Long-term users of warfarin had difficulty recognizing the clinical severity and urgency of anticoagulation-related situations such as stroke symptoms and medication mismanagement, the results of a survey indicated.
"Factual knowledge of the pharmacology of warfarin does not guarantee safe use of warfarin. Enhancing patient education regarding drug-related emergencies will likely narrow the gap between patient and health care provider and reduce the incidence of adverse drug events," said Dr. Christopher J. Moreland of the University of Texas Health Science Center, San Antonio, and his colleagues.
The researchers recommended that warfarin education programs implement patient-centered strategies that teach patients to discern high-risk from low-risk situations and take appropriate action based on those scenarios.
The survey participants were 184 long-term users of warfarin drawn from an initial pool of 480 randomly selected patients from the anticoagulation clinic at the University of California, Davis, Medical Center. Survey participants were contacted by phone and asked general-knowledge questions about their therapy. They also were asked to rate various warfarin-associated risk scenarios as not urgent, moderately urgent, or urgent. All scenarios had been previously reviewed and categorized by an expert panel of five anticoagulation pharmacists.
On average, 69% of patients correctly answered questions about warfarin therapy, but "certain high-risk scenarios appeared confusing to many respondents," the researchers wrote in the Joint Commission Journal on Quality and Patient Safety (Jt. Comm. J. Qual. Patient Saf. 2013;39:22-31).
More than 50% of respondents correctly identified four of six urgent risk scenarios: acute chest pain (95%), taking the wrong dose of warfarin for a week or more (79%), head trauma (56%), and sudden headache (87%). Just 25% of respondents, however, recognized the urgency of acute unilateral vision loss as a possible sign of stroke and 20% recognized the urgency of a hit or bump on the head for bleeding risk.
"Medication mismanagement (for example, inadvertently taking the wrong dose one day or starting a new medication) was also a clinically relevant area that remains a source of potential misunderstanding by patients," wrote Dr. Moreland and his associates.
Patients underestimated the seriousness of urgent situations 21% of the time (95% confidence interval, 19.0%-23.9%). Overall, 59% of participant responses agreed with the pharmacists’ determinations (95% CI, 57.3%-60.3%), indicating good agreement beyond chance.
More specific performance measures and clear education materials are needed for patients beginning warfarin or other anticoagulants, as currently mandated by Joint Commission National Patient Safety Goal NPSG.03.05.01 and the Joint Commission Venous Thromboembolism (VTE) National Hospital Inpatient Quality Measure VTE-5, the researchers said.
They stated that neither NPSG.03.05.01 nor Inpatient Quality Measure VTE-5 "overtly specifies educational content aimed at teaching patients how to identify (and manage) high-risk scenarios that might compromise patient safety." The National Quality Forum, the study noted, has "elected not to re-endorse VTE-5 because of concerns that the measure does not explicitly specify what constitutes ‘adequate warfarin education’ and that there is a lack of evidence indicating that the measure had led to an improvement in patient outcomes."
"I hope the Joint Commission and other national organizations will revisit and revise the national guidelines for anticoagulation education, particularly for warfarin, and potentially include patient-centered strategies," Dr. Moreland said in an interview.
Ann Watt, associate director for the department of quality measurement in the division of healthcare quality evaluation at the Joint Commission, said, "The Joint Commission is discussing with our technical advisory panel revisions/updates to all of the VTE measures, including VTE-5. We hope to incorporate some of the suggestions from the NQF Steering Committee that reviewed these measures as well as findings from recently published literature."
A Joint Commission spokesperson added that the commission has no plans to revise its National Patient Safety Goal NPSG.03.05.01 at this time.
The researchers had no financial conflicts related to their study. The study was supported by grants from Health Resources and Services Administration, the National Institutes of Health, and the University of California.