Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

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ĎKnowledge is treasure of a wise man.í The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help oneís reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journalsĖNo manuscriptsĖNo authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2009 | Month : August | Volume : 3 | Issue : 4 | Page : 1663 - 1670

Factors Associated with Warfarin Therapy Knowledge and Anticoagulation Control among Patients Attending a Warfarin Clinic in Malaysia

YAHAYA A H M *, HASSALI M A **, AWAISU A***, SHAFIE A A ****

*( M.Pharma) (Clin. Pharm),BPharm(Hons), Master of Clinical Pharmacy Pharmacy DepartmentHospital Teluk Intan ** (PhD),Senior Lecturer Discipline of Social & AdministrativePharmacy, School of Pharmaceutical Sciences, ***( M.Pharma) (Clin. Pharm) Doctoral Research Fellow Discpline of Clinical Pharmacy,**** (PhD)Discipline of Social & Administrative Pharmacy School of Pharmaceutical Sciences Universiti Sains Malaysia 11800 Penang,( Malaysia)

Correspondence Address :
Mohamed Azmi Ahmad Hassali,
Ph: +6046533888 ext. 4085,Fax: +604-6570017.
E-mail address:azmihassali@usm.my

Abstract

Objective: To determine the factors that correlated with the patientís knowledge of warfarin therapy, the level of medication adherence and INR control.
Methods: A cross-sectional survey was conducted at the Warfarin Clinic of Hospital Teluk Intan, Malaysia. The systematic random sampling method was used in sample selection and face-to-face interviews using standard questionnaires were administered to determine the demographic characteristics, the patientís knowledge of warfarin therapy and medication adherence. Medical records were reviewed to determine anticoagulation control during the study period.
Results: A total of 52 patients were enrolled in the survey (mean Ī SD age of 58.73  9.55 years), with a response rate of 95%. A large proportion (63.5%) of the respondents had only primary school education and 71.2% were low-income earners (below RM500 per month). About 69% of the respondents were able to read and 53.8% were able to understand Malay (the national language of the country). A majority of the patients (98%) had verbal medication education through medical or nursing officers. Only 44.2% of patients knew about their medications, but the medication adherence was fairly good at 76.1%. The study showed that age, income level, level of education, and literacy in various languages were significantly associated with the patientís knowledge on warfarin therapy (p< 0.05). The study also showed a significant difference between those patients who knew/did not know about their medications in terms of warfarin therapy knowledge (p<0.05).
Conclusion: Age, income, educational level, literacy and race were significantly correlated with the patientís knowledge of anticoagulation. The study did not find any association between anticoagulation control and the knowledge of anticoagulation.
Practice Implications: The disadvantaged groups receiving anticogulation therapy, including the low-income earners, the elderly, the less-educated and the illiterate, should be given utmost care and attention.

Keywords

warfarin, knowledge, patients, education, anticoagulation control.

How to cite this article :

YAHAYA A H M, HASSALI M A, AWAISU A, SHAFIE A A . FACTORS ASSOCIATED WITH WARFARIN THERAPY KNOWLEDGE AND ANTICOAGULATION CONTROL AMONG PATIENTS ATTENDING A WARFARIN CLINIC IN MALAYSIA. Journal of Clinical and Diagnostic Research [serial online] 2009 August [cited: 2018 Sep 26 ]; 3:1663-1670. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2009&month=August&volume=3&issue=4&page=1663-1670&id=550

Introduction
Warfarin has been the mainstay oral anticoagulant agent for the last several decades despite its narrow therapeutic index and difficulties to use (1),(2). It has become a successful agent for the medical management of thromboembolic diseases such as chronic atrial fibrillation, mechanical heart valve replacement, deep vein thrombosis, pulmonary embolism, and valvular heart disease, among others (3). This has led to a dramatic increase in the number of patients receiving warfarin therapy and those who are referred to anticoagulation clinics. However, warfarin therapy is plagued by the need to frequently fine-tune dosage, based on the International Normalized Ratio (INR), the relatively large variability in dosage requirements based in part on CYP2C9 activity, its slow action dependent onset and offset on the depletion and restoration of vitamin K-dependent clotting factors and many drug interactions (4).

Interactions with other drugs, dietary intake, poor adherence with medication and deficiency in patient knowledge are factors associated with non-therapeutic treatment outcomes (3). Therefore, it is pertinent to assess the patientís knowledge of and adherence to warfarin therapy. Adhering to prescribed recommendations during treatment is essential, but managing and educating patients with low literacy skills is a challenge for health care providers (3). The patientís knowledge on warfarin has been shown to be a determinant of anticoagulation control (5) and patient education and counseling is an integral component of a successful warfarin therapy.

