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Educating Patients about Atrial Fibrillation

Tonya Anderson

Auburn University/Auburn Montgomery

Abstract

Atrial fibrillation is the most common cardiac arrhythmia in the United States. This arrhythmia affects more than two million patients and more than 150,000 new cases are discovered each year. Historically, atrial fibrillation has not been perceived by physicians and other health care providers as a difficult cardiac condition that will affect a patient’s quality of life. Health care providers have failed to provide the proper education and support the patient needs to ensure that he/she understands the importance of following treatment. The purpose of this project is to evaluate medication adherence and follow-up after educating patients about atrial fibrillation. Medication adherence is important in atrial fibrillation to minimize the risk of stroke and congestive heart failure. Eight adult patients with the diagnosis of atrial fibrillation and receiving a heart rate control medication along with Coumadin were randomly selected from an internal medicine clinic. Following informed consent, the patients received one-on-one education about atrial fibrillation and why it is important to take medication properly. Medication adherence questionnaires were given prior to the education session and phone surveys were conducted at the end of the clinical trial. Adherence scales were analyzed to assess for increase in medication adherence. Although the results supported the effectiveness of one-on-one education with increase adherence, the results were not significant. Eight patients were approached and eight consented to participate with 87.5% of those being male. The average age was 67.25 years. 50% of patients showed an increase in compliance according to the medication adherence scale. One-on-one education with patients who have atrial fibrillation resulted in increased adherence to medication treatment even in a baseline compliant group of participants.

Introduction

This proposal focuses on the importance of patient education for patients with atrial fibrillation (AF). The question that will be addressed through the evaluation of evidence based research is the following: In patients with atrial fibrillation, how does individualized education rather than generalized education affect the patient’s ability to adhere to medication and follow-up treatment? This proposal will include the purpose behind this question, the goals of the project, the target population, the type of patients that have AF, and the expected outcomes of the project.

There is a need for more individualized education for patients with atrial fibrillation. Atrial fibrillation is noted by the Shea and Sears (2011) as the most common cardiac arrhythmia in the United States. The arrhythmia affects more than two million patients and more that 150,000 new cases are discovered each year (Shea et al, 2011). Atrial fibrillation has not been perceived in the past by physicians and other healthcare providers as a difficult cardiac condition that will affect a patient’s quality of life (McCabe, Schumacher, & Barnason, 2011). With this in mind, the healthcare providers tend to minimize the significance of the disease and fail to provide proper support and education the patient needs to cope with and self-manage the reoccurring symptoms (McCade et al, 2011). “Good communication between healthcare professionals and patients is essential. It should be supported by the provision of evidence-based information offered in a form that is tailored to the needs of the individual patient” (Bakhshi, Camm, Davis, Deason, Dewar, Gotherby,…& Sulke, 2006 p.5).

In a recent article by Zimetbaum (2011, p5), he refers to the morbidity associated with the current strategy of rhythm-control in AF and states that the “trials results from the toxicity of conventionally used antiarrhythmic drugs and the excess stroke rate with warfarin discontinuation in patients randomized to the rhythm control strategy”. Warfarin and digoxin are medications used in the treatment of atrial fibrillation and can be very harmful at toxic levels. In some patients the risks may out weigh the benefit of treatment when they are unable to be educated about or manage medication intake. Anticoagulants in the treatment for AF are underused. One reason for the under use is the concern for the safety of the older population due to life threatening risk of bleeding such as intracranial and subarachnoid bleeds from falls (Khan, Kamali, Kestevan, & Wynne, 2004). Proper assessment of each patient with consideration of the caregiver in the older population and individualized education could allow the patients to be treated more often with an anticoagulant. If the patient is not competent to take the medications as prescribed and the required follow-up for monitoring drug level then the risk of the patient taking the medication may out weigh the risk of not taking it.

The goals for this project are to help patients better understand the disease and treatment options, recognize and self –manage the symptoms, and know the risks of medication management. Through better understanding the patient will be more likely to adhere and manage their medications and treatment follow-ups. There are several factors that affect a patient’s adherence to mediations. These factors include poor drug and therapy information and not involving the caregiver in the education process (Ulfvarson, Bardage, Wredling, Bahr, & Adami, 2005). Other factors can include medication costs, transportation, and misinterpretation of treatment instructions.

The patient population that will be targeted in this proposal is the patients in a primary care facility. In the rural area of Thomasville, AL, most clinics are owned by family practice physicians. Due to the lack of specialty physicians in the area, the family practice physicians generally manage many chronic problems. A target of eight to twelve patients at the Thomasville Internal Medicine clinic that will receive individualized education on atrial fibrillation and will be evaluated to assess their adherence to medication treatment, symptom control, and follow-ups will be an ideal start size for this type of project.

The causes of AF are at times unclear. Many medical conditions can contribute to the causes of AF. These are conditions such as thyroid disease, poorly controlled hypertension, valvular heart disease, congestive heart failure, coronary artery disease, or the patient may have no identifiable reason at all (Shea et al, 2011). With atrial fibrillation comes the increase risk of stroke which is the leading cause of death in AF (Zawaneh & Stambler, 2011). Several factors raise the risk of stroke in patients with AF including increasing age, patients with valvular heart disease (especially those with mitral valve stenosis), patients with history of stroke, diabetic patients, and those with systemic hypertension. (Zawaneh & Stambler, 2011).

