Abstract
Oral anticoagulation self-control programs have demonstrated efficiency and cost-effectiveness over recent years. This study aimed to evaluate the effectiveness of a training intervention focused on patients with antivitamin K anticoagulants included in a self-care program. For this, we made a quasi-experimental study, pretest and post-test, using a validated questionnaire with 2 measures, before and after an educational intervention about oral anticoagulation focused on patients that will initiate the self-control program in consultation. To check the patient’s adherence and coagulation level, we evaluated the Rosendaal time in therapeutic rank, both before and after the intervention. One hundred fifty patients were included since the start of the self-monitoring program in our center in 2016. The mean age was 49 years (standard deviation [SD] = 17.24). The distribution by gender was 76 women and 69 men (52.4%–47.6%). The mean score for the first test was 14.61 (SD = 3.26) and the mean score for the second test was 17.01 (SD = 2.14) (P <.001). We also measured Rosendaal time in therapeutic rank, a parameter that indicates stabilization in international normalized ratio determinations and quality of the anticoagulation management. Values before and after interventions were also statistically significant (67.46 vs 70.53, P <.001). Patients’ knowledge improved after the training session, with statistical significance. Despite intentional sampling, the population was homogeneous. Scoring data dispersion in the second test was significantly lower than in the first one. Time on therapeutic rank values was better after the training. We intend to adapt its content to the rest of anticoagulated patients to enhance and improve their follow-up.
Keywords: anticoagulation, auto monitoring, health education, nursing, vitamin K
1. Introduction
The treatment with antivitamin K anticoagulants (AVK) (in Spain Acenocoumarol or warfarin, as usual) is still the most common oral anticoagulation treatment (OAT). They are indicated, as shown in their technical note, to prevent thromboembolic events. These types of pathologies are usually caused by prothrombotic diseases, as after an episode of venous thromboembolism, in cardiac valve replacement or when there is atrial fibrillation (AF),[1] despite the use of direct anticoagulants as the first option in recent years following international recommendations for this arrhythmia.[2] Patients affected by AF have a higher risk of thromboembolic events, stroke as the most frequent which is associated with high disability and dependence. That represents a significant increase in the costs and use of health systems.[3] Without treatment, stroke risk and other comorbidities are higher. In fact, AF increases the stroke risk by up to 5 times, causing 1 in 5 episodes. When AF causes a stroke, the risk of death is twice as high that other causes, with survivors having a higher level of disability and a higher risk of recurrence.[1,4,5]
The next most common indication for AVK treatment is the prevention of venous thromboembolic events, for a few months in primary cases and for life in case of recurrence.[6] Heart valve prostheses (especially those of the metallic type) and fibrinolysis disorders also require lifelong treatment, very usually monitored by nurses.[7]
In addition, the aging of the population is already, by itself, raising the use of health resources, both because of the increase in chronic diseases and longer life expectancy. In this respect, the ability of these patients to adequately control their symptoms, through adequate self-care, is particularly relevant.[8] In the present case, there is a strong relationship between age and the presence of AF, since the age group over 80 years presents rates up to 4 times higher than the younger population.[3]
On the other hand, the introduction of portable coagulometers has allowed the possibility of monitoring OAT by patients at home (self-monitoring), and even adjusting the dose based on the results obtained (self-monitoring).[9] These devices allow, through dry chemistry processes, the performance of the tests with a few drops of capillary blood, achieving a precision comparable to conventional laboratory methods. There are different models on the market, with similar characteristics, which allow, according to the determination of an internationally standardized parameter (the International Normalized Ratio, INR), to offer reliable results, and extensive experience, the first scientific report of which is already more than 40 years old.[10]
Therefore, depending on the INR obtained, patients can adjust their medication in 2 ways. First, following a predetermined algorithm of required dosages, which is known as self-monitoring. Second, they can consult a healthcare professional who will always indicate the appropriate dose, a modality called self-analysis.[5] The efficacy for both procedures is documented, both in terms of efficacy and cost-effectiveness, and even in comparison with patients taking direct anticoagulants.[11]
Highly motivated patients who followed a program of self-control and self-analysis in the maintenance phase of OAT with AVK, showed a reduction in overall mortality and a significant decrease in the risk of suffering major thromboembolic events, without an increase in bleeding episodes, when compared to standard follow-up (level of evidence 1++/1+). Mortality and major thromboembolic events decreased to a greater extent when the patients were responsible for adjusting the medication based on the INR (self-control) results (level of evidence 1++/1+). Self-controlled patients could improve self-perceived efficacy, without finding differences with usual care in the rest of the dimensions of the questionnaires used to assess quality of life and anxiety (level of evidence 1-).[11]
