Quality in Health Care 1994;3:79-85
`
`79
`
`Evaluation of patients' knowledge about
`anticoagulant treatment
`
`Fiona C Taylor, Mary E Ramsay, Grace Tan, John Gabbay, Hannah Cohen
`
`Abstract
`Objective-To develop a questionnaire
`knowledge
`patients'
`of
`evaluate
`to
`anticoagulation.
`Design-Anonymous
`completed
`self
`questionnaire study based on hospital
`anticoagulant guidelines.
`Setting-Anticoagulant clinic in a 580 bed
`district general hospital in London.
`Subjects-70 consecutive patients newly
`referred to the anticoagulant clinic over
`six months.
`Main measures-Information received by
`patients on six items of anticoagulation
`counselling (mode of action of warfarin,
`adverse effects of over or under anti-
`coagulation, drugs to avoid, action if
`bleeding or bruising occurs, and alcohol
`consumption), the source of such infor-
`mation, and patients' knowledge about
`anticoagulation.
`Results-Of the recruits, 36(51%) were
`male; 38(54%) were aged below 46 years,
`22(31%) 46-60, and 10(14%) over 75. 50
`(71%) questionnaires were returned. In
`all, 40 respondents spoke English at home
`and six another language. Most patients
`reported being clearly advised on five of
`items, but knowledge about
`six
`the
`anticoagulation was poor. Few patients
`identify adverse con-
`could correctly
`ditions associated with poor control of
`anticoagulation: bleeding was identified
`by only 30(60%), bruising by 23(56%), and
`thrombosis by 18(36%). Only 26(52%)
`patients could identify an excessive level
`of alcohol consumption, and only seven
`(14%) could identify three or more self
`prescribed agents which may interfere
`with warfarin.
`Conclusion-The questionnaire provided
`a simple method of determining patients'
`knowledge of anticoagulation, and its
`requires
`indicated
`this
`that
`results
`improvement.
`Implications-Patients'
`responses sug-
`gested that advice was not always given
`by medical staff, and use of counselling
`checklists is recommended. Reinforce-
`ment of advice by non-medical coun-
`sellors and with educational guides such
`as posters or leaflets should be con-
`sidered. Such initiatives are currently
`being evaluated in a repeat survey.
`(Quality in Health Care 1994;3:79-85)
`Introduction
`Oral anticoagulants, such as warfarin, are
`preventing and treating
`widely used for
`vascular and thromboembolic disease. The
`
`and com-
`narrow, I
`therapeutic
`is
`range
`plications, such as life-threatening bleeding
`and re-thrombosis, can occur if patients are
`over anticoagulated or underanticoagulated.
`The efficacy of warfarin can be adversely
`including
`the
`affected by many factors,
`patients' concurrent drug treatment, change in
`diet or alcohol intake, and physical illness.2 3 It
`is therefore essential that patients are well
`advised and fully recognise the risks of anti-
`coagulant treatment. Previous reports indicate
`anticoagulants
`receiving
`oral
`that patients
`commonly do not know the potential com-
`plications and risks of their treatment.4 The
`objectives of this study were to develop a
`questionnaire to determine patients' reports of
`information received and to evaluate patients'
`knowledge of anticoagulation treatment.
`Methods
`The study site was a 580 bed district general
`hospital with an anticoagulant clinic attended
`by over 60 patients a week. The hospital's
`guidelines on managing anticoagulation were
`drawn up by the consultant haematologist,
`based on those issued by the British Society
`for Haematology6 and after discussion at the
`audit meetings.7 They
`hospital physicians'
`recommend that patients undergoing anti-
`given
`should
`be
`coagulant
`a
`treatment
`standard information card8 on anticoagulation
`and should be counselled by the ward doctor
`on six items before discharge. These items
`include the mode of action of warfarin, adverse
`effects associated with over or under anti-
`coagulation, what drugs to avoid, what action
`to take if bleeding or bruising occurs, and
`alcohol consumption. In addition, the calendar
`method as outlined in the current Department
`of Health anticoagulant treatment booklet9
`should be explained. This simple method was
`developed to improve compliance and entails
`patients ticking off on a calendar the days on
`which warfarin is taken. Although not outlined
`in the guidelines, doctors in the anticoagulant
`clinic should reinforce the information on
`these six items at the patient's first clinic
`attendance and should also distribute the anti-
`coagulant treatment booklet.
