The Use of Oral Anticoagulant Medications PRESENTATION: Key Findings from Surveys of Patients, Caregivers, and Physic

1. Prepared for: The National Consumers League September 21, 2005 J23715 The Use of Oral Anticoagulant MedicationsPRESENTATION: Key Findings from Surveys of Patients, Caregivers, and Physicians

2. 2 Background The National Consumers League (NCL), on behalf of the SOS Rx Coalition (The Coalition), is working on an outpatient medication safety campaign aimed at consumers, caregivers, and physicians. The initial focus of this campaign is on oral anticoagulant drugs. Oral anticoagulants, or blood thinners, are highly effective at preventing blood clots and are used for numerous indications, including stroke and coronary event prevention. Despite their benefit, these agents are known to be relatively difficult to manage, require frequent monitoring, and may be associated with a large number of potential interactions with other medications or food. The SOS Rx Coalition would like to further explore these potential issues among patients, caregivers, and physicians in order to help design outreach and educational campaigns to help consumers and providers better manage this drug. Harris Interactive was commissioned to conduct a survey exploring use of and experiences with oral anticoagulants.

3. 3 Objectives Gain insight into the experiences of patients who are taking oral anticoagulants particularly issues around managing their medication regimen, adherence to recommendations, relationships and communications with their doctors, and sources used for information to help manage their regimen. Gain insight into the experiences of caregivers who assist in the management of patients’ anticoagulant regimen. Gain insight into the physician’s point of view on issues around the use and management of oral anticoagulant medication. Identify opportunities for improving education and communication about oral anticoagulant treatment, which could improve patient compliance, safety, and outcomes.

4. 4 Methodology Harris Interactive conducted surveys with patients, caregivers, and physicians about the use of oral anticoagulants. All three surveys were conducted online within the United States. Patients A total of 426 patients were interviewed. Patients were sampled from the Harris Interactive Chronic Illness Panel. Eligible respondents have been taking an oral anticoagulant medication for at least 3 months and are at least 30 years of age. Interviews conducted between April 4 -15, 2005. Caregivers A total of 109 caregivers were interviewed. Caregivers were sampled from the Harris Interactive Panel, prescreened as being the caregiver of someone who is chronically ill. Eligible caregivers are taking care of a person who has been on an oral anticoagulant medication for at least 3 months and is at least 30 years of age. Further, caregivers must assist the patient in at least 2 out of 11 care-giving tasks around anticoagulant use. Interviews conducted between May 19 - 26, 2005.

5. 5 Methodology, continued Physicians A total of 101 physicians were interviewed. Physicians were sampled from the Harris Interactive Physician Panel. Eligible respondents are primary care providers (specializing in family practice, internal medicine or general medicine) and cardiovascular specialists, practicing for at least 5 years, spending at least 70% of their time in direct patient care and treating 5 or more patients who are on an oral anticoagulant medication. Interviews conducted between August 11 - 18, 2005. Eligible respondents received a $50 honorarium for completing the survey.

6. 6 Summary of Key Findings

7. 7 Summary of Key Findings: Patients People on oral anticoagulants face complex health problems and have considerable health management needs. Almost all patients on oral anticoagulants also take other prescription drugs and many take over-the-counter (OTC) drugs and vitamins/supplements. According to patients, physicians are overall doing a good job educating new oral anticoagulant users, but there are gaps in education about dietary considerations, drug interactions, and possible side effects. There are gaps in the management of the health care of patients on oral anticoagulants. There is room for improvement in the relationship between oral anticoagulant users and their physicians.

8. 8 Summary of Key Findings: Patients, continued Communication about blood test goals should be improved. Patients are fairly knowledgeable about the things they should and should not do when taking an oral anticoagulant. However, actual behavior could be improved upon. Patients have some difficulties and concerns about being on an oral anticoagulant. Adverse reactions to oral anticoagulants are common. Many do not change their behavior or seek help. Patients could use more assistance with management of their oral anticoagulant use. Such assistance is associated with improved awareness, behavior, and confidence around the management of oral anticoagulant use. Doctors are the most used, perceived as being the most useful, and most trusted source of information about what patients should and should not do when taking an oral anticoagulant.