The expected outcome for this project is adherence to medication and follow-up treatment. Through individualized education and understanding of the disease, knowledge of the rationale and management of the medications and the importance of seeking care for symptoms and follow-up, the patient will be more likely to adhere to their medication therapy and follow-up treatment. Through providing education aimed to increase the adherence of medication and follow-up treatment, the patients will be better equipped to deal with the symptoms and emotional burdens of the disease.

Framework

The ACE Star Model of Knowledge Transformation is one of the frameworks that is used to understand how evidence based information is transformed to improve patient outcomes. This model contains the necessary steps to take evidence based clinical information and transform to into clinical practice. This was easily applied to the question that is being asked. This model has five points that describes the transformation. This transformation starts with the discovery of new clinical knowledge and ends with the evaluation of how this knowledge is applied to improved care and patient outcomes (Kring, 2008).

Patient education is an important aspect of nursing and healthcare. Knowledge, skills, attitude, and self-awareness empower patients to have a positive influence on their health behavior (Koponen, Recola, Ruotsalainen, Lehto, Leino-Kilpi, & Voipio-Pulkki, 2008). Through the use of this model, we will be able to see how education for atrial fibrillation patients can be transformed into practice and achieve measurable results and patient satisfaction.

The ACE Star Model is broken into five points or phases. Point one is discovery. This step is characterized by traditional research activity and is the discovery of new information (Kring, 2008). Patient education is critical in improving patient health and outcomes. According to Koponen et al (2008) patients with atrial fibrillation who have better knowledge of their disease, have a better sense of good coping. From the evidence that has been assessed for this project, it is evident that patient education is lacking in the area of atrial fibrillation. Our goal is to inform the patient well enough that they see the importance of medication compliance and management. Also, the patient will be more independent in knowing what steps to take if symptoms reoccur.

Point two in the model is evidence summary. The summary is taking all of the research and summarizing it into one statement (Kring, 2008). When a patient is educated about their disease, its process, and the treatment, they are better prepared to maintain optimal quality of life. This better quality of life can be achieved through compliance with medications and knowledge of symptoms. In this project it was identified that the there is a need for better education on AF. Through the summary of evidence it is noted that the educational needs for the patient is present and does improve patient outcomes.

Point three is the translation into practice recommendations. At this point the information is transformed into a guideline for practice (Kring, 2008). Patient education is ongoing during the interaction of the caregiver and the patient. Many physicians in the rural areas, due to decrease reimbursements, have larger workloads and do not have the time it takes to properly educate their patients. A pamphlet will be provided for each patient that has atrial fibrillation. The information will cover an explanation of the diagnosis, symptoms, treatment, diet, and how to maintain a healthy lifestyle. This is good information but tragically many patients are not likely to read the pamphlet. Physician -patient conversation and interaction to ensure understanding is a better way to achieve this goal.

The fourth point in the ACE Star Model is implementation into practice. This phase can be very difficult causing chaos and frustration among an organization or department due to change in routine (Kring, 2008). The patients with atrial fibrillation will receive information on the disease through discussions by the physician and the nurse about the treatment for their specific type of atrial fibrillation which will include medications, symptoms, and when to seek emergency treatment. An educational pamphlet will also be given as a reference at home.

Point five is evaluation of the new practice. This phase includes identifying and measuring the outcome (Kring, 2008). Evaluation can be done at each office visit. The patient will demonstrate or verbalized understanding of the disease, its symptoms, diet, and medications. Other ways to evaluate teaching is though patient compliance, outcomes, and surveys. Each patient will complete a medication adherence questionnaire prior to education and at the end of the project. Is the patient’s heart rate within range? Is the patient having their blood checked as they should due to the anticoagulant and the antiarrhythmic medications and are these in therapeutic range? Is the patient coming for their follow-up visits? Does that patient understand the risk associated with and without medication treatment? How is the patient coping with the disease?

Literature Review

The data bases used in the search were the following: ERIC, CINAHL, HealthSource: Consumer Edition, HeathSource: Nursing/Academic Edition, Medline, and PsycInfo, PsycArticles. These were searched through the Auburn University Library. The results showed that most of the sourced pulled were from Medline and CINAHL. The terms used were atrial fibrillation, education, compliance, adherence, medications. Although the search did reveal patient education on other chronic illnesses which resulted in good information on the short term and the long term effects of different approaches to education, very few articles were found about atrial fibrillation education Articles were also cited from the clinical practice guidelines for AF and recent publications from the Journal of Cardiovascular Nursing and Cardiovascular Consults.

In the study conducted by Kopenen et al (2007), they looked at the knowledge base of patients with atrial fibrillation. A group of 200 patients with confirmed AF were selected from those treated in the three different emergency rooms. The group of researchers evaluated the knowledge of the patients during the visit and three months after the visit. This study found that there was only minimal improvement after three months about the disease, treatment, symptoms, anticoagulants, and when to seek treatment. This study concluded that informational support should be available for the patients on the condition of AF upon diagnosis and treatment. This applies to the present proposal in that it shows a lack of education in the area of atrial fibrillation. Education in needed so that the patients have what they need to improve their care.