`We designed a questionnaire based on the
`six items of advice outlined in the guidelines
`first
`to complete after
`their
`patients
`for
`appointment with the anticoagulant clinic's
`doctor. The questionnaire asked patients for
`personal and clinical details, what information
`they had been given on each of the six items,
`and the source of this information. Patients'
`knowledge of the information contained in the
`Department of Health booklet was tested with
`a "quiz" section with multiple choice questions
`
`Health Care
`Development Unit,
`Academic Department
`of Public Health,
`St Mary's Hospital
`Medical School,
`London W2 1PG
`Mary E Ramsay, lecturer
`in public health medicine
`John Gabbay, senior
`lecturer in public health
`medicine
`Research Unit,
`Royal College of
`Physicians,
`London NW1 4LE
`Fiona C Taylor, research
`assistant
`Grace Tan, clinical
`research fellow
`Departments of
`Haematology,
`St Mary's Hospital
`Medical School,
`London W2 1PG and
`Central Middlesex
`Hospital,
`London NW1O 7NS
`Hannah Cohen, senior
`lecturer
`Correspondence to:
`Ms F C Taylor,
`Health Care Development
`Unit, Academic Department
`of Public Health, Central
`Middlesex Hospital, Acton
`Lane, London NW10 7NS
`Accepted for publication
`23 June 1994
`
`MYLAN - EXHIBIT 1037
`
`

`
`80
`
`in which patients were asked to tick the true,
`false, or don't know options. The question-
`naire was piloted in the clinic, and the final
`questionnaire (appendix 1) was found to be
`suitable, according to the Fog density index,
`for use by respondents who had received six
`years of schooling.'0
`Seventy consecutive patients newly referred
`to the anticoagulant clinic were recruited to the
`study over six months. All were given an anony-
`mous questionnaire by the doctor in the clinic
`at the first consultation. The doctor explained
`the purpose of the study to the patient, who
`was asked to complete the questionnaire at
`home and return it by post. Reminders were
`sent out by post two weeks later.
`Results
`STUDY POPULATION
`Of the
`patients
`study,
`recruited
`the
`to
`36(51%) were male; 38(54%) were aged less
`than 46 years, 22(31%) were aged 46-60, and
`10(14%) were aged over 75. Fifty (710%) of
`the
`70
`questionnaires
`administered were
`returned. Of the 50 respondents, 40(80%)
`spoke English at home, six (12%) spoke
`another language, and four (8%) did not
`specify. Nineteen respondents (38%) were
`retired, 1 1(22%) were in full time employ-
`11 (22%) either were claiming state
`ment,
`benefit or were unemployed, and nine (18%)
`gave no information. Thirty eight (76%) had
`been recent inpatients at the study hospital
`and six (12%) at another hospital, five (10%)
`were referred from the outpatient department
`and one (2%) from their general practitioner.
`CLINICAL DETAILS
`Of the 50 respondents, 29(58%) reported
`having venous thromboembolic disease, six
`(12%) heart disease or surgery, five (10%)
`stroke, eight (16%) multiple or other diag-
`(4%)
`and two
`did
`specify.
`not
`noses,
`Seventeen (34%) patients had been receiving
`anticoagulant treatment for fewer than two
`weeks, 16(32%) for two to three weeks,
`and the remaining 17(34%) for more than
`four weeks.
`In all, 34(68%) of patients
`expressed
`about
`receiving
`anti-
`concern
`coagulant treatment. Nineteen (38%) would
`have liked more medical advice, but only
`five (26%) felt unable to obtain sufficient
`medical advice.
`Thirty two (64%) patients reported taking
`other medicines and of these, eight (16%)
`were currently taking drugs that can adversely
`affect anticoagulation treatment. These drugs
`had been self prescribed in one patient,
`prescribed by other hospital doctors in six
`patients, and by the general practitioner in the
`remaining patient.