The bibliography has confirmed the efficacy of training courses for self-management in AVK treatments, mainly on clinical data such as reduction of complications and improvement in INR control[11–13]; however, it is less frequent to contrast the improvement in the knowledge of the basic notions about oral anticoagulation, which would allow a better management of AVK treatment. In this case, there are no references in which an improvement in the degree of knowledge acquired is verified, although there are instruments that can easily evaluate it.[14–16]
Moreover, the patient’s adherence for treatment is fundamental in this case, since a dose not taken causes a significant decrease in the INR value in the following days (more frequent in patients treated with Acenocoumarol, as occurs in our country), so they will be at risk of a thromboembolic event until they reach at least the lower INR limit, generally 2. To verify this correct adherence, the Rosendaal time in therapeutic range (TTRr) has been used for several years.[17]
On the other hand, data collection was altered by the COVID-19 pandemic, declared in March 2020, which forced the configuration of the sessions to be changed, from group to individual. Therefore, the objective of this study is to evaluate the effectiveness, in terms of improving knowledge, of a training intervention focused on patients with AVK included in a self-care program, comparing the results in an aggregate way and by type of session employee (group or individual).
We pretend to evaluate the effectiveness, with an increase of knowledge and the possible changes in TTRr values of a self-monitoring program with patients ongoing AVK treatment in the health area of the Haematology Department of the University Hospital “Virgen de la Victoria,” in Málaga, Spain.
2. Methods
2.1. Design
Quasi-experimental pretest and posttest study.
2.2. Population and sample
Candidate patients for self-monitoring in the health area of the Hematology Department from the Virgen de la Victoria University Hospital. Currently, this health area includes approximately 3900 anticoagulated patients, of which only a part meets the requirements to be included in the program: having a certain level of education, basic skills for managing technology as well as willingness and interest in joining the program or having a caregiver with the same features. Making an estimation, the candidate population amounts to a number of people close to 10% of the total (390). All patients integrated into the program were offered to participate in this study since its implementation in 2016. The data has been collected until 2022.
The participants belonged to Health Centers both in the health area of our AC and outside of it, in the case of the patient’s area there was no reference center for the self-monitoring program.
The sample, following the norms in use for a finite population, with a confidence level of 95%, a precision of 5%, a beta error of 5%, and a percentage of loss of 10% was estimated in a minimum of 80 patients.
Due to ethical aspects, randomization was not possible. Sampling was incidental and consecutive during the study period. Consequently, all patients who agreed to participate and met inclusion criteria were included.
2.3. Inclusion criteria
Patients or main caregivers of patients over 18 years of age, with no age limit, with the capacity to attend the training sessions, who can read and write and have basic skills to handle technology, considering those who had difficulties in attending the consultation due to work or health reasons, giving preference to high-risk patients. The ability to be included in the program will depend on the voluntary nature of the patient and a personalized interview with the staff nurses.
2.4. Exclusion criteria
Abandonment, for whatever reason, of the self-control program, going to routine follow-up in anticoagulation or primary care clinics, change of treatment, death or change of address of the patient to a health area outside the influence of our department.
2.5. Type of assistance mediated by the COVID-19 pandemic
Due to the special characteristics of the COVID-19 pandemic period, 2 groups of attendees have been held, depending on receiving training before the declaration of the state of alarm in our country (March 2020) or after. Those attending the sessions in the pre-pandemic period did so as a group (3–4 participants), while during said period and subsequently received it individually.
2.6. Intervention
The intervention consisted of a specific training activity aimed at patients who were included in the self-management program of our practice. The activity consists of 2 group sessions, with and estimated duration of 2 hours, within 1 week of each other. During the pandemic period, a single individual session lasting 3 hours was held. In the first session (first part in pandemic period), the content was as follows:
Basic concepts about the physiology of coagulation.
Notions about oral anticoagulant treatment. Therapeutic ranges.
The INR.
Alarm symptoms in complications.
Reminder about life habits.
In the second session (second part in pandemic):
Summary of the previous session.
Coagulometers. Operating mode.
INR measurement.
Practical assumptions.
Sampling and dosing practices.
The single session had the same contents, except for the summary of the previous session.