Khan et al (2004) tested the value of education and self-monitoring in the management of warfarin therapy in older patients with unstable control of anticoagulation. This study used an education program in one group and education and self-monitoring in another as interventions to improve patient anticoagulation control. Although the study showed that both groups did improve with education and education and self-monitoring, the control group improved as well which was likely due to increased monitoring of anticoagulation levels. This applies to the proposal because education can be included to help patients understand how important frequent monitoring of anticoagulation therapy is in the reduction of toxicity and managing risks of stroke. One of the major causes of death with AF is stroke. Appropriate management and frequent monitoring of blood levels have proved to improve therapy.

The impact of decisional aids among patients with atrial fibrillation in the study by McAlister, Man-son-Hing, Straus, Ghali, Anderson, Majumdar, …& Fradette (2005) used an intervention group that received a self-administered booklet and an audiotape decision aid tailored to their personal profile for decisions about AF treatment. The result of the study showed that the intervention group who received the self-administration booklet and audiotape decision aid has a 12% improvement over the intervention group after three months. The study also showed that after 12 months each group progressed closer to baseline. This study can be used to show that continued ongoing education is needed for the patients. Over time, patients tend to adhere less and relapse. The audio tape along with the decisional aid proved to be a good tool that could be used in the proposed project. In the proposed project, it is important to stress continued physician-patient education and encouragement to adhere to the prescribed treatments.

A study by Vaskey, Sathononthan, Bhagra, Fujioshi, Tom, & Murad (2009) used quality improvement techniques to enhance patient understanding of diagnosis, management, and follow-up at the end of the office visit. This was a pilot study that showed how they created a tool to improve quality in their clinic. The research team recognized an educational need for a quality improvement in patient understanding of treatment and disease management through research that showed that physicians frequently overestimate the level of patient understanding. Lack of adequate information can lead to medication errors, decrease patient satisfaction, and suboptimal outcomes. They used the plan-do-study-act (PDSA) technique. This is a tool that could be useful in formulating a tool for patient individualized education for the AF patient is the proposed project.

Cuspidi, Sampieri, Fusi, Salerno, Severgnini, Leonette, & Zanchetti (2001) looked at improving patient knowledge by a single educational meeting on hypertension. The team found that poor compliance was a major cause of insufficient control of hypertension in the clinic. The groups attended four meetings. The study showed that the health education in a large number of the patients was improved by a single educational meeting with a physician. This is important to know for the proposed educational project that group education strategies could be used for education to improve outcomes. This could be incorporated along with a person individualized education program.

In a qualitative study by McCabe et al (2011), they looked at patients living with AF. The purpose of the study was to understand patients’ experiences of living with AF in order to identify any interventions that would improve the patient’s quality of life with the disease. The study looked at several areas. These areas included the following: finding the meaning of symptoms, feeling uninformed and unsupported, turning point, steering clear of AF, managing unpredictable and function limiting symptoms, emotional distress, and accommodation to AF with hope for a cure. The results of the study conclude that there is a need for support for patient coping with AF interventions are needed to improve recognition of AF symptoms and to promote treatment and evaluation. The proposed project of individualized education needs could include the assessment of a patients coping skills and coping strategies for the patients. A patient who is able to understand the disease, symptoms, medications, and how to self-manage have better skills to cope with the disease.

The importance of patient education affecting outcomes among patient with AF was verified by the literature. Several sources noted that the education for atrial fibrillation has not been adequate due to it being a less severe disease in comparison to other cardiac conditions. Each study cited many sources referencing the lack of knowledge the patients have about their disease, the symptoms, medications, and treatment. In any disease process, the patient will have a greater change of better quality of life if they participate in their care. It is the important as healthcare professionals to understand the importance of educating the patients and involve them in management of their disease.

Through reviewing the literature for this proposal it was also noted that one time education is not enough to keep the patient involved. In the long term it was noted that patient participation declined. Education of our patients should be a continuous process geared toward patient knowledge to self-manage their care through the physician or healthcare provider’s guidance. Through this process our goal is to see better adherence to medication and follow-up care.

Critical Appraisal and Recommendations

Atrial fibrillation is a challenging health problem due to the potential complications which include stroke, dementia, heart failure, and death. The focus of treatment is early detection, anticoagulation therapy, and rate control to prevent the complications. These treatments are essential for all patients with AF. Other preventative measure can also be taken to help with prevention such as statins, omega3 fatty acids, diabetes control, and weight loss. Research has found that several cultural, health, and lifestyle factors influence a patients risk for having atrial fibrillation. This knowledge is useful in early diagnosis as well as complication prevention. (Esters III, Sacco, Al-Khatib, Ellinor, Bexanson, Alonso, …Benjamin. 2011)

Although there was not a large quantity of research about atrial fibrillation, several studies do support the use of education to promote improved outcome for the patient. The critical appraisal of the evidence and level of evident that was found is in a table in Appendix A. It was noted that all of the studies found were conducted to promote or assess patient education in an effort to improve patient outcomes and satisfaction. These studies include a cohort study by Kopnonen et al (2008), two randomized trial studies by Khan et al (2004) and Mcalister et al (2005), qualitative descriptive study by McCabe et al (2011), a pilot-study, descriptive/observational by Vaskey et al (2009), and quasi experimental by Cuspidi et al (2001).

Based on the critical appraisal of the evidence, recommendations related to this proposal were determined. It has been established that there is an educational need in the area of atrial fibrillation. One recommendation for this project is to include a decision aid tailored to the individual patient with atrial fibrillation as evidenced by the randomized control trial by McAlister et al (2005). The decision guide along with patient- healthcare provider education at each visit will improve the patient outcomes including adherence to medications and follow-up visits. This is a Level II evidence based study showed a 12% improvement in the intervention group. According to the researchers and evidence the results were compatible with other decision aid trials. The grade of this recommendation with consideration of the evidence found is a B.