Several factors could play a role on the patientís knowledge on warfarin therapy, adherence to its treatment and overall management of the therapy. A multidisciplinary education program may improve the patientís knowledge on warfarin therapy, drug adherence, as well as adherence to medical advice (6). Malaysia, a multiracial Southeast Asian nation with Malay, Chinese, and Indians as the majority, is an entity with cultural diversities and distinct genetic variability among the several races. These diversities have important clinical implications on how therapeutic agents with genetic polymorphism such as warfarin, should be used in practice, as well as the impact of cultural practices and knowledge on warfarin therapy. This study therefore, aims to determine the sociodemographic factors associated with the patientís knowledge on warfarin therapy, the level of therapy adherence, and INR control.

Material and Methods

Setting
The study was conducted at the Warfarin Clinic of Hospital Teluk Intan, which operates on a once weekly-basis (every Wednesday). The clinic was established in August 1999 to accommodate the expansion in the number of patients undergoing outpatient anticoagulation therapy (i.e. warfarin). A Warfarin dosing protocol was designed to ensure a more efficient and standardized system of evaluating anticoagulation therapy. It consists of dosage initiation, maintenance and adjustment of warfarin based on diagnosis, intervention required if the INR is outside normal therapeutic range and a recommended schedule for the patientís follow-up. All patients on warfarin therapy are referred to this clinic for review and management by a physician. The patient has his/her INR checked before seeing the physician for further management.

Study Design
This was a cross-sectional study conducted over 4 months. A face-to-face interview using a structured questionnaire was performed by trained data collectors at the anticoagulation clinic. During the study, the patientís current and previous INRs were also assessed to evaluate the level of anticoagulation control.

Sampling
A randomized systematic sampling was used in the patientís selection. A minimum sample size of 47 patients was needed to detect an estimation of 20% patients who had poor knowledge on warfarin therapy, with 10% accuracy (EpiInfo version 6). Patients eligible for inclusion in the study were those who had been to the anticoagulation clinic for more than 5 visits. This criterion was set up because most previous studies showed the patient INR to be stable after the fifth visit. Fifty-two patients responded to the questionnaires. The medical records of the selected patients were then reviewed to assess the overall management of warfarin therapy, including the 5 most recent INRs recorded and warfarin doses prescribed.

Data Collection Procedure and Instruments
Data were collected using a standardized form and two questionnaires (one for adherence assessment and the other for knowledge evaluation). The collected data included: demographic information such as the highest level of education, household income and literacy level; indication for and duration of warfarin therapy; and concurrent drug therapies. The patientís source(s) of information on their warfarin therapy, access to the warfarin booklet and understanding of its contents were also recorded. The patientís adherence to warfarin therapy was assessed through counting of tablets and a 4-item Moriskey questionnaire during the session.

The questionnaire to assess warfarin therapy knowledge was designed in 3 major Malaysian languages; Malay, Chinese and Tamil. It was validated by an expert panel consisting of 2 physicians and 2 senior pharmacists employed at the study hospital. The forward-backward translation method was used in translating the questionnaire into each language, to ensure conceptual equivalence. Face-to-face interviews were conducted by three researchers trained in questionnaire administration, who did not work in the clinic, as an effort to decrease potential bias.

The patientís knowledge of warfarin therapy was also evaluated during the interview sessions. The standardized assessment of knowledge consisted of questions that were intended to determine the patientís knowledge of: indication, dose, mechanism of action, administration time, importance of blood monitoring, food-warfarin interactions, drug-warfarin interactions, actions to be taken in case of missed doses, adverse effects and the actions to be taken if an adverse effect occurs. The precautionary steps on certain occasions such as warfarin in pregnancy and before tooth extraction, were also asked. For the purposes of analysis, each question was assigned a point and the total point obtained, indicated the patientís overall knowledge on warfarin therapy.

The patientís medical profiles were further reviewed to determine the indication of warfarin therapy. The 5 most current INR values were reviewed and compared with target INRs specified in the local anticoagulant protocol. An audit concerning the management of anticoagulation was also conducted. The anticoagulation protocol provided guides for healthcare providers in patient management and ensured uniformity and continuity of service. The audit of patient management helped the investigators to ensure that other factors were considered in the analysis.

Statistical Analysis
Descriptive statistics were used to present the data on demographic characteristics, literacy level, adherence to warfarin therapy, and knowledge of warfarin therapy. Continuous variables were expressed as mean Ī standard deviation (SD), whereas categorical variables were expressed as percentages and frequencies. Factors thought to contribute to the patientís knowledge on warfarin therapy and adherence, were analyzed using correlation analysis. The a priori level of significance for all analyses was two-tailed at 0.05. All statistical analyses were performed using SPSS software, version 11.0.