2.7. Measurement of effectiveness
To verify the effectiveness of the training intervention, the participants answered a questionnaire (test of knowledge about their treatment) validated and cross-culturally adapted to the Spanish language, before the first session and after the last or before and after the single session.
We also evaluated the adherence status of the patients by means of the TTRr, before the training sessions and 3 months after.
2.8. Instrument
Adapted cross-cultural version of the “Oral anticoagulation knowledge test.”[15,16] This is a questionnaire on aspects related to oral anticoagulant treatment, which consists of 20 items with 4 answer options each and only one correct. Subsequently, the maximum score was 20 points.
TTRr values are provided by the web application TAONet (Roche Diagnostics, Switzerland). TTRr calculates the INR changes in a linear progression between 2 consecutive values and manages, in this way, to calculate the value specific INR for each day. A TTRr above 65 is considered an acceptable anticoagulation level.[17]
2.9. Study limitations
The main limitations of the study are derived from the non-randomization of the sample (possibility of not obtaining sufficient age ranges or proportionality in gender, fundamentally), because it was ethically impossible to design a randomized study. However, we pretend, after these results, to design a multicenter study to be carried out that includes more clinics or departments that performed specific training programs for self-control in patients receiving AVK treatment. The change from group to individual education that had to be carried out due to the state of pandemic is also considered a potential limitation. To find out these possible differences, analyzes were developed based on the type of training received.
2.10. Statistical analysis
To analyze the differences between continuous quantitative variables in 2 related groups, the Student t test was applied for paired samples in the event that the condition of normality can be accepted, which was verified by the Shapiro–Wilk test.
To analyze the differences between continuous quantitative variables in 2 independent groups, the Student t test has been applied for 2 independent samples in the event that the condition of normality of the variables in each of the groups can be accepted, which has been confirmed by the Shapiro–Wilk test.
A linear regression model was employed, to analyze the possible influence of independent variables in the dependent variables. A P value <.05 was considered statistically significant. Statistical calculation was performed with SPSS v. 25, with license from the University of Málaga (Spain).
2.11. Ethical aspects
Patient participation was voluntary, and all current ethical and legal requirements were met. The ethical requirements of the latest Declaration of Helsinki (Fortaleza, Brazil, 2013) were adopted. The study also followed all the law requirements about research of our country and was authorized by the Malaga Northwest Research Ethics Committee (code TAO-002).
3. Results
Once the minimum sample size (80) was established, 150 patients finally participated. Five of them did not finish the program for different reasons, so the sample has been made up of a total of 145 participants, being 61 men and 84 women (42.03% and 57.97%, respectively). In 2 cases the training was received by the main caregiver of the patient.
The mean age was 49.18 years (standard deviation [SD] 17.24). By gender, men had a mean age of 50.46 (SD 16.78) years and women of 47.64 (SD 15.53) (P < .312). The most widely used anticoagulant was Acenocoumarol, with 134 patients (92.41%), of whom 14 took Acenocoumarol 1 mg and 120 took Acenocoumarol 4 mg. The rest of the patients, 11 (7.59 %), were taking Warfarin (5 and 10 mg) (Table 1).
Table 1.
Characteristics of the participants.
| Men (n) | Women (n) | Overall (n) | |
|---|---|---|---|
| Gender | 69 | 76 | 145 |
| Mean age | 50.46 (SD 16.78) | 47.64 (SD 15.53) | 49.18 (SD 17.24) |
| Urban Health centers | 46 | 38 | 84 |
| Rural Health centers | 35 | 26 | 61 |
| Group sessions | 33 | 36 | 69 |
| Individual sessions | 36 | 40 | 76 |
| Pathology: atrial fibrillation | 4 | 11 | 15 |
| Pathology: cardiac prostheses | 20 | 24 | 44 |
| Pathology: thrombotic events | 31 | 39 | 70 |
| APS/thrombophillia | 5 | 11 | 16 |
| Acenocumarol | 63 | 70 | 133 |
| Warfarin | 6 | 6 | 12 |
Overall, the mean score of the first test was 14.61 (SD 3.26) and the mean score of the second test was 17.63 (SD 2.09) (P < .001). By gender, men reach 15.30 (SD 2.75) points on the first test and 17.63 (SD 1.69) points on the second, while women had 14.44 (SD 3.22) points on the first test and 16.82 (SD 2.14) points on the second (P = .585 and 0.389, respectively), being the maximum score 20 points (Table 2).
Table 2.
