Optimising anticoagulant education in the paediatric setting using a validated model of education

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Abstract

Objective

Providing education to patients requiring anticoagulant therapy may be associated with improved outcomes. This study investigated the knowledge outcomes of a validated educational intervention.

Methods

Parents of children with congenital heart disease requiring warfarin therapy took part in an educational intervention. Warfarin knowledge was assessed prior to commencing the program, immediately following its completion and 6 months following completion.

Results

Parents demonstrated a statistically significant improvement in their warfarin knowledge immediately following completion of the program (p < 0.0001), with this improvement being sustained over time.

Conclusion

Current approaches to educating parents of children requiring warfarin therapy are likely suboptimal. Using a validated model of education may be associated with improved knowledge outcomes for patients.

Practice implications

Consideration to the processes used in delivering patient education may result in improved patient knowledge outcomes.

Introduction

Warfarin (Coumadin™ or Marevan™) is the most widely prescribed anticoagulant in the world and is prescribed for the treatment or prevention of thrombotic complications [1]. The management of warfarin is complicated by its narrow therapeutic window which necessitates regular blood monitoring to ensure safety and efficacy of therapy.

The level of knowledge the patient and family have regarding warfarin therapy is indirectly proportional to their risk of complications, primarily major bleeding [2], [3]. As major bleeding is the most serious side effect of warfarin therapy, education programs that inform families of techniques to reduce that risk are of significant importance.

Numerous papers have been published with respect to the provision of warfarin education to adult patients [3], [4], [5], [6], [7], [8], [9], [10], [11]. Unfortunately, these papers did not routinely assess whether their interventions were associated with the primary aim of patient education, that is, an improvement in patient understanding. No papers to date have been published addressing warfarin education in the paediatric setting.

A nurse-coordinated Anticoagulation Clinic was established at the Royal Children's Hospital (RCH) (Melbourne, Australia) in April 1999. All patients requiring warfarin management at this institution must be referred to the Anticoagulation Clinic. At the time of commencing this study, 86 children were receiving warfarin management. As RCH is the major cardiac referral centre for south-eastern Australia, the majority of patients managed by the Anticoagulation Clinic had an underlying cardiac anomaly.

The anticoagulation service routinely provides warfarin education to patients and their families. In the past, families were provided with information regarding their child's indication for warfarin therapy, warfarin tablet presentation and dosing, warfarin's mechanism of action, monitoring requirements, possible confounders to stable therapy and potential warfarin-related adverse events. A purpose-designed handout reiterating key principles of warfarin therapy in children was provided to families. This education was not based upon any established model or published template for warfarin education. Parental understanding of warfarin therapy following implementation of this education strategy was previously assessed and found to be suboptimal [12]. Only 26% of parents knew why their child was receiving warfarin. Parental understanding of the timing of warfarin's effect and the impact of dietary changes upon control of anticoagulation was particularly poor.

We hypothesised that a coordinated education strategy, using a validated model of education, would likely produce improved knowledge outcomes for the parents of children requiring warfarin therapy. As well as determining whether such an intervention produced an immediate improvement in parental understanding of warfarin therapy, we aimed to determine if any such improvement could be sustained over time. A structured plan outlining the objectives and strategies that would facilitate achievement of desired outcomes was developed [13], [14], [15]. For the purpose of this study, the Predisposing, Reinforcing and Enabling Causes in Education Diagnosis and Evaluation (PRECEDE) model of health education was employed [14]. The PRECEDE model had previously been used to develop a successful education intervention for adult patients receiving warfarin therapy [7]. This model enables the development of a rigorously designed and structured educational intervention [14].

Section snippets

Methods

Data obtained from a previous assessment of parental understanding of warfarin therapy at the RCH was used to determine knowledge deficits and key learning needs [12]. The PRECEDE educational model provided the framework for this educational intervention. The program incorporated oral presentation, group discussion and the provision of written material. Fig. 1 summarises the education program.

All families of children requiring warfarin therapy at the RCH who had English language proficiency (n = 

Results

Fourteen families with children who were established on warfarin therapy provided written informed consent to participate in this program which commenced in March 2003 and concluded in October 2003. One parent only from each family completed all the study requirements (10 mothers; 4 fathers). This parent was self-chosen as the person designated to perform the home INR tests. The academic background of participating parents ranged from parents with a high school certificate to post-graduate

Discussion

The provision of education to patients requiring oral anticoagulant therapy has reportedly been associated with significant benefits, including improved compliance, reduced frequency of adverse events and improved stability of therapy [2], [3], [16], [17], [18], [19], [20]. Invariably, studies reporting such outcomes have assumed the benefits reflected improved knowledge outcomes following education. Whether these reported improvements in clinical outcomes are reflective of an improvement in

Acknowledgement

This work was supported by a research grant from the Quality Use of Medicines Division of the Commonwealth Department of Health and Ageing (Australia).

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    A portion of this article was presented as an oral presentation at the 45th American Society of Hematology Annual Meeting (December 2003), San Diego, USA.

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