`
`PATIENTS REPORTS OF INFORMATION
`RECEIVED
`Apart from the
`calendar method,
`most
`patients reported receiving clear information
`on each of the six items (table 1). Among the
`38 inpatients in the study hospital, however,
`only 19(50%) reported having been given an
`information
`card
`and
`10(26%)
`reported
`
`Taylor, Ramsay, Tan, Gabbay, Cohen
`
`Patients reporting clear advice given on six
`Table I
`items from any source (n = 50)
`Items
`Calendar method
`How warfarin works
`Action if bleeding or bruising occurs
`Problems with anticoagulant treatment
`Drugs to avoid
`Alcohol
`
`No (°0) ofpatients
`22 (44)
`38 (76)
`25 (50)
`31 (62)
`37 (74)
`41 (82)
`
`receiving clear advice on three items or more
`from the ward doctor. This compares with
`19/50(38%)
`respondents
`reported
`who
`receiving such advice from the doctor in the
`anticoagulant clinic. Of the 50 respondents,
`only 10(20%) reported other sources of infor-
`mation, which included ward nurses, other
`hospital medical staff, general practitioners,
`and written literature.
`PATIENTS' KNOWLEDGE OF ANTICOAGULATION
`Although
`46(92%)
`correctly
`patients
`of
`answered that warfarin "thinned" the blood,
`knowledge of the possible side effects of poor
`control of anticoagulant treatment was low
`(table 2). Only 27(54%) patients were able to
`identify correctly three or more of the six
`genuine effects from a list of 13 conditions,
`and 18(36%) chose one or more of the seven
`unrelated conditions. In the quiz 33(66%)
`patients correctly reported that a new treat-
`ment could affect anticoagulant treatment, but
`only 26(52%) knew that changing the dose of
`concurrent tratment could also affect anti-
`coagulation.
`knowledge
`Patients'
`self
`of
`prescribed treatment which can affect anti-
`coagulant control was mixed (table 3); from a
`list of 11 self prescribed agents, only seven
`(14%) patients were able to identify three or
`more of the six agents which could adversely
`affect anticoagulation and, 11(22%) patients
`named as harmful one or more of the five
`"safe" agents listed.
`Forty one patients reported having been
`clearly advised on alcohol (82%), but, only
`26(52%) patients could correctly identify an
`excessive level of alcohol consumption, and
`19(38%) patients thought that alcohol would
`not affect anticoagulant treatment.
`Discussion
`This study used patients' reports to evaluate
`the completeness of counselling about anti-
`coagulation given at the study hospital and the
`
`Table 2
`Patients identifying conditions associated with
`poor control of anticoagulant treatment (n = 50)
`Condition
`No (%o) ofpatients
`
`Associated effects
`
`Non-associated effects
`
`Blood in stools
`Nose bleeds
`Prolonged bleeding
`Bruising
`Blood in urine
`Blood clots
`Sleeplessness
`Weakness
`Loss of appetite
`Ringing in the ears
`Nausea
`Nervousness
`High blood pressure
`
`20 (40)
`26 (52)
`30 (60)
`23 (56)
`18 (36)
`18 (36)
`5 (10)
`9 (18)
`7 (14)
`4 (8)
`7 (14)
`7 (14)
`9 (18)
`
`

`
`Evaluation ofpatients' knowledge about anticoagulant treatment
`
`81
`
`Patients identifying selfprescribed agents which
`Table 3
`should be avoided when taking anticoagulants (n = 50)
`No (Oo) ofpatients
`Selfprescribed agent
`40 (80)
`9 (18)
`11 (22)
`4 (8)
`2 (4)
`7 (14)
`
`Aspirin
`Cough medicines
`Nurofen
`Codliver oil
`Garlic capsules
`Health shop remedies
`
`To be avoided
`
`Ma, be used
`
`0 (0)
`Vitamin C
`2 (4)
`Throat lozenges
`1 (2)
`Optrex
`0 (0)
`TCP (Trichlorophenol)
`8 (16)
`Antacids*
`*The safety of antacids in warfarin treatment is controversial.
