Quality control of oral anticoagulation with vitamin K antagonists in primary care patients in Poland: a multi-centre study.

BACKGROUND: Vitamin K antagonists (VKAs) remain the mainstay of anticoagulation therapy, which requires monitoring of international normalised ratio (INR). Quality of oral anticoagulation, clinical benefits, and the risk related to VKA use are determined by the time in therapeutic range (TTR). AIM: The aim of this study was to assess the therapeutic quality of oral anticoagulation and to determine the factors that affect the incidence of INR outside the recommended range in primary care patients undergoing long-term VKA therapy in Poland. METHODS: A multi-centre cross-sectional analysis was carried out in 15 general practices from three voivodeships of Poland. At the planned time, INRs measured closest to the designated date in all patients were assessed in terms of being within the therapeutic range. TTR was determined as the percentage of visits with INR in therapeutic range on a given date. RESULTS: Overall, 430 patients aged 70.3 ± 12.7 years (222 men aged 72 ± 12.8 years and 208 women aged 68.5 ± 12.4 years) were included in the study. In the groups with INR below, within, and above therapeutic range, the patients' age was 67.3 ± 13.4, 72 ± 12, and 70.5 ± 13 years (p = 0.001), respectively. TTR for all the participants was 55%. Statistically significant factors associated with INRs outside the therapeutic range were: age below 60 years (compared to older persons; p = 0.003), more or less frequent INR control compared to the recommended intervals of four to eight weeks (p < 0.001), and the type of the VKA used, i.e. acenocoumarol compared to warfarin (p < 0.001). Logarithmic regression analysis showed that the use of acenocoumarol compared to warfarin, increased the chances of INRs below therapeutic range (odds ratio [OR] 3.19; 95% confidence interval [Cl] 1.65-6.16), while male sex increased the probability of INR being above this range (OR 2.01; 95% Cl 1.12- 3.59). CONCLUSIONS: The TTR in primary care patients on VKA therapy was 55%. Better quality of oral anticoagulation with VKA could be achieved by using warfarin instead of acenocoumarol, proper INR monitoring in the recommended interval of four to eight weeks, and tighter INR control in younger and male patients.

[Knowledge of patients from the rural environment on the risk factors and prevention of cardiovascular diseases]. / Wiedza pacjentów ze srodowiska wiejskiego na temat czynników ryzyka i profilaktyki chorób ukladu krazenia.

UNLABELLED: Cardiovascular diseases (CVDs) are the leading cause of death in Poland. The aim of the study was to assess the knowledge of patients from the rural environment on the risk factors and prevention CVDs. MATERIAL AND METHODS: In the period from January to February 2006. one hundred and twenty patients [69 (57.5%) females and 51 (42.5%) males] from Primary Care Practice in Zabludow living in rural areas in the vicinity of Bialystok were interviewed using questionnaires developed by the authors of the work. It contained questions on demographic data (gender, age, education and residence), health status and level of knowledge about risk factors and prevention CVDs. RESULTS: The vast majority of patients had a thorough understanding of risk factors CVDs. The least known factor is diabetes--just as the second test (55.8%) believe that it contributes to the formation of CVDs. As prophylaxis 77.5% of respondents reported a diet low in salt, and 75%--regular physical activity. Advancing our knowledge about the disease as an existing preventive recognized 70.8% of respondents. Comparing knowledge of patients with the knowledge of healthy CVDs participating in the survey stated that they know more about risk factors and prevention CVDs than the differences are statistically significant (p < 0.05). Better educated person knows more about risk factors and prevention of CVDs than the less educated people. These differences were statistically significant (p < 0.05). CONCLUSIONS: Examined patients living in rural areas have a wide knowledge on risk factors and prevention CVDs. This applies especially to people with higher education or with known cardiovascular diseases. People with lower education require more attention and education. Emphasis should be given to promoting information on the impact of diabetes on the development of CVDs.

[Educational role of community nurse in care of patients treated with oral anticoagulation therapy]. / Edukacyjna rola pielegniarki srodowiskowej w opiece nad pacjentami leczonymi acenokumarolem w poradni lekarza rodzinnego.

UNLABELLED: Different methods allowing for assessment of anticoagulation effects in patients receiving oral anticoagulants (OAC) are applied. Among them estimation of total time of international normalized ratio (INR) within the therapeutic range (time in therapeutic range--TTR) is used. The aim of the study was to assess the knowledge of patients about safety measures when on acenocumarol (AC) therapy as well as to measure TTR and potential impact of education provided by community nurse on TTR. MATERIAL AND METHODS: The study lasted for 20 months since August 2006 till March 2008. Twenty-five patients remaining under care of a family physician were interviewed about safety rules while on treatment with AC. In May 2007 an educational intervention was provided by a trained community nurse. RESULTS: We have shown that older age was related to lower number of correct responses to questions (p < 0.064). Individuals with higher number of correct responses measured their INR more frequently, statistically significant difference (p < 0.045). TTR of all subjects before education was 48% and increased after education to 52%. We have shown that changes of TTR after education were related to education, age group and gender. The biggest improvement of TTR was observed among people younger than 75 years of age and those with higher education (not statistically significant differences). CONCLUSIONS: Education has biggest effect in persons under 75 years and with higher education. Older persons and those less educated require longer education and monitoring by health care professionals to maintain INR in the therapeutic range. Patients with better knowledge about DAK--monitor INR more frequently and their anticoagulation is better controlled.