9. 9 Summary of Key Findings: Caregivers Caregivers are assisting oral anticoagulant users who have considerable health management needs. Caregivers are highly involved in helping their family members manage their oral anticoagulant regimen. Caregivers are generally aware of the complexity of oral anticoagulant medication, knowledge of precautions could be improved. Caregivers could use more assistance in helping their family members with management of their anticoagulant regimen. Nearly one in four caregivers is less than very confident that their family members are taking the anticoagulant correctly; Family members need encouragement to follow recommendations for safe use of medication.

10. 10 Summary of Key Findings: Caregivers, continued A small but troubling minority of caregivers report that their family members experienced adverse reactions to anticoagulant medications that led to an ER visit and/or hospital stay. Caregivers rate physicians highly on their responsiveness to patients; However there is room for improvement in explanations of precautions both to caregivers and family members. Doctors are the most used source of information on the dos and don’ts of managing and anticoagulant regimen.

11. 11 Summary of Key Findings: Physicians Managing patients on anticoagulant medication is a challenge for physicians. Most physicians feel that the effort to manage multiple conditions and medications is the main reason why oral anticoagulant patients experience difficulties with their regimen. There is room for improvement in communication by physicians about oral anticoagulant regimen requirements and blood test results. Physicians could be doing more to help their patients with ongoing management of their oral anticoagulant regimen. Improving blood testing, communication, and involvement with health care professionals are seen as key components in helping patients comply with their oral anticoagulant regimen.

12. 12 Executive Summary

13. 13 Three Key Themes Across Groups Oral anticoagulant use presents a challenge to patients, caregivers, and physicians. There are gaps in education around oral anticoagulant use, both for patients and caregivers. There are gaps in the health care management of oral anticoagulant patients.

14. 14 Key Theme #1  Oral anticoagulant use presents a challenge to patients, caregivers and physicians.

15. 15 Patients on oral anticoagulant medications have complicated health needs, use numerous medications, and see multiple doctors. 3 in 5 suffer poor or fair health Most suffer four or more conditions Almost all take multiple medications, and many take OTCs Almost all see multiple doctors, with 2 in 5 seeing 4 or more doctors Half of patients have been hospitalized or have gone to the ER past 12 months Generally, caregivers report even greater health management challenges among their family members Most caregivers care for someone memory impairment

16. 16 3 in 5 oral anticoagulant users suffer poor or fair health.

17. 17 More than half of oral anticoagulant users suffer four or more of these conditions.

18. 18 Most oral anticoagulant patients are taking multiple prescription medications and OTCs.

19. 19 Oral anticoagulant users see multiple doctors, in addition to their regular doctor.

20. 20 Most caregivers are caring for someone with memory impairment.

21. 21 Following the oral anticoagulant treatment regimen is difficult for many. A substantial minority of patients are less than very confident that they are taking the oral anticoagulant medication correctly. 1 in 5 caregivers are less than very confident that their family member is taking the medication correctly. Assistance with following treatment recommendations is needed. 2 in 5 caregivers feel that family members need encouragement to follow recommendations. A small minority needs a great deal of encouragement (8%). Physicians report that patient non-compliance with medication regimen and recommended blood tests are the top challenges to treating anticoagulant patients. Physicians indicate that nearly half of patients are managing their anticoagulant regimen less than very well. They report that 1 in 4 patients have a difficult time following the recommendations.

22. 22 A substantial minority of patients are less than very confident that they are taking the oral anticoagulant correctly.

23. 23 Nearly 1 in 4 caregivers are less than very confident that their family members are taking the oral anticoagulant medication correctly.

24. 24 Patients recognize the importance of safe behaviors; Compliance is more difficult.

25. 25 Following an appropriate diet is difficult for many patients.

26. 26 2 in 5 of caregivers feel that family members need at least some encouragement to follow instructions associated with taking the anticoagulant medication safely

27. 27 Most caregivers report that their family members need at least some assistance following recommendations.