`
`outcome of such counselling in terms of
`patients' knowledge. Recent inpatients at the
`hospital reported receiving little information
`of anti-
`risks and complications
`on the
`coagulant treatment from the ward doctors.
`According to patients' reports, the doctors in
`the anticoagulant clinic were better at giving
`advice, but as the questionnaire was admin-
`istered at the first clinic appointment, patients
`would be expected to have better recall of
`information given at this time.
`This study also highlights a substantial gap
`between the information patients reported
`having received and the outcome in terms of
`their knowledge of anticoagulant treatment.
`For example, even though most patients
`reported having been advised on the problems
`associated with oral anticoagulants, only a
`correctly
`proportion
`small
`able
`to
`were
`identify most of the adverse events and some
`patients were confused about other
`side
`effects. This lack of knowledge was apparent
`all patients knowing that
`despite virtually
`warfarin "thins" the blood.
`Patients' knowledge about anticoagulation
`was disappointing and there are two possible
`explanations for these findings. The first is
`that ward doctors at the study hospital are not
`giving all the information recommended in
`the guidelines. Previous audits of inpatient
`referral
`management and of the
`process
`showed poor compliance of ward doctors
`with other aspects of the guidelines on anti-
`coagulant treatment,1 1 12 and compliance with
`the recommended counselling may also be
`poor. In this study 14% of patients had been
`treatment which can interfere
`prescribed
`with warfarin, which accords with the results
`study which showed poor
`of a previous
`knowledge among doctors of which drugs
`can interact with oral anticoagulants. A lack
`staff may
`of knowledge among medical
`contribute to a reluctance to advise patients
`about the risks and complications of anti-
`coagulation. More widespread dissemination
`of guidelines to medical staff is required, with
`specific instructions on counselling patients
`receiving anticoagulation.
`The second explanation, supported by the
`gap between patients'
`of advice
`reports
`received and their knowledge, is that patients
`are unable to understand and retain the
`advice they are given, as shown in previous
`studies.'3 14 The poor quality of doctor patient
`
`communication has been well described in
`other chronic conditions,15-17 and training in
`communication skills for doctors has received
`until
`little
`medical
`schools
`emphasis
`in
`recently.'
`communication
`More effective
`arises from understanding patients' expec-
`tations, involving patients in negotiating their
`treatment plan,'5 and continuity and accessi-
`of staff.'5
`levels
`of patient
`Better
`bility
`knowledge may also be achieved if information
`is reinforced by simple measures such as
`repetition or using written material.'9 The
`availability of a non-medical counsellor, such
`as a clinical pharmacist or nurse practitioner,
`has also been shown to increase patients'
`treatments.20 2
`medical
`about
`knowledge
`Non-medical staff may be better able to offer
`continuing support, to talk with the patient,
`and to ensure that written information has
`been read and understood.
`two
`importance
`of
`the
`The relative
`explanations for the poor level of patients'
`knowledge was not addressed in this study.
`That would require independent observation
`of the consultation or inclusion of the doctors'
`perspective and would be difficult to replicate
`in routine practice. Our questionnaire focused
`on the patients' perspective and could be
`repeated at the study hospital to evaluate
`changes in practice or adopted for use at other
`sites.
`This study's aim was not to relate patients'
`levels of knowledge to clinical outcome. A pre-
`vious small study was unable to demonstrate a
`relation between a structured programme of
`education and rate of complications or thera-
`peutic control.23 Therefore, patient education
`forms only one part of effective anticoagulant
`control; we are currently developing methods
`to audit other aspects of management.
`Recommendations
`To improve patients' knowledge it is import-
`ant to focus on the process of giving infor-
`mation. To increase the number of patients
`being counselled about anticoagulant treat-
`ment by ward doctors, the guidelines have
`been disseminated through the computer
`system and through the development of con-
`densed guidelines in the form of practice
`points.24 For doctors in the anticoagulant
`clinic a checklist for counselling has been
`incorporated into the clinic history sheets for
`all new patients. Doctors often omit important
`items of advice,25 and the checklist can act as
`an "aide memoire" (appendix 2).