[Haemorrhagic complications among patients on life-long acenocumarol therapy]. / Powiklania krwotoczne u pacjentów przewlekle leczonych acenokumarolem.

The aim of our study was to determine factors influencing occurrence of haemorrhagic events during acenocumarol therapy. A total of one hundred and forty patients were interviewed using a questionnaire. From one hundred forty (100%) of interviewed patients, forty one (29.3%) had haemorrhagic events and in eighteen (12.9%) cases the event followed the use of nonsteroid anti-inflammatory drugs (NSAID's) or paracetamol in combination with acenocumarol (AC). We found eleven cases of major bleeding in eight (5.7%) of patients Eight cases of bleeding were followed the use of NSAID's or paracetamol in combination with (AC). We found that there is a statistical relationship between the higher frequency of INR examination (at least as every four weeks) and decreased occurrence of haemorrhagic events (p<0.05). The frequency of INR examination should be done once every four weeks or more often, if there is evidence to suggest that testing more frequently. Monitoring of INR with frequency less than once in 4 weeks may increase the risk of bleeding in those patients. Concomitant use of NSAID's or paracetamol in combination with acenocumarol in patients without medical consultation can be associated with growing number of bleeding. Patients on AC therapy need to be inform about frequency of INR examination and acaenocumarol interactions with other medications, which are available without the prescription, to avoid haemorrhagic events.

[Factors influencing activity of oral anticoagulants. Interactions with drugs and food]. / Czynniki wplywajace na dzialanie doustnych antykoagulantów. Interakcje z lekami i pozywieniem.

Oral anticoagulants (OAC) are commonly used as a life-long therapy in prevention of systemic embolism in patients with atrial fibrillation, valvular heart disease and prosthetic hart valves and in the primary and secondary prevention of venous thromboembolism. They are also used for the prevention of thromboembolic events in patients with acute myocardial infarction and with angina pectoris, in patients with biological hart valves and after some types of orthopaedics surgery. The International Normalized Ratio (INR) is used to evaluate the efficacy of anti-coagulant therapy. The risk of thromboembolic and haemorrhagic complications increases when the INR is out of the therapeutic range. The aim of this study was to present information about the factors influencing activity of oral anticoagulants and interactions between oral anticoagulants and drugs or food. The effect of oral anticoagulants is influenced by genetic and environmental factors such as: medicines, food, diseases and pre-existing conditions. A common mutation in the gene coding for the cytochrome P450 (CYP2C9), with one or more combinations of its polymorphisms, is responsible for the reduced warfarin requirements or for the resistance to warfarin. A mutation in the factor IX is responsible for the risk of bleeding during OAC therapy without excessive prolongation of the prothrombin time (PT). Drugs, herbs and multivitamin supplements can alter the absorption, pharmacokinetics or pharmakodynamics of OAC. Nonsteroid anti-inflammatory drugs and paracetamol in combination with OAC seem to be the most dangerous because they are available without prescription and are used without medical consultation. Patients on OAC therapy are sensitive to changing dietary intake of vitamin K, which is supplied from phylloquinones in plants or from vitamin K-containing medicines. The effect of OAC can be influenced by other existing factors like: fever, diarrhoea, alcohol abuse or physical hyperactivity. Some malignancies or other diseases like cardiac insufficiency, hyperthyroidism and hypothyroidism or hepatic dysfunction may also affect OAC therapy. This treatment requires patients and doctors to be knowledgeable about factors influencing the activity of oral anticoagulants. For this reason educational programme on OAC therapy should be conducted among patients and doctors.

[Use of oral anticoagulants in outpatient setting]. / Stosowanie doustnych antykoagulantów w ramach opieki ambulatoryjnej.