Another recommendation for this project is to initiate group education and support sessions for patients who have AF and spouses or caregivers. As evidenced by the findings of Caspidi et al (2001), a group of patients that receive even a single educational meeting can significantly improve understanding of the disease which improves outcome. This strategy would also allow the patients to give support to each other. Patients with reoccurring symptomatic AF have difficulty coping due to the interference of the episodes with everyday life. A support group strategy might prove to be beneficial at an even greater level to these patients. Considering this evidence the grade for this recommendation is a B.

It is important for the healthcare professionals to focus more on empowering patients with information needed to understand and be a part of the treatment plan. Healthcare providers cannot expect the patient to always comply with treatments that they do not understand. Many patients have the ability and desire to self-manage their symptoms and medications. Through the recommended interventions the patients will gain understanding of their disease, symptoms, and medications which will increase their chances of compliance and to seek follow-up care.

Needs Assessment

This project will take place at Thomasville Internal Medicine in Thomasville, AL. Thomasville is a rural area in Clarke County Alabama. The population in the city is around 5,500. It is centrally located approximately 100 miles from Mobile, Montgomery, and Meridian. There are two full-time family practice physicians, two part-time family practice physicians, and a general surgeon presently practicing in the area. A cardiologist commutes from Mobile to Thomasville one day a week to see patients and also sees patients one day a week in a small town 20 minutes from Thomasville.

Thomasville Internal Medicine is staffed and owned by one physician, who is board certified in internal medicine. He has been in practice in this area for almost 20 years. He serves a large number of patients with cardiac problems. Thomasville Internal Medicine sees approximately ten patients per week who have a diagnosis of atrial fibrillation and take Coumadin. The patient’s Coumadin is managed in the clinic where blood work is drawn and rapid results are received. This physician also has a patient that has been trained to manage her Coumadin at home which is becoming more common. Some insurance companies will now pay for monitors and provide strips for home INR monitoring. Although only one of his patients at this time have been trained, it is possible that this project will help to identify patients that are capable of doing self-monitoring and promote more independence to the patients.

In many rural areas, patients depend on their primary care physicians for management of diseases that are normally managed by a specialist. It is very difficult for patients to travel to a specialist in the larger cities due to transportation needs, price of gas, and having to take time off from work. Due to larger patient loads in the rural areas, the physicians may not have the extra time to educate the patients enough about atrial fibrillation and Coumadin. There is a need in the rural internal medicine clinic for education and better monitoring in order to benefit the AF patients and the small rural hospitals which struggle with costly treatments for noncompliant, indigent patients with multiple health problems. The need for Nurse Practitioners seems especially relevant in this patient population in the rural setting.

Implementation Plans

The focus of this project is to provide education to atrial fibrillation patients who take Coumadin with the goal of understanding and improving medication adherence. The education will include one-on-one interaction with each patient to discuss the meaning of AF, what to do when symptoms arise, the risks of uncontrolled heart rate and sub-therapeutic blood thinning levels, and the importance of monitoring anticoagulants and heart rate medications. Because the patients in the rural area do not have immediate access to their specialist, it will be even more critical for them to have better control of the symptoms and treatment.

Atrial fibrillation is a challenging health problem due to the potential complications which include stroke, dementia, heart failure, and death. The focus of treatment is early detection, anticoagulation therapy, and rate control to prevent the complications. These treatments are essential for all patients with AF. Other preventative measures can also be taken to help with prevention such as statins, omega3 fatty acids, diabetes control, and weight loss. Research has found that several cultural, health, and lifestyle factors influence a patients risk for having atrial fibrillation. (Esters III, Sacco, Al-Khatib, Ellinor, Bexanson, Alonso, …Benjamin. 2011)

The patient will be individually educated about the complications of uncontrolled heart rate, risk factors of AF, and treatment with special teaching on the anticoagulant Coumadin and normal heart rate. The patients will have atrial fibrillation that was verified by an EKG. This intervention will be provided to patients that are newly diagnosed or those who already are receiving treatment for AF.

Eight to twelve patients will be selected for the project. Each will received informed consent about the trial. All project information will be included in the written consent that will be signed by each participant. After agreement to participate the patient’s age, gender, race, heart rate, INR, and medications will be documented. All information will remain confidential. The Morisky Medication Adherence Scale (MMAS) will be completed by each patient prior to education (Morisky et al, 2008). This tool is to assess the patient’s compliance to medications. This questionnaire should take five minutes or less to complete.

Patient education will then be provided one-on-one so the understanding can be assessed throughout the session to give maximal understanding of the information. Education will be presented in a way that is easy to comprehend using brochures. Atrial fibrillation educational brochure is called “Atrial Fibrillation: The Beat Goes On, Living with AFib” (Preventative Cardiovascular, 2011). The Coumadin education is provide in a brochure called “Warfarin: Guide for Patients and Families” by John Hopkins Hospital (2009). The education intervention will take approximately 20 minutes. More time may be needed for questions.

After the educational intervention, the patients will follow-up every two to four weeks for assessment of INR, HR, and to address any questions that may arise. This will be done over the next six to 12 months to affectively evaluate the patient’s progress. The patient will receive the MMAS questionnaire again at the end of the project to evaluate adherence to treatment.

