Please reflect while youre waiting Welcome The focus

Please reflect while you’re waiting… Welcome. The focus of this webinar is to discuss your role in partnering with patients to promote adherence to their anticoagulant medication plan. Assess Arrange l l What might be some causes of fluctuating INRs? What do you think might be some challenges you face and actions you might take as you complete the five As (at right) with the patient? Assist Advise Agree Clinical Pearls: Overcoming the Headache of Fluctuating INRs 1

Overcoming the Headache of Fluctuating INRs National Blood Clot Alliance Clinical Pearls Series CDC Cooperative Agreement # 1 U 27 DD 000545 -01

About This Webinar For healthcare professionals l l Nurses Physician assistants Nurse practitioners Pharmacists Clinical Pearls: Overcoming the Headache of Fluctuating INRs 3

Webinar Objectives l l l Describe common difficulties patients encounter when trying to keep their INRs in therapeutic range. Discuss ways that healthcare professionals can help patients overcome these difficulties and maintain therapeutic levels of anticoagulation. Apply the 5 A model to partner with patients to influence adherence. Clinical Pearls: Overcoming the Headache of Fluctuating INRs 4

Today’s Speakers Kathryn Hassell, MD l l l Brenda Riske, MS, MBA Professor, Hematology University of Colorado School of Medicine l Kathryn. hassell@ucdenver. edu l l Director, Operations, Hemophilia & Thrombosis Center University of Colorado Brenda. riske@ucdenver. edu Clinical Pearls: Overcoming the Headache of Fluctuating INRs 5

Case Study Introduction Barbara Birmingham… l l Woman in late 20 s Full-time bartender, irregular hours Busy lifestyle Loves music, night life, fashion Clinical Pearls: Overcoming the Headache of Fluctuating INRs 7

Case Study Introduction Her health history… l l l Overweight, but not obese (BMI 27) Trying to lose weight Occasional smoker Moderate to heavy drinker Taking antidepressant inconsistently Used birth control pills prior to DVT, now using condoms Clinical Pearls: Overcoming the Headache of Fluctuating INRs 8

Case Study Introduction Her clotting history… l DVT two years ago l Completed three months of warfarin l No testing for thrombophilias l Had a PE five months ago l Warfarin restarted after PE Clinical Pearls: Overcoming the Headache of Fluctuating INRs 9

Case Study Introduction Her current clinical picture… l l l INR had been stable for months, but has been erratic in the past month She has been coming in weekly for INRs The last four weekly monitoring visits showed several low INRs followed by a high one Clinical Pearls: Overcoming the Headache of Fluctuating INRs 10

Case Study Introduction Clinical Pearls: Overcoming the Headache of Fluctuating INRs 11

Case Study Introduction l Now: • Ms. Birmingham is back for a follow-up appointment l Your job: • Figure out why INR is fluctuating and help her figure out what to do Clinical Pearls: Overcoming the Headache of Fluctuating INRs 12

The Five A Model Why We’re Organizing Around the Five As Organizes an approach to influence patient adherence Assess Arrange Source: Whitlock et. al. “Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-Based Approach. ” American Journal of Preventive Medicine. 2002; 22(4). P. 267 -284. Assist Advise Agree Clinical Pearls: Overcoming the Headache of Fluctuating INRs 13

The Importance of Relationships Improve adherence Work where the patient is Listen and learn Build trust Clinical Pearls: Overcoming the Headache of Fluctuating INRs 14

Assess: Key Concepts l Assess behavioral strengths and limitations affecting adherence. Assess Arrange Assist Advise Agree Clinical Pearls: Overcoming the Headache of Fluctuating INRs 15

Assess Things to consider when faced with INR fluctuation Look at the pattern of INRs over the patient’s history If If monthly pattern: Related to menstrual cycle? too high: Binge drinking? too low: Food intake irregularities? certain days of the week: Weekend alcohol use or changes in eating habits? If correlated to dose changes: Overadjusting? Never stabilized in the first place? Clinical Pearls: Overcoming the Headache of Fluctuating INRs 16

Assess adherence to regimen l l l Missed doses Extra doses Incorrect dose Clinical Pearls: Overcoming the Headache of Fluctuating INRs 17

Assess factors that might influence adherence l l l l Insurance coverage Time of day for taking meds Day of week for INR testing Transportation to appointments Communicating INR results Fear (of needle stick, of HCP disapproval) Coping strategies Clinical Pearls: Overcoming the Headache of Fluctuating INRs 18