Oral anticoagulants (OAC) have been used for more than 60 years and are being prescribed to a steadily increasing number of patients as a life-long therapy The Intenational Normalized Ratio (INR) is used to evaluate the efficacy of anti-coagulant therapy. The risk of thromboembolic and haemorrhagic complications increases when the INR is above the therapeutic range. The aim of our study was to provide information about oral anticoagulant therapy and how to treat patients on OAC therapy in specific situations such as: pregnancy, intramuscular injection, tooth extraction and small invasive procedures performed in outpatient setting. INR needs to be frequently monitored during treatment and in many countries this is done in specialist anticoagulant clinics. Such clinics do not presently exist in Poland and patients on OAC treatment typically fall under the care of doctors of different specialization including general practitioners. OAC therapy is safe until fourth--sixth week of pregnancy, after his time anticoagulant treatment should be replaced by heparins. Intramuscular injections are contra-indicated during OAC therapy. In most cases general dental treatment and straightforward single dental extractions can be performed without discontinuing OAC, provided INR is in the therapeutic range of 2,0-3,5. Risk of bleeding can be minimized by the use of mouthwashes (used three or four times a day for 2 days) containing 4,8% tranexamid or 25% e-aminocapronicum acid. Prior to undergoing invasive procedures with a middle risk of bleeding and single extraction in patients with a risk of major bleeding should consult with a physician specializing in the use of anticoagulants to discuss the treatment and to assess the risk of bleeding and thromboembolism. This is why education about the therapeutic range of INR and procedures which need to be adopted in specific situations, is very important and the educational programme on OAC therapy should be targeted at patients and doctors of different specialization including general practitioners.

[Knowledge of patients undergoing long-term acenocumarol treatment about the safety of anticoagulant therapy]. / Wiedza o zasadach bezpiecznego stosowania doustnych antykoagulantów u chorych leczonych przewlekle acenokumarolem.

UNLABELLED: Oral anticoagulation with coumarin derivatives (OAC) has been used for more than 50 years and is being prescribed to a steadily increasing number of patients as a long-term therapy. The aim of our study was to evaluate patients' knowledge about the safety of acenocumarol treatment, the therapeutic range of International Normalized Ratio (INR) and its interactions with other medications and food. MATERIAL AND METHODS: One hundred and forty patients on long-term acenocumarol treatment were included in the study. They were interviewed using a questionnaire specifically prepared by the authors. The questions concerned their understanding of the reasons for the treatment, knowledge of target INR ratio, frequency of INR examination. Additionally the questionnaire contained questions specifically designed to check the patients' knowledge about factors influencing INR values e.g. drugs, food, alcohol and the like. RESULTS: One hundred and fifteen (82.1%) patients declared knowledge of target INR ratio, but only eighty eight (62.9%) answered correctly. Percentages of correct answers for the questions evaluating knowledge about acenocumarol treatment did not exceed 50%. Patients' responses suggested that advice was not always provided by doctors. CONCLUSIONS: Level of patients' knowledge about the safety of OAC treatment was very low. Insufficient knowledge was observed particularly in patients with lower education levels and those over 60 years of age. Those groups require a special attention and longer education to be able to self-manage the treatment. Special anticoagulant clinics do not exist in Poland. So, it seems very appropriate to develop concise guidelines available for patients in practices of family doctors. Education should be systematic and modified according to changing recommendations.

Management of sore throat by family physicians in northeastern Poland: possible benefits of applying clinical algorithm.

BACKGROUND: The objective of this study was to describe current sore throat management practices among family physicians and to estimate potential benefits of applying clinical algorithm - Centor's scale (presence of tonsillar exudates, fever, lymphadenopathy and absence of cough) in decision-making process. METHODS: Each of 44 participating family physicians was asked to fill in questionnaires for 30 consecutive patients with respiratory tract infection. RESULTS: Almost all decisions were made on clinical grounds. Among 169 adult patients with the clinical diagnosis of bacterial pharyngitis only 55% fulfilled 3 or more criteria on Centor's scale. CONCLUSIONS: Family physicians overdiagnose bacterial pharyngitis. Screening adult patients with Centor's criteria would probably lead to a reduction in the prescribing of antibiotics.

Perception of risk information. Similarities and differences between Danish and Polish general practitioners.

OBJECTIVE: The objective of the study was to gain better insight into how general practitioners (GPs) perceive risk reduction and the way this perception may be influenced by healthcare environment. DESIGN: Questionnaires with clinical episodes were sent to Danish and Polish GPs, who were randomised into four groups, each receiving the same case story with differently phrased information about risk reduction achieved through medical treatment. The GPs were asked whether they would recommend medical treatment, knowing the case story and expected risk reduction. SUBJECTS: Danish and Polish GPs. RESULTS: A greater proportion of Polish GPs than Danish GPs would definitely or probably recommend treatment (93% versus 72%; p < 0.001). Both groups of doctors were more inclined to recommend treatment when the achievable benefits were presented in terms of relative risk reduction rather than absolute risk reduction or number needed to treat. CONCLUSION: Neither information on number needed to treat nor relative risk reduction alone provides doctors with all the information they need to recommend treatment or prevention to their patients. The present study showed that the professional handling of risk information is affected by differences produced by healthcare cultures.