Factors that will influence the success of the project will be the cooperation of the patients, their ability to learn, and their willingness to volunteer extra time for the project. Many patients may not want to take time for extra follow-up visits. By promoting better outcomes through education the patients may be more willing to cooperate. By involving family in the educational process, this may help understanding of the information and management for the patient. Some patients may not have the mental ability to understand the presented information. Educating families will also be encouraged in the project.

For the small test of change, the patients will be reevaluated every two to four weeks for assessment. The patient’s INR and HR will be recorded at each visit. The patient will also have the opportunity to ask questions. The implemented project will last for six to eight weeks.

Project Timeline/Budget

The IRB approval will take approximately two to three weeks. In weeks 1-3, after IRB approval, subjects will be recruited for the project. The initial visit will consist of taking the MMAS, collecting graphical data, heart rates, INR results, and provide one-on-one education which will last approximately 20 minutes. In weeks 4-6, patients will be reevaluated through MMAS by phone, or at follow-up visits recommended by the physician. In week 7-8, data will be compiled, analyzed, and summarized for report.

The costs associated with this project are educational materials and cost of INR strips for testing. The remaining materials will be provided by the researcher. INR strips will be donated by the Thomasville Internal Medicine clinic.

Evaluation Plan

The outcomes that this project will be evaluating are increased compliance with medication and follow-up treatment. Through individualized education about AF the patients will better understand their treatment goals and are better equipped to manage symptoms to minimize risks of stroke and other complications. In 2007, a report entitled “Enhancing Prescription Medication Adherence: A National Action Plan” was issued by the American National Council on Patient Education to address the increasing rated of medication non-adherence (Lehane, McCarthy, 2009). According to Lehane and McCarthy (2009) the problem has been under-addressed as a serious health issue.

Compliance with medication and follow-up treatment are behavioral outcomes. Evaluation of behavioral outcomes will be assessed through the MMAS that the participants will complete prior to evaluation and at the end of the project. By measuring the patient’s heart rate (HR) and international normalized ratio (INR) at each visit the healthcare provider can evaluate medication compliance. These are clinical outcomes. The patient’s HR will be within the normal limits of 60-90 beats per minute. The patient’s INR will be within the therapeutic range of 2.0-3.0. At each office visit the patient’s HR and INR will be measured. This will be done by the nurse and recorded. These values will be assessed on the initial visit prior to education and at all follow-up visits. Other values that can be evaluated through successful adherence are a decrease in symptoms of uncontrolled AF and hospitalizations.

For the small test of change the project will evaluate the MMAS results and compare these to the post test results after the six week period. The project will also evaluate the HR and INR. These values will be assessed every two to four weeks in the small test of change project.

All data will be complied, compared, and analyzed to see if education does improve compliance. The goals for this project are to give the patients a better understanding of the disease and treatment options, recognize and self –management the symptoms, and know the risks of medication non-adherence. Through better understanding, the patient will be more likely to adhere to their medications, manage their medications, and follow-up with recommended treatment. This result will be presented to physicians, nurse practitioners, nurses, and professional peers through poster presentations and through power point presentations.

Small Test of Change

In this small test of change, time was spent in the clinic at Thomasville Internal Medicine to identify, recruit, and educate the patients. Each chart was reviewed for the following information: a diagnosis of AF, a rate control medication, and Coumadin therapy. As the patient was identified he/she was approached and presented with the proposal to participate in the study. Eight patients throughout the three weeks of recruitment were identified. Each patient signed the consent to participate and provided a copy. The patients were then asked to complete a MMAS questionnaire. The patients were provided education about AF and Coumadin through discussion and through written brochures. Other data including age, race, and sex were collected. Participants were called at home two to three weeks after intervention for the post MMAS questionnaire.

This project was inexpensive to conduct. Supplies included copies of the teaching material which were provided by the researcher. The originals were identified through the internet and copies were made for distribution to the participants. No other supplies were needed.

The IRB approval took 17 days. During that time the educational material and questionnaires were prepared for the project. The recruitment time took three weeks, which included six days in the clinic reviewing charts. This was a week longer than planned because of the difficulty finding patients with AF that took Coumadin. Two weeks after the intervention, all patients were contacted via phone for the post questionnaires. This process took two days. All data was complied, analyzed, and prepared for presentation in two weeks. In the original plan the HR and INRs were to be collected prior to and at follow-up visit. Due to the amount of time it took to recruit the patients, the follow-up visits fell after the time data collection had to be completed.

The sample size in this small test of change was eight participants. Each participant had a diagnosis of AF, receive a rate control medication, and Coumadin. The goal size in this project was eight to twelve. The sample consisted of the following: females=1, males=7, white=6, black=2. The mean age of the group was 67.25 years old.

Only one measurement was used in the evaluation of medication adherence. This tool was the MMAS questionnaire which was given prior to and post education to each participant. The results were compared. Initially, each patient’s heart rate and INR were also going to be compared pre and post education. These were not unable to be collected due to the short period of time to conduct the experiment.