Assess changes in health l Acute illness Clinical Pearls: Overcoming the Headache of Fluctuating INRs 19

Assess changes in medications l Consider all medications • OTC • Chronic • Vitamins, herbs l Changes in dose Clinical Pearls: Overcoming the Headache of Fluctuating INRs 20

Assess alcohol intake l l l Amount Consistency Bingeing Clinical Pearls: Overcoming the Headache of Fluctuating INRs 21

Assess food intake l Vitamin K intake • Typical use • Consistency Clinical Pearls: Overcoming the Headache of Fluctuating INRs 22

Assess lifestyle factors l l Stress Weight loss • Intentional • Unintentional Clinical Pearls: Overcoming the Headache of Fluctuating INRs 23

Other Reasons for Fluctuating INRs l l l Missed appointments for monitoring Chronic illness (e. g. , asthma, heart failure) Unknown (we can’t always determine why it fluctuates) Clinical Pearls: Overcoming the Headache of Fluctuating INRs 24

Assess Apply what we’ve discussed to Ms. Birmingham l Please type in a sample question you might want to ask Ms. Birmingham. • Focus on questions relevant to her • Focus on questions you might find difficult to ask l Please enter your questions in the chat pane. Clinical Pearls: Overcoming the Headache of Fluctuating INRs 25

Assessment Findings for Barb Birmingham l l l l High INR—consistent until recently, then up & down Stopped anti-depressant due to financial issues Has had asthma—tapering prednisone dose for past three days; no other medications Has been drinking more than usual (3 -5 drinks a day) because of struggles with weight, depression, work Hasn’t missed any doses of warfarin Consistent/steady food intake Steady levels of activity Clinical Pearls: Overcoming the Headache of Fluctuating INRs 26

Advise Key Concepts l l l Clear, specific, and individualized advice Personal health risks/benefits Recognize what patient is ready to hear or do Assess Arrange Assist Advise Agree Clinical Pearls: Overcoming the Headache of Fluctuating INRs 27

Advise Specific Advice for Fluctuating INRs Lifestyle Medication Alcohol intake Food intake Clinical Pearls: Overcoming the Headache of Fluctuating INRs 28

Advise Apply what we’ve discussed to Ms. Birmingham l l Listen as we role play a discussion between a healthcare professional and Ms. Birmingham. Have we covered the items we discussed earlier? … … alcohol food other medications illnesses Clinical Pearls: Overcoming the Headache of Fluctuating INRs 29

Agree Key concepts l Partner with patient to select treatment goals and methods based on the patient’s interest, ability, and willingness to make changes Assess Arrange Assist Advise Agree Clinical Pearls: Overcoming the Headache of Fluctuating INRs 30

Agree Specific Information for Fluctuating INRs Put it in writing! Lifestyle Finalizing the agreement Clinical Pearls: Overcoming the Headache of Fluctuating INRs 31 31

Assist Key Concepts l l Help patient build skills, confidence, and supports for behavior change or adherence Supplement with adjunctive treatments as appropriate (e. g. , pharmacotherapy for tobacco dependence or depression) Assess Advise Arrange Assist Agree Clinical Pearls: Overcoming the Headache of Fluctuating INRs 32

Arrange Key Concepts l l Schedule follow-up contacts (in person or by telephone) Provide ongoing assistance/support Adjust treatment plan as needed Help patient obtain medic alert Assess Advise Arrange Assist Agree Clinical Pearls: Overcoming the Headache of Fluctuating INRs 33

Summary and Wrap Up Key Messages l l First, assess “what has changed? ” Patient consistency is critical. Motivation is highly individual. Sometimes, reasons for INR fluctuation may be unidentifiable or unclear. A stable relationship can help the patient achieve stable INRs. Clinical Pearls: Overcoming the Headache of Fluctuating INRs 35

Q&A Questions? Clinical Pearls: Overcoming the Headache of Fluctuating INRs 36

Upcoming Webinars Part of a Series Building a Partnership with the Newly Anticoagulated Patient Overcoming the Headache of Fluctuating INRs l Preventing Complications of Blood Clots l Clinical Pearls: Overcoming the Headache of Fluctuating INRs 37

Additional Resources l l Recording of this session Copy of the Power. Point slides used in this webinar Article on the 5 As Additional citations All available at http: //www. stoptheclot. org/webinars/webinar_resources. html Clinical Pearls: Overcoming the Headache of Fluctuating INRs 38

Help Us Help You l Please complete the very brief survey that will immediately follow the webinar. Clinical Pearls: Overcoming the Headache of Fluctuating INRs 39

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