Development of an Anticoagualtion Assessment Questionnaire in an Ambulatory Care

Setting:

Evaluating patient attitudes and time management in pharmacist-managed anticoagulation

clinic
Gurgul SJ, Mako ML. DuPage Medical Group, Anticoagulation Clinic, Downer’s Grove, IL.

Background

Pharmacist-managed clinics provide an optimal structure for monitoring anticoagulation

and provide not only expert drug therapy management with better outcomes but also
convenience to patients.1 The complexity of anticoagulation therapy requires the grasp of
patients’ anticoagulant-related knowledge to aid in maintaining optimal therapy and preventing
adverse events.2 The typical patient interview allows limited time for recollection, thereby
increasing procedural bias through temporal stress. High volume clinics produce increased
clinician burden and time constraints which may lead to omission of pertinent queries during
patient interviews.3 Frequency of international normalized ratio (INR) monitoring calls for an
effective way to streamline visits while providing the most optimal patient care.

Addressing concerns through questionnaire assessment aids in targeting anticoagulant

therapy management and education tailored to individual patient needs. This also allows for
efficient collection of data so that the primary focus of visit attention may be to pertinent
concerns or changes. Use of open-ended questions develops trust and allows for unrestrained
and more fully articulated responses from patients due to a lesser perceived threat. 4 Data is
needed in this area to further support the rationale of how to best increase discussion with
patients regarding their education and concerns.

Objectives

The primary objective of this study was to create an assessment questionnaire

designed to better standardize the patient consultation process in an anticoagulation clinic that
is in the process of initiating medication therapy management (MTM). Secondary objectives
included assessing patient attitudes towards this questionnaire and the questionnaire’s impact
on time management.

Methods
 Development of this questionnaire involved input from two staff pharmacists, a full time
nurse and the above primary investigators. Inclusion criteria included active patients at the
DuPage Medical Group anticoagulation clinic. No patients were excluded from participating.
Collection of data was performed over seven clinic days between September 22 nd and
September 30th, 2010. Informed consent was not required given that no names or other patient
identifiers were recorded.

Initial concerns included addressing all routine questions, incorporating the questionnaire
into clinic visits and maximizing patient compliance with use of the questionnaire. Routine
questions assessed adverse events, missed warfarin doses, diet, changes in medication list
and future medical procedures. Based on these questions an informal written survey was
developed, comprising five sections:

 Occurrence of adverse events

o Bruising and various bleeding events
o Nausea/vomiting/diarrhea (including frequency)
 Medication related problems
o Missed doses of warfarin (frequency)
o Changes to medication list
 Diet-typical weekly frequency and recent weekly frequency of alcohol and several listed
vitamin k sources
 Future medical procedures
 Assessment of patient attitude toward questionnaire’s utility and educational potential

Incorporation of the questionnaire into clinic visits was facilitated by creating a form with the
focus on ease of reference. Basic checkboxes and a simple chart were used to collect the
majority of data. To maximize patient compliance, the form was limited to one double-sided
page. A 16-point font was used to address visual limitations of our population, which is
primarily elderly.

Results

25 patients were issued a written questionnaire, of these, 5 were unfinished. Unfinished forms
were defined as those missing answers to the last two questions (patient attitude).

GRAPH (pie chart)

Secondary endpoints were assessed by the final two questions of the questionnaire. Patients
were asked if they found the form helpful and were afforded space to elaborate. Of the
questionnaires completed, 50% found the form to exhibit utility in clinic visit facilitation. Of
these, 40% elaborated further. Of the negative responses, 30% were further elaborated. The
second of the final two questions assessed patient attitude toward the educational aspect of
the form. Of the 20 completed, 45% felt they had learned something from completing the
questionnaire. Of these, 33% elaborated further. Of the negative responses, 10% were further
elaborated.

DOUBLE GRAPH (pie or bar graph)

Post-hoc we further divided completion of the questionnaire into categories of ≥ 25%, ≥ 50%
and ≥ 75% completed.

20

15

10 Questionnaire
Completion
5

0
≥ 25% ≥ 50% ≥ 75% 100%

CHART 25 (1) 50 (1) 75 (3) the rest were 100% completed

Discussion
References

1) Wilt VM, Gums JG, Ahmed OI, et al. Outcome analysis of a pharmacist-managed
anticoagulation service. Pharmacotherapy. 1995 Nov-Dec;15(6):732-9.

2) Briggs AL, Jackson TR, Bruce S, et al. The development and performance validation of
a tool to assess patient anticoagulation knowledge. Res Social Adm Pharm. 2005
Mar;1(1):40-59.

3) Foss MT, Schoch PH, Sintek CD. Efficient operation of a high-volume anticoagulation
clinic. Am J Health Syst Pharm. 1999 Mar 1;56(5):443-9.

4) Richardson JV. Open versus closed ended questions. UCLA.

http://polaris.gseis.ucla.edu/jrichardson/dis220/openclosed.htm .