`To reinforce counselling and to provide on-
`going education a trained health care assistant
`asks each patient attending the anticoagulant
`five key questions. These questions
`clinic
`highlight the most important potential com-
`plications; changes in medication, hospital
`admission, episodes of bleeding or bruising,
`attendances at the accident and emergency
`or forthcoming surgery. The
`department,
`assistant also distributes and explains written
`information in the form of a leaflet which
`focuses on these key points.
`The use of written educational guides may
`also successfully alert patients to the possible
`
`

`
`82
`
`Taylor, Ramsay, Tan, Gabbay, Cohen
`
`about anticoagulant treatment. A repeat survey
`of patients at the anticoagulant clinic is being
`performed to evaluate the effects of changes in
`practice at the hospital. The questionnaire
`proved easy to administer and has been
`shortened to concentrate on the important
`aspects of education, which are reinforced at
`each visit. The method has also been adapted
`and is currently being used at other clinic sites
`in North West Thames region.
`We thank the Research Unit, Royal College of Physicians
`(London), headed by Dr Anthony Hopkins, for funding this
`work; Mrs Millie Simpson, anticoagulant clinic coordinator for
`helping in data collection; and Dr Adrian Renton for advice on
`the manuscript.
`
`risks and complications of treatment. Such
`guides, including posters and leaflets, have
`been instructive
`other conditions and
`in
`promote positive changes in patients' well-
`being and improve compliance.18 26 Clear
`explanation of the rationale for and potential
`problems with anticoagulant treatment may
`help to improve patients' compliance with
`advice given. For the anticoagulant clinic at
`the study hospital, a poster and a patient
`leaflet based on the information contained in
`the Department of Health anticoagulant treat-
`ment booklet9 have been devised.
`The
`questionnaire
`in
`successful
`was
`evaluating the level of patients' knowledge
`Appendix 1
`Patient questionnaire
`Section A: This section tells us about your general health and the anticoagulant
`treatment (for example, warfarin or phenindione) that you are now receiving
`Since starting anticoagulant treatment, would you say that your general health has:
`1
`(Please tick)
`Improved D
`Worsened D
`Stayed the same D
`2 How long ago was your present anticoagulant treatment started?
`Less than 1 week
`D
`Between 1-2 weeks
`Lii
`Between 2-4 weeks
`L
`More than 4 weeks
`D
`El
`Can't remember
`If more than 4 weeks, please state how long
`3 As far as you know, which of the following are reasons for your present anticoagulant treatment?
`(Please tick Yes, No, or Not sure for each item)
`Not
`sureDo
`-Ii
`Lii
`
`Deep venous thrombosis (DVT) - blood clot in leg vein
`a
`b
`Pulmonary embolus (PE) - blood clot in lung
`Heart disease
`c
`d
`Heart surgery
`Stroke
`e
`Anything else?
`4 About your present anticoagulant treatment:
`a Have you wanted to approach anyone for medical advice?
`Yes E
`No D
`b Have you been able to?
`El
`Yes
`No L
`If YES, who?
`c
`5 Do you worry about being on anticoagulant treatment?
`A lot E
`A little E
`Not at all
`Lii
`If so, what are your concems?
`Please list ALL medications, tablets, and remedies you are taking now. Please include those obtained with
`and without a prescription (egfrom your GP, hospital, health shops and chemists). Please also state
`whether taken regularly OR only when you think you need to
`Name of preparation
`(Please tick one or other)
`Taken regularly Taken when needed
`
`Yes
`
`No
`
`-IIFo:
`
`6
`
`For how many
`weeks/months/years
`have you been taking it?
`
`Started by whom?
`(eg GP, hospital,
`anticoagulant clinic,
`self, pharmacist)
`
`

`
`Evaluation ofpatients' knowledge about anticoagulant treatment
`
`83
`
`Section B: The questions in this section are about the time you spent in the ward
`as a patient at Central Middlesex Hospital
`Were you recently an inpatient in a ward at Central Middlesex Hospital?