Results

A total of 55 patients were selected for the study, with 52 responding to all the study questionnaires (95% response rate). The male to female ratio of the participants was 1.1:0.9. The mean age Ī SD of the respondents was 58.73 Ī 9.55 years, with nearly half of them in the 60-79 year-old category. Two-thirds of the study patients were Malay and an overwhelming proportion of the patients (86.5%) had been to the anticoagulation clinic for more than 10 times. Moreover, the vast majority of the patients (63.5%-71.2%) belonged to the low household income category and had only primary school education. Most of the patients lived within more than 10 kilometers radius away from the clinic. The majority (61.5%) of the patients had received warfarin therapy due to chronic atrial fibrillation. The detailed patientís characteristics are presented in (Table/Fig 1).

Opportunities to receive education on warfarin therapy were determined during the interview sessions. On normal clinic days, patients should receive counseling from the prescriber or nurses regarding warfarin therapy as soon as possible, after initiation of therapy. In this study, no documentation was found in the patientís medical records, on whether the patients had been educated on warfarin therapy. However, the majority of the patients (94.2%) admitted that they received education on warfarin from medical officers (93.9%). Nearly all the patients were given a warfarin booklet, but only 78.4% indicated that they read it. Of this, 85% reported that they understood the contents of the booklet.

The international normalized ratios (INRs) for all patients were reviewed. The complete medical records of two patients could not be found and they were therefore excluded from further evaluations. Only 10% of study participants had 80% or more of their 5 consecutive INR readings within the targeted range. About 16% had 4 to 5 (80-100%) INR readings outside the target range and 6% had 3 (60%) INR readings within the supratherapeutic range (Table/Fig 2).

A review of the patientís medical records and appointment schedules found that all patients adhered to the appointment schedules of the clinic. The patientís warfarin therapy adherence was assessed using the 4-item Moriskey instrument and was further verified by pill counting. A total of 12 patients (23.1%) had poor adherence when assessed using Moriskey instrument; 10 patients (19.2%) claimed that they had sometimes forgotten to take medications, while the other 2 claimed that they had inadequate medications refill (an insufficient supply of medication). About 58% of the non-adhered patients missed a warfarin dose once a month, whereas 25% and 17% missed 2 to 4 doses and at least 5 doses per month, respectively. Patients were asked further questions about the awareness of their current warfarin dose and this was correlated with what was prescribed in the medical profile. This study found that the proportion of agreement of self-reported awareness of the warfarin dose by the patient, as compared to the assessments in medical records, was 92%, (N=52) kappa = 0.923, p<0.001. Only 44.2% were aware of the warfarin doses prescribed to them (Table/Fig 3)

Assessment of the knowledge on warfarin therapy was conducted using the knowledge questionnaire. The results showed that a majority (67.3%) of the patients had poor knowledge of different tablet dosage forms and their strength. The knowledge concerning the indication for warfarinization was also assessed. The proportion of patients who knew the indication and those who did not, was almost equal. Nearly 71.2% of the patients understood the mechanism of action of warfarin. The patientís knowledge was assessed, regarding the following: missed doses and actions to be taken, importance of INR monitoring, warfarin-food interactions, warfarin-drugs interactions, adverse events of warfarin and actions to be taken when they are perceived to occur and precautions to be taken while on warfarin therapy. (Table/Fig 4) summarizes these key findings.

The overall score for each patientís knowledge on warfarin therapy was calculated (i.e. a point was given for each correct answer). An overall total score above 80% was considered as good knowledge, 50% to 80% as fairly good and less than 50% as poor knowledge. (Table/Fig 5) shows the overall scores. (Table/Fig 6) presents the factors that might be associated with the patientís knowledge on warfarin therapy. Correlation analysis showed that the patientís knowledge on warfarin therapy was significantly associated with their age (r = -0.367, p = 0.007), household income (rs = 0.291, p = 0.036), educational level (rs = 0.328, p = 0.018) and the number of readable languages (rs = 0.387, p = 0.005).

The average percentage of INR that achieved targeted range (over 5 readings) was 41.92 Ī 25.44, with a median of 40%. None of the factors was associated with the anticoagulation control.


Discussion

Unlike most previous studies on the patientís knowledge on warfarin therapy (5), this study also assessed the incidence of the international normalized ratio (INR) at or outside the targeted range via the assessment of the patientís medical records. Ninety percent of the 50 patients reviewed, had an INR that might indicate an inadequate therapy or over-warfarinization. However, no relationship was found between the patientís knowledge and anticoagulation control. This was contrary to a previous study where the patientís education and knowledge were identified as important factors which could affect the anticoagulation control (5). Prior knowledge of warfarin has been associated with a decreased risk of bleeding. Written and verbal information has been shown to improve anticoagulation control. While past studies suggest that patient education may be associated with better clinical outcomes, doubts remain about the effectiveness of patient education strategies (7).