Paired t test results.
| Comparison (N = 145) | t test P | Correlation coefficient (r Pearson) | 95% confidence interval |
|---|---|---|---|
| Test 1 vs Test 2 | <0.0001 | 0.6739 | 2.089–2.863 |
| TTR1 vs TTR2 | <0.0001 | 0.9188 | 2.266–3.860 |
Regarding the distribution by Health Centers, in our health area, there are 16 rural and 11 urban Health Centers. Forty-eight patients belonged to rural Health Centers, and 97 to Malaga town. The patients belonged to 43 different ones because 14 patients outside our health area were included into the program. The most represented Health centers were “Huelin” and “Cruz de Humilladero” with 10 patients each 1, followed by the “El Cónsul” with 9 patients, all of them from urban centers. Scores do not have statistical differences (P = .906 and .792 first and second test, respectively).
The main pathology in our group of patients was Venous Thrombotic Events (mainly Pulmonary Thromboembolism or Deep Venous Thromboembolism), with 70 patients (38.88%), followed by Cardiac Valve Prostheses (mainly mitral valve) with 45 patients (30.55%). We also included 16 patients with Antiphospholipid Syndrome (11.11%), and 15 patients with AF (10.18%), 3 of them also carrying a Cardiac Valve Prosthesis.
The patients who attended group sessions were 69 (33 men and 36 women) while 76 patients (36 men and 40 women) attended individual sessions. The score obtained was 14.8 and 17.19 in the group sessions and 14.4 and 17.07 points in the individual sessions. We did not find statistically differences between scores before and after the formative session according to the type (P = .799 and .503, respectively) (Table 3).
Table 3.
Comparison of overall data and by sex, origin (type of Health centres) and type of session (individual or group) attended by participants.
| N = 145 | Overall Mean and SD |
Men Mean and SD (n = 69) |
Women Mean and SD (n = 76) |
P value | Urban Health centres (n = 97) Mean and SD |
Rural Health centres (n = 48) Mean and SD |
P value | Group session (n = 69) | Group session (n = 76) |
P value |
|---|---|---|---|---|---|---|---|---|---|---|
| Test 1 score | 14.61 (3.26) | 15.30 (2.75) | 14.44 (3.22) | .585 | 14.44 (3.59) | 14.97 (2.77) | .906 | 14.53 (3.08) | 14.8 (3.18) | .799 |
| Test 2 score | 17.01 (2.09) | 17.63 (1.69) | 16.82 (2.14) | .389 | 16.86 (2.42) | 17.44 (1.46) | .792 | 17.1 (2.13) | 17.33 (1.94) | .503 |
| TTRr score 1 | 67.5 (12.14) | 65.69 (11.2) | 65.34 (14.64) | .626 | 67.47 (10.85) | 68.21 (13.64) | .992 | 67.94 (12.97) | 66.95 (11.62) | .719 |
| TTRr score 2 | 70.5 (10.4) | 69.06 (10.24) | 68.27 (13.06) | .822 | 70.96 (8.87) | 70.2 (11.36) | .665 | 70.88 (10.83) | 70.28 (10.14) | .912 |
TTR results showed a mean value of 67.46 (SD 10.54) prior the intervention and 70.52 (SD 8.94) after (P < .0001). By gender, men had a first TTRr measure of 67.48 (SD 10.54) and a second of 70.96 (P = .0016); women had 68.21 (SD 13.64) and 71.12 (SD 11.36) (P = .0008).
We also constructed a linear regression model, attending to the 2 main dependent variables (second test score and second TTRr measure). Both models were statistically significant.
The first model explained 44.3% and the second 88.28% of each model. In the first, the score of the first knowledge test is the most influential variable, with a positive relationship, and being attended in a rural Health Center seems to negatively influence TTRr values in the second model. Main data are depicted in Figures 1 to 4. Correlation matrices are described in Tables 4 and 5.
Figure 1.
Test 1–Test 2. Actual vs predicted plot: Multiple lin. Reg.
Figure 4.
TTR1–TTR2. Residual plot: Multiple lin. Reg. of Data. TTR = time on therapeutic rank.
Table 4.