`1
`Yes R
`No C
`Please answer question 2 only ifyou started anticoagulant treatment while in the ward at Central Middlesex
`Hospital
`a When you left the ward were you handed a white card "Advice for patients on anticoagulant
`2
`treatment"?
`Yes R
`No R
`Not sure D
`b Was the information on the card:
`Too complicated? D
`D
`Too simple?
`D
`Just right?
`Please state any problems you had with the white card:
`
`c
`
`LI
`
`Don't know LI
`
`Section C: The questions in this section are about the information you may have
`been given about your anticoagulant treatment
`a Were you told how anticoagulant treatment works, and was this clear to you?
`1
`No D
`Yes, but not clear D
`Yes, and clear E
`b Who told you?
`LI
`Doctor in the ward
`Doctor in the anticoagulant clinic
`Who else (for example, GP, nurse, other clinic staff) Please state:
`a Were you told of the problems with anticoagulant treatment, and was this clear to you?
`LI
`No L
`LI
`Yes, and clear
`Yes, but not clear
`b Who told you?
`Don't know LI
`EI
`Doctor in the ward L
`Doctor in the anticoagulant clinic
`Who else (for example, GP, nurse, other clinic staff) Please state:
`a Were you told what to do if you have a nosebleed or are bruising, and was this clear to you?
`No LI
`LI
`LI
`Yes, but not clear
`Yes, and clear
`b Who told you?
`Don't know LI
`Doctor in the ward L
`Doctor in the anticoagulant clinic L
`Who else (for example, GP, nurse, other clinic staff) Please state:
`a Were you told of the calendar method to check your anticoagulant treatment, and was this clear
`to you?
`El
`No L
`Yes, and clear L
`Yes, but not clear
`b Who told you?
`Doctor in the ward L
`Doctor in the anticoagulant clinic L
`Who else (for example, GP, nurse, other clinic staff) Please state:
`a Were you told what drugs to avoid, and was this clear to you?
`No LI
`LI
`LI
`Yes, but not clear
`Yes, and clear
`b Who told you?
`aI
`Doctor in the ward LI
`Doctor in the anticoagulant clinic
`Who else (for example, GP, nurse, other clinic staff) Please state:
`a Were you given advice on drinking alcohol, and was this clear to you?
`EI
`No LI
`LI
`Yes, but not clear
`Yes, and clear
`b Who told you?
`LI
`Doctor in the ward
`Doctor in the anticoagulant clinic
`Who else (for example, GP, nurse, other clinic staff) Please state:
`Section D: This section is a miniquiz because we would like to find out how well patients
`have been informed about anticoagulant treatment and the problems it may cause
`1 How does warfarin work?
`(Please tick Yes or No for each statement)
`No
`Yes
`E]
`LI
`Warfarin does not affect the blood
`a
`LI
`LI
`b Warfarin thins the blood
`LI
`LI
`Warfarin thickens the blood
`c
`Could starting a new treatment or any other preparation affect your anticoagulant treatment?
`Don't know LI
`No LI
`LI
`Yes
`Could changing the dose of a treatment you are already taking affect your anticoagulant treatment?