Perhaps, there could be some explanations for the low patientís knowledge of anticoagulation. There might be flaws in the nature and extent of information provided by healthcare personnel on anticoagulation, as well as the method of delivery. This was shown by a low score of the patientís knowledge in those patients who claimed to be educated by prescribers or nurses. A lack of knowledge and skills among health care professionals providing anticoagulation services might contribute to reluctance in advising patients on the risks and complication of anticoagulation. More widespread dissemination of guidelines to the medical staff is required, with specific instructions for counseling patients receiving anticoagulation. The other possible factor involved, might be the patientís inability to understand and retain the advice given. Poor doctor-patient communication has been well described for other chronic conditions (8). More effective communication arises from understanding the patientís expectations, involving patients in negotiating their treatment plan and the continuity and accessibility of the staff. Better levels of the knowledge of the patients may also be achieved if the information is reinforced by simple measures such as repetition or use of written materials. The availability of a non-physician counselor such as a clinical pharmacist or a nurse practitioner, has also been shown to increase the patientís knowledge about medical treatments (9).

There was a difference in the patientís knowledge of anticoagulation among the different age groups. The elderly patients had poor knowledge on the subject as compared to the younger ones. This might be due to the inability to remember, and to the fact that the former category is often given many medications. Improvement in s enhancing the knowledge of anticoagulation among elderly patients is needed, as they are at a high risk of side effects. There is also a need of specific anticoagulation dosing and introduction of an initiation protocol for the elderly, as a study showed that the protocol performs better than empirical dosing for older patients (10).

Household income and education level are the other factors which are found to be associated with the patienís knowledge of anticoagulation. Patients with low anticoagulation knowledge were found to have low levels of education and low household income. For patients with low household income, medication and treatment adherence may be major problems. A study on the knowledge of cardiovascular disease among the Canadian population, found that patients from a low socioeconomic background had poor knowledge of disease11. Thus, the educational approach in enhancing the patientís knowledge should consider individual differences.

Illiteracy has become an increasingly important problem, especially, as it relates to health care. Literacy is defined as the basic ability to read and speak in the common language (Malay language in the Malaysian context). Health care professionals cannot assume that all patients know how to read, but direct questioning based on the assumption that the inability to read amounts to illiteracy often causes shame and embarrassment. Assessing a patientís reading skills in the clinical setting is important and provides insight into an individualís ability to function adequately in the healthcare environment. In this study, the illiteracy rate was almost 30%. This was probably because a majority of the study patients had low levels of education. The illiteracy levels also had a significant correlation with the knowledge of poor patients towards warfarin therapy. In the United States, researchers have found that illiteracy directly correlated to poorer health and disease.12. The consequences of health illiteracy are lack of knowledge about medical care, lack of understanding of services, poorer adherence rate, increased rate of hospitalization and increased health care cost (13).

The purpose of written patient education materials (warfarin booklet in this case) is to provide information about health promotion, diagnostic procedures, treatments and medications. Patients need information that they can understand in order to undertake self-care behaviours. The potential for serious adverse effects of anticoagulation therapy requires that written patient informational material is at a reading level that patients can understand. Older patients with poor reading abilities are at a greater risk of not following instructions because of the difficulty that they have in formulating questions to ask to their healthcare provider and are further hampered by the burden of shame and embarrassment associated with illiteracy. Healthcare providers have a responsibility to use education materials that will meet the unique learning needs of patients with low literacy. Understandable information is important in reducing health care barriers to patient education and improved patient outcomes. There are many steps which can be taken to improve patient communication. Providing visual materials (for instance photos or drawings) while verbally explaining instructions to patients could increase the probability that patients will recall the information when compared to only providing instruction verbally. Another medium that could be used is the audiotape. In one study, researchers found that patients with low literacy chose an audiotape over a paper tool written at an appropriate grade level (14),(15).


Conclusion

Warfarin still remains the drug of choice for patients with thromboembolic diseases, and therefore appropriate educational strategies must be considered. The patientís age, educational status and household income were significantly associated with his/her knowledge of anticoagulation.

Practice Implications
The disadvantaged groups receiving anticogulation therapy, including the low-income earners, the elderly, the illiterates, and those with low levels of education, should always be given utmost care and attention to enhance their knowledge and awareness on warfarin therapy.

Acknowledgement

We hereby acknowledge with thanks the assistance of the under-listed persons during the conduct of this study:Director of Hospital Teluk Intan, Amutha Selvaraj, BPharm (Hons), RPh, Lim Gean Yee, BPharm (Hons), RPh, Norirmawath Shaharuddin, BPharm (Hons), RPhRokiah Isahak, BPharm (Hons), MPharm(Clin.Pharm), RPh

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