28. 28 Physicians feel that patient non-compliance with medication regimen and recommended blood tests are the top challenges when dealing with oral anticoagulant patients.

29. 29 Physicians report that almost half of patients are managing their anticoagulant regimen less than very well (Case Study)

30. 30 Physicians report that 1 in 4 patients have difficulty following recommendations (Case Study)

31. 31 Adverse reactions due to oral anticoagulant use are not uncommon. Many patients do not change their behavior or seek help. Almost all patients have experienced at least one side effect to the anticoagulant medication. A troubling minority have been to the ER and/or the hospital because of problems related to their medication. Only about 2 in 5 patients contacted their doctor in response to a problem. Only about half say that they did anything to change their behavior in response to a problem. A majority of physicians report that, in the past 12 months, they have had anticoagulant patients who called or visited the office and/or went to the ER or hospital due to problems with their medication.

32. 32 Most patients have experienced adverse reactions to oral anticoagulant use.

33. 33 A troubling minority of patients have been to the hospital or emergency room because of problems with their oral anticoagulant.

34. 34 Half of patients who experience adverse reactions do nothing to change their behavior.

35. 35 Many patients who experience adverse reactions do not contact their doctor about the problem.

36. 36 Most physicians have anticoagulant patients who contact them with problems due to their anticoagulant use; Half have patients who end up in the ER or hospital.

37. 37 Caregivers struggle to help manage the complex care needs of their loved ones. Many oral anticoagulant users have family members or friends assisting with their care, physicians report that more than 1 in 3 new anticoagulant patients are accompanied by a caregiver Caregivers are involved in a multitude of aspects related to their family members anticoagulant regimen, from accompanying them to the doctor to keeping track of all their medication Many of these caregivers feel that it is their responsibility to ensure that their family member takes their anticoagulant medication as prescribed Many caregivers find it difficult to assist with the oral anticoagulant regimen

38. 38 According to physicians, 1 patient in 3 was accompanied by a caregiver when their oral anticoagulant treatment was initiated.

39. 39 Caregivers are involved in all aspects of anticoagulant management.

40. 40 2 in 5 caregivers feel that they are primarily responsible for ensuring that their family member takes the oral anticoagulant correctly.

41. 41 Many caregivers find it at least somewhat difficult to assist with their family member’s oral anticoagulant regimen.

42. 42 Physicians see care for oral anticoagulant patients as a challenge, requiring more time than patients with other chronic conditions According to physicians, oral anticoagulant patients require more time than other patients with other chronic diseases. The average anticoagulant patient visits the doctor 7 times a year, with more than 1 in 5 making 10 or more visits a year

43. 43 Anticoagulant patients require more of physicians’ time than other chronically ill patients.

44. 44 According to physicians, the average anticoagulant patient visits the doctor 7 times a year (Case Study)

45. 45 Key Theme #2 There are gaps in education around oral anticoagulant use, both for patients and caregivers.

46. 46 Need for greater education, particularly around dietary considerations, drug interactions, and side effects. While most patients and caregivers recognize the importance of following the precautions, there are some gaps in knowledge, particularly around dietary concerns, potential interactions, and side effects. Troubling minorities of patients report that their doctor did not tell them about important elements of their anticoagulant regimen. Many physicians also admit that they do not tell all their patients this important information when they first start them on anticoagulant medication. Opportunities for education at initiation of treatment are being lost.

47. 47 Patients recognize the importance of safe behaviors, with some weaker areas.

48. 48 There are some gaps in caregiver knowledge about dietary concerns, potential interactions, and side effects.

49. 49 A small but troubling minority of caregivers have had problems with a lack of information or conflicting information.

50. 50 There are gaps in education of new oral anticoagulant patients.

51. 51 Many physicians do not tell their patients important information when they first start patients on and anticoagulant medication.

52. 52 Key Theme #3There are gaps in the health care management of oral anticoagulant patients.