`3
`No LI
`Don't know LI
`Yes
`LI
`4 The following are statements about any patient drinking alcohol when receiving anticoagulant
`treatment
`(Please tick Yes or No for each statement)
`No
`Yes
`L
`Alcohol does not affect anticoagulant treatment
`L
`Alcohol must be avoided totally
`LI
`L
`El
`8 units of alcohol a night is OK (for example, 4 pints of beer or 8 glasses of wine)
`L
`1 unit of alcohol a night is OK (for example, 2 pint of beer or 1 glass of wine)
`L
`L
`
`2
`
`3
`
`4
`
`5
`
`6
`
`2
`
`Don't know L
`
`Don't know LI
`
`LI
`
`Don't know LI
`
`

`
`84
`
`Taylor, Ramnsay, Tant, GabbaY, Cohen
`
`5 Of the list below, which drugs should be avoided when receiving anticoagulant treatment? Please
`do not be alarmed, some of the drugs listed below should not be avoided
`(Please tick True, False, or Don't know for each item)
`Don't know True False
`Aspirin
`Li
`Li
`L
`Cough medicines
`Li
`Li
`L
`Nurofen
`Li
`Li
`L
`Antacids (for example, Rennie, Settlers)
`Li
`L
`Li
`Optrex (eye solution)
`Li
`Li
`Li
`Li
`Codliver oil
`Li
`Li
`Garlic capsules
`Li
`Li
`Li
`TCP/Dettol
`Li
`Li
`Li
`Vitamin C tablets
`Li
`Li
`Li
`Throat lozenges
`Li
`Li
`Li
`Health shop remedies
`Li
`Li
`E
`6 Which of the following could be possible side effects of taking the wrong (too little or too much)
`amount of anticoagulant treatment? Please do not be alarmed, some of the items are wrong
`(Please tick True, False, or Don 't know for each item,)
`Don't know True False
`Blood in stools
`LL
`Li
`Nose bleeds
`L
`Li
`L
`Sleeplessness
`L
`Li
`L
`Prolonged bleeding after cuts
`LL
`Li
`Bruising without injury
`Ei
`Li
`E]
`Weakness
`Li
`Li
`Li
`EL
`Loss of appetite
`Ci
`L
`Ringing in the ears
`F
`G]
`Nausea
`Blood in urine
`Nervousness
`Blood clots
`High blood pressure
`
`L-iL-iL-iL-iLi
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`Li
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`L
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`Patient details
`CONFIDENTIAL
`So that we can be sure that this questionnaire reaches a cross section of patients we would appreciate
`the following information
`Are you replying on behalf of:
`a
`Somebody else
`Yourself
`Li
`If somebody else, please explain:
`b
`i)
`Your relationship to the patient:
`ii) The reason your help is needed:
`Ifyou are completinlg this form on7 behalf of the patient please anszwer the following qitestion
`b
`Are you (the patient):
`Male
`Female
`Li
`Li
`c Which of the following age groups are you (the patient) in:
`Under 16
`Li
`16-30
`Li
`31-45
`Li
`46-60
`Li
`61-70
`2i
`71 and over
`Li
`d What language do you (the patient) speak at home?
`English
`Other (please specify)
`Li
`Which of the following best describes your (the patient's) employment status?
`e
`Employed full time
`Employed part time
`Li
`Li
`Unemployed
`Long term sick leave or benefit
`Li
`Li
`Student
`Retired
`Li
`Li
`Thank you very much for taking the time to complete this questionnaire
`
`as they applyi to hiin /her
`
`1
`
`2
`
`3
`4
`
`5
`
`6
`
`McInnes GT, Helenglass G. The performance of clinics for
`outpatient control of anticoagulation. .7 R Coll Phs'sicians
`Lond 1987;21:42-5.
`Standing Advisory Committee for Haematology of the
`Royal College of Pathologists. Drug interaction with
`coumarin derivative anticoagulants. BMJ 1982;285:274.
`Duxbury BMcD. Therapeutic control of anticoagulant
`treatment. BMJ 1982;294:702-4.
`Colwell N, O'Neill T, Tyrell J. Robinson K, Clarke R,
`Graham I. An evaluation of an anticoagulant clinic. Irish
`Med]_ 1990;83:94-7.
`Burns E, Wyld P, Bax N.
`Doctors'
`and patients'
`perspectives of adverse drug reactions in
`a general
`medical and an anticoagulant clinic. . R Coll Phvsicinam
`Lond 1988;22:248-51.
`British Society for Haematology, British Committee for
`Standards in Haematology: Haematosis and Thrombosis
`Task Force. Guidelines on oral anticoagulation: second
`edition. Y C/li Pathol 1990;43:177-83.
`
`7
`
`Gabbay J, McNicol M, Spiby J, Davics S, I ayton A. What
`did medical audit achieve? Lessons from the preliminary
`evaluation of a sear's medical audit. BMA7 1990;301:
`526-9.
`Advice ofi
`patients on antltioagniant
`8
`tretianent. London:
`Pharmaceutical Society of Great Britain, 1988.
