Patient-focused interventions to support vulnerable people using oral anticoagulants: a narrative review.

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

A community health worker-based program for elderly people with hypertension in Indonesia: A qualitative study, 2013

Introduction: Hypertension is prevalent in the elderly, but treatment is often inadequate, particularly in developing countries. The objective of this study was to explore the role of a community-based program in supporting patients with hypertension in an Indonesian rural community. Methods: A qualitative study comprising observation and in-depth interviews was conducted in an Integrated Health Service Post for the Elderly (IHSP-Elderly) program in Bantul district (Yogyakarta province). Eleven members of IHSP-Elderly program (ie, hypertensive patients), 3 community health workers (CHWs), and 1 district health staff member were interviewed to obtain their views about the role of the IHSP-Elderly program in hypertension management. Data were analyzed using thematic analysis. Results: CHWs played a prominent role as the gatekeepers of health care in the rural community. In supporting hypertension management, CHWs served members of the IHSP-Elderly program by facilitating blood pressure checks and physical exercise and providing health education. Members reported various benefits, such as a healthier feeling overall, peer support, and access to affordable health care. Members felt that IHSP-Elderly program could do more to provide routine blood pressure screening and improve the process of referral to other health care services. Conclusion: CHWs have the potential to liaise between rural communities and the wider health care system. Their role needs to be strengthened through targeted organizational support that aims to improve delivery of, and referral to, care. Further study is needed to identify the key factors for effective CHW-based programs in rural communities and the incorporation of these programs into the health care system

Potential use of a “blood pressure action sheet” for indonesian patients with hypertension living in rural villages: A qualitative study

© 2018 Rahmawati and Bajorek. Purpose: The aim of the study was to obtain feedback on the layout, content, and potential use of a blood pressure (BP) action sheet, a purpose-designed written resource for Indonesian patients with hypertension. Methods: Telephone interviews were conducted with 13 health professionals, 12 community health workers, and 12 patients in rural Yogyakarta, Indonesia, to explore their impressions of the BP action sheet, how the sheet might affect management of hypertension, and suggestions for improvement. Results: Participants felt that the sheet presented useful information about achieving the target BP and managing hypertension. The use of the sheet could be optimized by engaging community health workers to help explain the information and to provide assistance around the stated actions for hypertension management. A more attractive design and inclusion of more details were suggested. Both patients and health care workers expressed interest in using the sheet. Conclusion: The BP action sheet has potential as a useful resource for patients with hypertension by providing information, recording target BP, and facilitating patient-centered communication. Use of the BP action sheet might provide an effective low-cost way for health professionals and community health workers to encourage patients to achieve their target BP

The Influence of Yb Substitution on the Magnetic, Electric Properties and Electronic Structure of YbxGd1-xNi5 System

The crystal and electronic structure, magnetic and electric properties of intermetallic compounds YbxGd1¡xNi5 (x = 0:0, 0.2, 0.4, 0.5) are presented. The whole series crystallize in the hexagonal CaCu5 type of crystal structure. The ordering temperatures TC and the e®ective magnetic moments decrease with increase in ytterbium concentration. The electronic structure studied by X-ray photelectron spectroscopy method shows the domination of Ni 3d states nearby the Fermi level. The multiplet structure visible in valence bands is typical of Yb3+ ions

Perspectives on antihypertensive medication: a qualitative study in a rural Yogyakarta province in Indonesia

© 2015, Springer International Publishing Switzerland. Aim: Patients’ perceptions and beliefs underpin their adherence to pharmacotherapeutic regimens and are influenced by access to appropriate information and education. This study explores the perceptions of lay persons from a low-resource community in Indonesia regarding antihypertension medication. Methodology: Individual, semi-structured interviews were conducted, transcribed and thematically analysed. Fourteen respondents (i.e. older persons with hypertension and lay health workers) from a local community-based health programme in Yogyakarta province (Indonesia) were recruited for this qualitative study. Results: Four themes emerged: (1) participants felt that medication for hypertension is unnecessary, instead preferring lifestyle changes and traditional medicines; (2) a fear of becoming dependent on medication underpinned non-adherence to antihypertensive agents—participants with hypertension wanted to achieve normal blood pressure, but without taking long-term medication; (3) symptom-based drivers for treatment led participants to rank other health problems a higher priority than hypertension; and (4) although lay health workers had an opportunity to provide information about hypertension and its management, participants themselves considered this to be currently inadequate. Conclusion: Some misconceptions regarding the role of antihypertension medication that negatively influenced adherence were identified. Beliefs that hypertension can be easily treated by lifestyle modifications can undermine motivation to take antihypertensive agents. Participants expressed their need for more targeted information about hypertension and its treatment; however, they do not expect to obtain such information from their physician. The potential role of lay health workers needs to be further explored as a strategy to enhance understanding and adherence