53. 53 Improvement is needed in communication between doctors and patients about the management of their treatment regimen. Many physicians do not always contact patients with reminders about blood test results, appointments, or to check on health status. Patients and physicians do a good job managing multiple prescriptions; Could improve management of OTCs. During physician visits, many patients are not being asked about compliance, problems they may be having, and diet. Serious gaps in the management of and communication around blood testing.

54. 54 Good communication and information are seen by physicians as most effective in increasing patients’ compliance with oral anticoagulant medication.

55. 55 The majority of physician offices do not contact their patients every time to remind them about their next appointment or to have their blood tested.

56. 56 Patients and physicians do a good job managing multiple prescriptions; Could improve management of OTCs.

57. 57 While physicians are doing well with reviewing medication, many patients are not being asked about compliance, problems, and diet. (Case Study)

58. 58 There are considerable gaps in knowledge and communication about the blood test goals.

59. 59 Many patients do not know their latest PT/INR number.

60. 60 Many patients are not always getting clear and timely feedback about blood test results.

61. 61 One in four physicians do not always call or mail the patients to inform them about their INR test results.

62. 62 When informing their patients about their INR test results, many physicians do not tell their patients their actual numeric INR value.

63. 63 Caregivers also need better ongoing communication with physicians to help assist patients manage their treatment. Many caregivers find it difficult to speak to their family members’ doctor. Caregivers see areas for improvement in communication between themselves and their family members doctor, particularly around education about treatment requirements.

64. 64 Many caregivers find it difficult to speak with somebody in the doctor’s office when they have questions about the use of the anticoagulant; Pharmacists are more accessible.

65. 65 Caregivers see areas for improvement in communication with their family members’ physician.

66. 66 Assistance is needed to remain compliant with treatment requirements and goals. Caregivers need assistance in helping their loved ones to do so. 2 in 5 patients do not have the assistance of a health care professional, in addition to their doctor, to help them manage their blood thinning medication. Almost 2 in 5 physicians do not have a nurse or other health care professional in their office to help patients manage their oral anticoagulant. Many patients and caregivers do not receive written instructions about all of the things they need to do when taking an oral anticoagulant. Better health care management is associated with improved awareness, behavior, and confidence around the management of oral anticoagulant use.

67. 67 2 in 5 respondents do not have an additional health care professional to help manage oral anticoagulant use.

68. 68 Nearly 2 in 5 physicians do not have a nurse or other health care professional in their office to help patients manage their oral anticoagulant.

69. 69 Most caregivers feel they would benefit from having someone in the doctor’s office they could call for information. Other solutions could also be of help.

70. 70 Written communication is seen by many physicians as a good method of relaying information.

71. 71 Just over half of patients received written instructions about taking the oral anticoagulant.

72. 72 1 in 3 physicians does not provide any of their oral anticoagulant patients with written instructions.

73. 73 Patients with access to another health care professional have better management of blood testing.

74. 74 Health Care Management Score

75. 75 Patients with better health care management are more aware of the importance of oral anticoagulant precautions.

76. 76 Patients with better health care management are more compliant with oral anticoagulant precautions.

77. 77 Patients with better health care management are more confident that they are taking the medication correctly.

78. 78 Patients with better health care management find it easier to follow the precautions of oral anticoagulant use.

79. 79 Preliminary Conclusions

80. 80 Education, ongoing communication, and assistance with health care management are key to improving oral anticoagulant treatment. It is important to strengthen the education provided by physicians (and/or nurses in physician offices), both at the time of first prescription and ongoing. Doctors are the first line of education, but nurses, pharmacists and other health professionals can take on some of the burden. Patients and caregivers need more resources for information and counseling. Pharmacists and designated nurses at physician offices could be important resources. Written information about the precautions associated with anticoagulant use would be a simple and effective educational tool, yet many patients do not receive this. Educating patients about the importance of blood testing and the meaning of blood test results is key to improving compliance and positive outcomes. Caregivers need to be educated and recognized for their role in provision of care for anticoagulant patients. Physicians, nurses, pharmacists and other health care professionals involved in patient’s care need to be accessible to caregivers.