`Department of Health. Antocoagniant trcatinscnt. London:
`9
`HMSO, 1985. (Dd 8933025.)
`10 Gilliland J. Readability; UKRA tcachi'n,
`'cadinl, 11mono)-
`o/
`graph. London: University of London Press, 1972.
`11 Tan G, Cohen H, Taylor F, Gabbas J. The audit of
`anticoagulation therapy: initiation of anticoagulation in
`inpatients. .7 Cliii Pathol 1993;46:67-71.
`12 Tan GBT, Cohen H, Taylor FC, Gabbay J. Referral of
`patients to an anticoagulant clinic: implications for better
`management. Quality in Health Care 1993;2:96 9.
`13 Ley P, Bradshaw PW, Eaves D, Walker CM. A method for
`increasing patients' recall of information presented bh
`doctors. Psvchol Med 1973;3:217 20.
`
`

`
`Evaluation ofpatients' knowledge about anticoagulant treatment
`
`85
`
`Appendix 2
`Checklist for patient counselling
`Please tick to confirm that the use of the yellow Department of Health
`anticoagulant treatment book has been explained to the patient
`E
`Please tick the boxes to confirm that you have counselled the patient on
`the following items:
`D
`Compliance (the calendar method)
`1
`Rationale for treatment
`E
`2
`3 Mode of action of warfarin
`D
`Obtaining supply of warfarin from general practitioner
`I
`4
`Possible effects of poor control of anticoagulation
`5
`Bleeding or severe bruising
`L
`Recurrence of thromboembolism
`L
`Appropriate action if bleeding or bruising occurs
`Appropriate action if patient has diarrhoea or is vomiting
`Starting new treatment and changing dose of current treatment
`Self prescribed drugs:
`LI
`Avoid aspirin
`Avoid Nurofen
`C]
`LI
`Avoid health shop remedies
`L
`Ask pharmacist, doctor for advice
`Alcohol intake
`10
`Contraception, pregnancy, and hormone replacement therapy
`11
`(if relevant)
`Surgical procedures (including dental work)
`12
`Injections
`13
`Leisure activities
`14
`Counselled by:
`
`6
`7
`8
`9
`
`Date:
`
`Pollock A.
`14 Roddie A,
`of anti-
`control
`Therapeutic
`coagulation: how important is patient education? CGin
`Lab Haematol 1988;10:109-12.
`15 Wikblad K. Patient's perspectives of diabetes care and
`education. Jf Adv Nursing 1991 ;16:837-44.
`16 Mechanic D. Health and illness behaviour and patient-
`practitioner
`relationships.
`Soc
`Sci Med 1992;12:
`1345-50.
`17 Greenfield S. Sherrie H, Kaplan H, Ware J, Martin E,
`Harrison J. Patients' participation in medical care. _7 Gen
`Intern Med 1988;3:448-57.
`18 McManus I, Vincent C, Thom S, Kidd J. Teaching
`communication skills to clinical students. BMJ 1993;
`306:1322-7.
`19 Kitchen J. Patient information leaflets - the state of the art.
`J R Soc Med 1990;83:298-300.
`20 Dodds L. Industry produced patient information leaflets:
`are hospital pharmacies making use of them? Pharm .7
`1993;243:311-2.
`21 Vogt BH, Kapp C. Patient education in primary care
`practice. Patient Education 1987;81:273-7.
`22 Kornblit P, Senderoff J, Davis-Erikson M, Zenk J. Nurse
`Practitioner 1990;15:21-33.
`23 Wyness MA. Evaluation of an educational programme for
`_7 Adv Nursing
`patients
`taking
`1990;15:
`warfarin.
`1052-63.
`24 Taylor F, Ramsay M, Renton A, Cohen H. Referral of
`patients to an anticoagulant clinic. Quality in Health Care
`1994;3: 120.
`25 Wells F. Patient information - the present and the future.
`.7 R Soc Med 1990;83:300-2.
`26 Siminioff L. Improving communications with cancer
`patients. Oncology (Huntingt) 1992;10:83-9.
`
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`L
`L
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`LI
`El