The findings are seen in Tables 1 and 2 below. The scores for the MMAS range from 0-11. A high adherent score is 0-3, a moderate compliant score is 4-8, and a low compliant score is 9-11. The mean score in the pre-questionnaire was 1.38, which showed that the group of participants were initially reporting high adherence to their medications. In the post-questionnaire the mean score was 0.50. Improvement was noted in the post-questionnaire. Four of the eight participants reported no improvement with three of the four reported complete adherence. The other four participants reported an increase adherence in medication. The analysis of the data shows that the increase in adherence was not a significant value.

Table 1

|N=8 |Mean |Std. Dev. |

| PreQuest |1.38 |1.30 |

|PostQuest |0.50 |0.76 |

Table 2

| |t |Sig. |

|Pre/Post |2.20 |0.06 |

Application to Overall Project

To better achieve the goals of the research, this project warrants several changes. The sample size should be larger and should include patients who show moderate and low adherence according to their MMAS scores. In the small test of change the participants initially reported high adherence with three reporting the greatest adherence prior to the educational session. This gave the participants no room to report improvement. Another change would be to add the evaluations of patient’s heart rates and INR levels at each visit. This would allow the researcher to have clinical data to support the results. The researcher could also evaluate adherence by the number of emergency room visits and hospital stays that the patient has had. This may be compared to the previous hospital visits and stays that the patient may have had in the previous time period. The overall goal for these patients is to have improved quality of life with less complications that are associated with AF.

One challenge through this process was finding the patients that were taking Coumadin. Now many patients are on a new anticoagulant medication called Pandaxa. This medication does not require frequent blood testing. In future implementation of this project, including patients who take this mediation would provide a larger population for research.

Conclusions

Although this project did not produce significant results, education is an important part of the healthcare provider’s duties. With the new healthcare act that has been implemented it is more important than ever to provide the patients what they need to manage their own care and stay out of the hospitals. This is important with any disease or diagnosis. Quality is of great importance and also how healthcare providers will soon be reimbursed for their care.

This process has shown this researcher how cooperative and receptive the patients are to learning about their disease. A little time to educate a patient at each visit can make a large amount of impact in their lives and the way they can manage and cope with their disease. This is the standard of care that, as a nurse practitioner, this researcher should provide for each patient.

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McCabe, P., Schumacher, K., & Barnason, S. (2011). Living with atrial fibrillation: a qualitative study. Journal of Cardiovascular Nursing 26(4), 336-344. Morsiky, A., Krousel-Wood, M. Ward, H. Predictive validity of a medication adherence measure for hypertension control. Journal of Clinical Hypertension 10(5), 348-354.

Morisky, A., Krousel-Wood, M. Ward, H. (2008). Predictive validity of a medication adherence measure for hypertension control. Journal of Clinical Hypertension 10(5), 348-354.

Preventative Cardiovascular Nursing Association. (2011). Atrial fibrillation: The beat goes on living with afib. Retrieved from: .../pdf/AFIB_Brochure.pdf

Shea, J., & Sears, S. (2008). A patient’s guide to living with atrial fibrillation. Circulation 11, e340-e343. doi: 10.1161/CIRCULATIONAHA.108.780577

Ulfvarson, J., Bardage, C., Wredling, R., Bahr, C., & Adami, J. (2005). Adherence to drug treatment in association with how the patient perceives care and information of drugs. Journal of Clinical Nursing 16, 141-148.

Vaskey, P., Sathononthan, A., Bhagra, S., Fujioshi, A., Tom, A., & Murad, M. (2009). Using quality-improvement techniques to enhance patient education and counseling of diagnosis and management. Quality in Primary care 17, 205-13.

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Zimetbaum, P. & Stambler, B. (2011). Risk stratification for stroke in patients with atrial fibrillation. Cardiovascular Consults 1(13), 10-12

Appendix A

| |

|Quality Evaluation Assignment |

|Article citation and level |Purpose of |Design type and methods (sampling method/sample size, |Major findings/findings relevant to |Critique of validity, bias and |

|of evidence |study/research |description of interventions (if any), and outcomes measured |project |significance |

| |questions | | | |

|Level IV |To assess the knowledge|-Cohort study because it studies a population with a similar |-Significant knowledge changes about |-Isolated to one area which was Finland. |

|Koponen, L., Rekola |of patients with atrial|characteristic over a period of time. |AF and its treatment, or AF symptoms |-Sample size of 200 was a good size. |

|Appendix A, L., |fibrillation 3 months |-This study was part of a larger prospective and observational|and the effect on everyday life. |All competent patients with a positive |

|Ruotsalainen, T., Lehto, |after they had been |study on the quality of acute care of atrial fibrillation (AF)|-Knowledge of symptoms remained good.|EKG for AF who gave consent were |

|M., Leino-Kilpi H. & |seen in the emergency |in three ERs (two primary ERs and a university ER). The | |included. |

|Voipio-Pulkki, L. (2008). |room (ER). |--Population base = 560,000. |-Knowledge of detection of the |-No one was excluded by the researcher |

|Patient knowledge of atrial| |-Participation was voluntary. |condition and seeking treatment |except those incompetent. |

|fibrillation: 3-month | |- All patients gave written informed consent. |improved slightly. |-Not all of the questions were answered |

|follow-up after an | |-Patients were informed about the purpose of the study and the|-Knowledge about anticoagulant |in the questionnaire by all the patients.|

|emergency room visit. | |follow-up contact. |therapy was clearly improved at the |The |

|Journal of Advanced Nursing| |-participants= 200pts |follow-up. |-Bias of non-responsiveness was assessed |

