Transcript The Headache of Fluctuating INRs

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
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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
Clinical Pearls: Overcoming the Headache of Fluctuating INRs
Advise
Agree
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Overcoming the Headache of
Fluctuating INRs
National Blood Clot Alliance
Clinical Pearls Series
CDC Cooperative Agreement # 1U27DD000545-01
About This Webinar
For healthcare professionals
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Nurses
Physician assistants
Nurse practitioners
Pharmacists
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Webinar Objectives
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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 5A model to partner with patients to influence
adherence.
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Today’s Speakers
Kathryn Hassell, MD
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Professor, Hematology
University of Colorado School of
Medicine
[email protected]
Brenda Riske, MS, MBA
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Director, Operations, Hemophilia
& Thrombosis Center
University of Colorado
[email protected]
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Case Study Introduction
Barbara Birmingham…
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Woman in late 20s
Full-time bartender, irregular hours
Busy lifestyle
Loves music, night life, fashion
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Case Study Introduction
Her health history…
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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
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Case Study Introduction
Her clotting history…
 DVT two years ago
 Completed three months of warfarin
 No testing for thrombophilias
 Had a PE five months ago
 Warfarin restarted after PE
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Case Study Introduction
Her current clinical picture…
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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
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Case Study Introduction
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Case Study Introduction
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Now:
• Ms. Birmingham is back for
a follow-up appointment
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Your job:
• Figure out why INR is
fluctuating and help her
figure out what to do
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The Five A Model
Why We’re Organizing Around the Five As
Organizes an approach
to influence patient
adherence
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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.
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Clinical Pearls: Overcoming the Headache of Fluctuating INRs
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The Importance of Relationships
Improve
adherence
Work where the
patient is
Listen and learn
Build trust
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Assess: Key Concepts
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Assess behavioral strengths and limitations affecting
adherence.
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Assist
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Assess
Things to consider when faced with INR fluctuation
Look at the pattern of INRs over the patient’s history
If
If
If
If
monthly pattern:
too high:
too low:
certain days of the week:
If correlated to dose changes:
Related to menstrual cycle?
Binge drinking?
Food intake irregularities?
Weekend alcohol use or
changes in eating habits?
Overadjusting?
Never stabilized in the first
place?
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Assess
Assess adherence to regimen
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Missed doses
Extra doses
Incorrect dose
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Assess
Assess factors that might influence adherence
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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
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Assess
Assess changes in health
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Acute illness
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Assess
Assess changes in medications
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Consider all medications
• OTC
• Chronic
• Vitamins, herbs
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Changes in dose
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Assess
Assess alcohol intake
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Amount
Consistency
Bingeing
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Assess
Assess food intake
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Vitamin K intake
• Typical use
• Consistency
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Assess
Assess lifestyle factors
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Stress
Weight loss
• Intentional
• Unintentional
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Other Reasons for Fluctuating INRs
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Missed appointments for monitoring
Chronic illness (e.g., asthma, heart failure)
Unknown (we can’t always determine why it fluctuates)
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Assess
Apply what we’ve discussed to Ms. Birmingham
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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
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Please enter your questions in the
chat pane.
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Assessment Findings for Barb Birmingham
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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
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Advise
Key Concepts
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Clear, specific, and
individualized advice
Personal health
risks/benefits
Recognize what patient is
ready to hear or do
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Clinical Pearls: Overcoming the Headache of Fluctuating INRs
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Advise
Specific Advice for Fluctuating INRs
Lifestyle
Medication
Alcohol intake
Food intake
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Advise
Apply what we’ve discussed to Ms. Birmingham
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Listen as we role play a discussion
between a healthcare professional and
Ms. Birmingham.
Have we covered the items we
discussed earlier?
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…
alcohol
food
other medications
illnesses
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Agree
Key concepts
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Partner with patient to
select treatment goals and
methods based on the
patient’s interest, ability,
and willingness to make
changes
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Clinical Pearls: Overcoming the Headache of Fluctuating INRs
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Agree
Specific Information for Fluctuating INRs
Put it in writing!
Lifestyle
Finalizing the
agreement
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Assist
Key Concepts
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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)
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Assist
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Arrange
Key Concepts
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Schedule follow-up
contacts (in person or by
telephone)
Provide ongoing
assistance/support
Adjust treatment plan as
needed
Help patient obtain medic
alert
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Assist
Advise
Agree
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Summary and Wrap Up
Key Messages
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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.
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Q&A
Questions?
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Upcoming Webinars
Part of a Series
Building a Partnership with the Newly
Anticoagulated Patient
 Overcoming the Headache of Fluctuating INRs
 Preventing Complications of Blood Clots
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Additional Resources
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Recording of this session
Copy of the PowerPoint slides used in this webinar
Article on the 5 As
Additional citations
All available at
http://www.stoptheclot.org/webinars/webinar_resources.html
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Help Us Help You
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Please complete the very brief survey that will
immediately follow the webinar.
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National Blood Clot Alliance
Clinical Pearls Series