Pilot of a Computerised Antithrombotic Risk Assessment Tool Version 2 (CARATV2.0) for stroke prevention in atrial fibrillation

  Background: The decision-making process for stroke prevention in atrial fibrillation (AF) requires a comprehensive assessment of risk vs. benefit and an appropriate selection of antithrombotic agents (e.g., warfarin, non-vitamin K antagonist oral anticoagulants [NOACs]). The aim of this pilot-test was to examine the impact of a customised decision support tool — the Computerised Antithrombotic Risk Assessment Tool (CARATV2.0) using antithrombotic therapy on a cohort of patients with AF. Methods: In this prospective interventional study, 251 patients with AF aged ≥ 65 years, admitted to a teaching hospital in Australia were recruited. CARATV2.0 generated treatment recommendations based on patient medical information. Recommendations were provided to prescribers for consideration. Results: At baseline (admission), 30.3% of patients were prescribed warfarin, 26.7% an antiplatelet, 8.4% apixaban, 8.0% rivaroxaban, 3.6% dabigatran. CARATV2.0 recommended a change of therapy for 153 (61.0%) patients. Through recommendations of CARATV2.0, at discharge, 40.2% of patients were prescribed warfarin, 17.7% antiplatelet, 14.3% apixaban, 10.4% rivaroxaban, 5.6% dabigatran. Overall, the proportion of patients receiving an antithrombotic on discharge increased significantly from baseline (admission) (baseline 77.2% vs. 89.2%; p < 0.001). Prescribers moderately agreed with CARATV2.0’s recommendations (kappa = 0.275, p < 0.001). Practical medication safety issues were cited as major reasons for not accepting a desire to continue therapy with CARATV2.0’s recommendations. Factors predicting the prescription of antiplatelets rather than anticoagulants included higher bleeding risk and high risk of falls. An inter-speciality difference in therapy selection was detected. Conclusions: This decision support tool can help optimise the use of antithrombotic therapy in patients with AF by considering risk versus benefit profiles and rationalising treatment selection. (Cardiol J 2017; 24, 2: 176–187

Health literacy and knowledge in a cohort of Australian patients taking warfarin

© 2018, Grupo de Investigacion en Atencion Farmaceutica. All rights reserved. Objectives: To 1) characterise older patients taking warfarin, 2) assess these patients’ level of warfarin knowledge, and 3) describe their strengths and limitations in health literacy, and 4) explore relationships between participants’ characteristics, warfarin knowledge and health literacy. Methods: A warfarin knowledge questionnaire and Health Literacy Questionnaire (HLQ) were administered to older patients (aged >65 years, N=34) taking warfarin in an Australian general practice setting. Results: Key gaps in participant knowledge pertained to the consequences of an international normalized ratio (INR) being below the target INR range and safety issues such as when to seek medical attention. A limitation for participants with a lower level of health literacy was the ability to appraise health information. Patients who needed assistance in completing the HLQs had significantly lower warfarin knowledge scores (p=0.03). Overseas-born participants and those taking 5 or more long-term medications had lower HLQ scores for specific scales (p<0.05). Conclusion: In this study warfarin knowledge gaps and a limitation of health literacy amongst a small sample of older patients were identified. The findings suggest that education and resources may need to be tailored to the needs of older patients taking warfarin and their carers to address these knowledge gaps and limitations in health literacy. Patients who may need greater support include those that need assistance in completing the HLQ, are overseas-born, or are taking 5 or more long-term medications