|61(1), 51–61. | |-Questionnaire was administered at time of the ER visit and 3 |-Study shows the lack of education in|by the researches and the findings |

| | |months later. |atrial fibrillation patients and |suggested that the non-response was not |

| | |-Test to assess knowledge which was piloted and evaluated by |supports my proposal for |biased. |

| | |medical, nursing science experts, and clinical nurses. |individualized patient education in |-Questionnaire addressed a large variety |

| | |-Test included 5 sets of questions covering the following |all areas of healthcare. |of information. |

| | |areas: AF as a disease and its treatment, symptoms, detection| |-Similar questionnaire may be appropriate|

| | |of AF and seeking treatment, and the impact of AF on everyday | |in the educational evaluation of my |

| | |life. | |patients as well. |

|Level II |To assess the effect of|-True experimental because the patients randomly selected were|-Major outcome showed that the |-Study might have been better if they had|

|Khan, T., Kamali, P., |an anticoagulation |from the clinic database that meet the variables. |results from the two treatment groups|used more than one data base for the |

|Avery, P., & Wynne, H. |education programme |- Did have a control group and two treatment groups. |were similar in improvement. |patient selections. -Sample sized were |

|(2004). The value of |with and without |-Three groups of 35. One control group, one group that |-Study did show that education and |35 per group which was adequate. |

|education and |self-monitoring in |received education only and one with education plus |self-monitoring improved that |– Patients were randomly assigned and the|

|self-monitoring in the |patients with atrial |self-monitoring group. |patient’s outcome. |patients were unaware that they were in a|

|management of warfarin |fibrillation (AF) aged |-Results were measured from the standard deviation of the INR.|-Noted that the control group |study so that this would not affect their|

|therapy in older patients |> 65 years, upon | |improved as well. |behavior. |

|with unstable control of |stability of |- Looked at the 6 months prior to the intervention and the 6 |-Likely due to the increase |-Study was done within a clinic setting |

|anticoagulation. British |anticoagulant control |months after intervention. |monitoring of the drug level in all |and may have been better if done in a |

|Journal of Haematology, |and treatment-related | |groups. |variety of setting. Many of the refused |

|126,557-564. doi: |quality-of-life | | |to participate which made the group more |

|10.1111/j.1365-2141.2004.05|measures. | | |select. |

|074 | | | |-Study did not look at was the cost for |

| | | | |the monitoring equipment for the |

| | | | |self-monitor group. |

|Level II |The purpose was to |-True experimental study. |-Control group there was a decrease |-The patients and the physicians were not|

|McAlister, F., |determine the impact of|-Groups were randomized. |by 3% over the three months in the |blinded to the group allocations. This |

|Man-Son-Hing, M., Straus, |a patient decision aid |-One control and one experimental. |number of patients receiving the |could affect the patient’s participation,|

|S., Ghali, W., Anderson, |for patients with |-Assessors were blinded to the groups but the participants |appropriate therapy for their risk of|attitude, and receptiveness to the |

|D., Majumdar, S.,… & |nonvalvular atrial |were not. |stroke. |education creating bias. |

|Fradette, M. (2005). |fibrillation (NVAF) on |-Trial used 446 (219 in the intervention group and 215 in the |-Intervention group there was a 9% |-Groups were a good sample size for the |

|Impact of a patient |taking the appropriate |control group) NVAF patients from 102 community-based primary |increase. |study. The assessors were blinded to the|

|decision aid on care among |antithrombotic therapy |care practices. |-12% improvement in the intervention |groups. |

|patients with nonvalvular |to improve outcomes. |-Control group received usual care and the intervention group |group over the control group after |-Patients were assessed at 3 months and |

|atrial fibrillation: a | |received a self-administered booklet and an audiotape decision|three months. -After 12 months both |12 months. This was good because the |

|cluster randomized trial. | |aid tailored to their personal stroke profile. |the control group and intervention |patient were not blinded to their |

|Canadian Medical | |-Follow-up with both groups was identical. |group had progressed toward baseline.|participation. |

|Association Journal, | |-Primary outcome was the change in the proportion of patients | |-Participants were selected randomly and |

|173(5), 496-501. | |taking antithrombotic therapy appropriate to their risk of |-Relevant to my proposal because it |from a large group of practices which |

| | |stroke. |shows that continuous education and |gives a good sample. |

| | |-This was assessed at three and 12 months. |counseling with the patient is needed| |

| | |- Secondary outcome included knowledge about stroke and |to keep that patient on the right | |

| | |bleeding risks, expectations for antithrombotic therapy, and |path to compliance and better | |

| | |decisional conflict. |outcome. | |

|Level V |The goal is to learn |-Qualitative descriptive study using open-ended interviews |-Main finding that is protonate to |-There were several limitations to the |

|McCabe, P., Schumacher, K.,|about patient’s |with seven women and eight men with recurrent atrial |this project was that the |study. |

|& Barnason, S. (2011). |experience living with |fibrillation. |participants felt uninformed and |-Sample group lacked racial and cultural |

|Living with atrial |recurrent AF in hopes |-Themes were identified that reveal experiences of living with|unsupported. They did not receive |diversity. |

|fibrillation: a |that it will provide a |recurrent symptomatic AF over time and how AF may diminish |information on what to expect with |-Study was limited into one area. |

|qualitative study. Journal|foundation for |quality of life. |the diagnosis of AF from their |-Participants also received educational |

