCES orally anticoagulated patients without self- monitoring: a baseline survey in primary 1. Morillo CA, Banerjee A, Perel P et care. BMC family practice; 15(1):104. al (2017). Atrial fibrillation: the current epidemic. Journal of geriatric cardiology: 10. Ebrahim S, Taylor F, Ward K et al JGC;14(3):195. (2011). Multiple risk factor interventions for primary prevention of coronary heart 2. Nguyen Lan Viet (2007). Practice in disease. Cochrane Database of Systematic cardiovascular diseases. Medical Publishing Reviews. House, pp.374-92 (in VietNamese). 11. Nguyen Ngoc Phuoc (2013). Current 3. Nguyen Van Phan (2008). Overview adherence to treatment of vitamin K of valvular disease treatment. Viet Nam anticoagulants and related factors among Medicine, Vol.356:49-55. patients after mechanical heart valve 4. Ageno W, Gallus AS, Wittkowsky A replacement surgery at Viet Nam National et al (2012). Oral anticoagulant therapy: Heart Institute. Public Health Master antithrombotic therapy and prevention of Thesis, Hanoi University of Public Health thrombosis: American College of Chest (in VietNamese). Physicians evidence-based clinical practice 12. Le Thi Thuy (2014). Knowledge guidelines. Chest. 2012;141(2):e44S-e88S. and adherence to treatment of vitamin k 130 Journal of Nursing Science - Vol. 04 - No. 01
8. RESEARCH ARTICLE anticoagulants in patients after mechanical 20. Bandura A (2004). Health promotion heart valve replacement surgery at by social cognitive means. Health Education cardiovascular center of Hanoi E Hospital. & Behavior, 31,143-164. Master thesis, Hanoi University of Public 21. Hughes M and Lip G (2007). Health (in VietNamese). Risk factors for anticoagulation-related 13. World Health Organization (2000) bleeding complications in patients with WHO “Sample Size Determination in Health atrial fibrillation: a systematic review. QJM: Studies” software, version 2.021 (release 2) An International Journal of Medicine; (00.07.11) Copyright (c) Chuah Aaron. 100(10):599-607. 14. Viet Nam National Heart Institute 22. World Health Organization (2003). (2020). Oral anticoagulants: anti-vitamin Adherence to long-term therapies: K anticoagulants evidence for action. accessed date: 10/8/2020. chp/knowledge/publications/adherence_ report/en/ accessed date: 10/8/2020. 15. Ministry of Health of Viet Nam (2015). Drug interactions and cautions for prescription. Hanoi: Medical Publishing House, p.869-82 (in VietNamese). 16. Kandola A (2019). What to know about the warfarin diet. medicalnewstoday.com/articles/324419. php. 17. Morisky DE, Ang A, Krousel-Wood M et al (2008). Predictive validity of a medication adherence measure in an outpatient setting. The Journal of Clinical Hypertension. 10(5), pp. 348-354. 18. Shehab A, Bhagavathula AS, Abebe TB et al (2019). Patient adherence to Novel Oral Anticoagulants (NOACs) for the treatment of atrial fibrillation and occurrence of associated bleeding events: a systematic review and meta-analysis. Current vascular pharmacology. 19. Nguyen Thi Thu Thuy (2018). Changes in knowledge and practice of compliance with hypertension treatment among the elderly at Bac Ninh General Hospital after an educational intervention. Nursing Master Thesis, Nam Dinh University of Nursing (in VietNamese). Journal of Nursing Science - Vol. 04 - No. 01 131