|of Cardiovascular Nursing |intervention to improve|-Themes include finding the meaning of symptoms, feeling |physicians. |intervention prior to the interview and |

|26(4), 336-344. |quality of life for |uninformed and unsupported, turning point, steering clear of |-Physician did not acknowledge the |the patients had to remember past |

| |these patients. |AF, managing unpredictable and function limiting symptoms, |negative influence of the AF. |experiences by recall. |

| | |emotional distress, and accommodation to AF tempered with hope|-Project is focused on educating the | |

| | |for a cure. |patient to promote compliance. | |

| | | |-Patients must first understand the | |

| | | |disease and its symptoms to take | |

| | | |control of their lives. | |

|Level V |The aim of this study |-“Pilot-study” – observational/descriptive. |-PDSA methodology proved to be |-Limitations were that this study did not|

|Vaskey, P., Sathononthan, |was to use quality |-Study evaluated an intervention and did not contain a control|efficient, feasible, and acceptable |use randomization to select it sample and|

|A., Bhagra, S., Fujioshi, |improvement techniques |group. |for creating, implementing and |was designed without a control group. |

|A., Tom, A., & Murad, M. |to enhance patient |-Bone Clinic, a Division of Endocrinology at the Mayo Clinic |studying the effects of an optimal |-Participants were not blinded. The |

|(2009). Using |understanding of |Rochester. In the study a group of observers first observed |patient education tool in a total of |article did state that one of the |

|quality-improvement |diagnosis, management |the staff, residents, and patients for the informational flow |three weeks. |challenged for the teams was that a |

|techniques to enhance |and follow-up at the |at the clinic. They were also interview and noted any |-Concluded that individualized |number of patients already rated their |

|patient education and |end of the office |discrepancies in what the patients heard and what they |documented information provided at |knowledge as excellent at baseline. This|

|counseling of diagnosis and|visit. |understood. This information was taken and a series of |the end of the visit enhanced patient|was not a well conducted study to assess |

|management. Quality in | |intervention tools were developed, implemented, and modified |satisfaction. |patient outcomes, clinical efficiency and|

|Primary care 17, 205-13. | |over a 3 week period based on feedback from patient and | |cost-effectiveness. |

| | |providers. The team then decided on a “plan-do-study-act” |This is a tool that I could look at |-Self-reporting to evaluated outcomes can|

| | |(PDSA). This was the development of individualized education |using in my proposal to provide |cause potential bias is the study. It is|

| | |for each patient to reduce the volume of information received.|individualized education to patients |difficult to validate the understanding |

| | |The PDSA was carried out in repeated small cycles designed to |with Atrial Fibrillation to improve |of the patient. |

| | |lead to improvement at each cycle. The informational tool was|satisfaction but the study was not | |

| | |modified after each cycle according to the provider’s |large enough or structured enough | |

| | |recommendation. |study to assess that full value of | |

| | |-Ninety-three patients participated in the study. |the tool. | |

| | |-Twenty-three patients were surveyed before implementation of | | |

| | |the QI measure to obtain baseline data. | | |

| | |-Seventy patients were surveyed during all of the PDSA cycles.| | |

| | |-Survey assessed understanding of the patient’s condition, | | |

| | |reason for the tests ordered, treatment recommended and when | | |

| | |to follow-up. | | |

|Level III |Poor compliance is a |-Quasi experimental. |-Results of the study showed that |-Study showed good short term results in |

|Cuspidi, C., Sampieri, M., |major cause of |–No control group but did include an intervention with |health education of a large number of|patients knowledge it did not study long |

|Fusi, M., Salerno, M., |insufficient control of|evaluation of the group before and after. |patients may be significantly |term results of the educational session. |

|Severgnini, R., Leonette, |hypertension (HTN). |-Participants were randomly invited to the meetings. |improved after a single educational |-Study was only conducted in one area at |

|G. & Zanchetti, A. (2001). |The purpose of this |-Team invited 225 consecutive patients that were referred to |meeting by physicians. |one clinic. -Study group was of |

|Improvement of patients’ |study was to organize |their hypertension clinic to participate in an educational |-Patient education is important in |sufficient size it would have been better|

|knowledge by a single |two pilot educational |meeting on hypertension. |the management of all diseases to |to include the study in others areas. |

|educational meeting on |meeting aimed at |-One hundred forty-four patients attended. |improve compliance. | |

|hypertension. Journal of |assessing the support |-Patients were divided into two groups that would attend 4 |-Relevant to my project because I | |

|Human Hypertension 15, |of the patients of the |meetings. |will be looking for different | |

|57-61. |meeting and to verify |-First meeting, a questionnaire was completed to assess the |educational strategies to promote | |

| |the impact on the |patient’s base knowledge of HTN. |compliance medication and treatment. | |

| |patient’s education. |-Second meeting included oral educational presentation by two |Although the short-term outcome | |

| | |members of the medical staff. |improved I want to focus more on | |

| | |-Third meeting the patients were asked to complete the same |individualized, personal education. | |

| | |questionnaire in the first meeting. |Although a group education program | |

| | |-Fourth session was devoted to general discussion. |along with individual education may | |

| | |-Outcomes (measures of knowledge?) were measured by the |be beneficial also. | |

| | |questionnaire. The researchers also looked at the demographics| | |

| | |of the patients that attended the meetings in comparison of | | |

| | |those who did not. | | |

| | | | | |

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