Correlation matrix Model “Test 2”.
| Correlation matrix | Variable | β0 | β1 | β2 | β3 | β4 | β5 | β6 | β7 |
|---|---|---|---|---|---|---|---|---|---|
| β1 | Age | -0.4022 | 1.000 | ||||||
| β2 | Sex | -0.2566 | 0.2284 | 1.000 | |||||
| β3 | Test 1 | -0.6363 | 0.3281 | 0.1434 | 1.000 | ||||
| β4 | TTR1 | 0.1289 | 0.06112 | -0.06492 | 0.004349 | 1.000 | |||
| β5 | TTR2 | -0.3081 | -0.04785 | 0.03437 | -0.001213 | -0.9385 | 1.000 | ||
| β6 | ACO | -0.03657 | -0.1466 | -0.06194 | -0.07360 | 0.1192 | -0.1301 | 1.000 | |
| β7 | CS | -0.2644 | -0.1270 | -0.3323 | 0.08660 | -0.004980 | -0.01018 | -0.01761 | 1.000 |
| β8 | DIAG | -0.3525 | -0.2268 | -0.1196 | 0.1596 | 0.07884 | -0.07719 | 0.09905 | 0.3618 |
Table 5.
Correlation matrix Model “TTRr 2”.
| Correlation matrix | Variable | β0 | β1 | β2 | β3 | β4 | β5 | β6 | β7 |
|---|---|---|---|---|---|---|---|---|---|
| β1 | Age | -0.3524 | 1.000 | ||||||
| β2 | Sex | -0.1976 | 0.2345 | 1.000 | |||||
| β3 | Test 1 | -0.1871 | 0.3066 | 0.1552 | 1.000 | ||||
| β4 | Test 2 | -0.4597 | -0.07841 | -0.06865 | -0.6137 | 1.000 | |||
| β5 | TTR1 | -0.3199 | 0.06316 | -0.07675 | 0.1439 | -0.2227 | 1.000 | ||
| β6 | ACO | -0.04088 | -0.1482 | -0.05308 | -0.01707 | -0.06766 | 0.007019 | 1.000 | |
| β7 | CS | -0.3082 | -0.1365 | -0.3375 | -0.01314 | 0.1318 | -0.07005 | -0.02781 | 1.000 |
| β8 | DIAG | -0.3750 | -0.2344 | -0.1204 | 0.09518 | 0.05042 | 0.006870 | 0.08631 | 0.3651 |
Figure 2.
Residual plot: Multiple lin. Reg. of Test 1–Test 2.
Figure 3.
TTR1–TTR2. Actual vs predicted plot: Multiple lin. Reg. TTR = time on therapeutic rank.
4. Discussion
It is increasingly common to establish strategies that enhance the empowerment of the patient, especially in the aspect related to self-care, following the Theoretical Model of Dorothea Orem.[16] One of the most significant target populations in this regard is diabetics, with extensive experience.[17,18] There is also experience in self-controlled anticoagulated patients. In this sense, the latest systematic review on the subject found a reduction in the presence of thromboembolic events compared to those controlled in a conventional way, although no effect was detected in reducing major bleeding.19,20
There are some studies carried out with a similar population, but none of them considered the knowledge of the patients as the final objective of their results.21 In this sense, we found a cross-sectional study carried out in Africa that showed a low level of knowledge in its population, so we planned an intervention study as a better strategy to increase it,[22] as shown by other studies carried out in a scenario similar to ours.[23]
The results of our study show that, in addition to the advantages described by the available evidence, there is a statistically significant improvement in the level of knowledge about anticoagulation, and in the TTRr values too. This is an important topic, because it can be considered that a good knowledge can provide a better handling of their treatment. It has been shown that an intervention similar to ours may improve the patient’s knowledge on warfarin as well as patient’s compliance.[24]
Similar results were found in an interesting Randomized Clinical Trial held in Germany, in which they found that, after 12 months, the improvement in the level of knowledge (compared to baseline) was significantly larger in the intervention group than in the control group, using a complex intervention.[25]
Our results are along these lines, although different tests were used, and the sessions had to be adapted to the special circumstances of the COVID-19 pandemic. In fact, we also looked for possible differences between rural or urban health centers, sex, and type of training session (group or individual). Although some small differences in the scores were found, none of them were statistically significant, but it should be noted that in the linear regression model of the second variable studied, in which it seems that being attended in a Rural Health Center had a small influence on the TTRr values (Rural centers were coded as 1, so the less code number the high score in test), although the t test analysis was not significative. Another aspect to highlight is that INR controls in self-controlled patients are usually carried out weekly, so the INR deviations are easier to control and, therefore, their impact on TTRr can be minimized.
Our patients constituted a relatively homogeneous distribution by sex, type of course, and origin. We found dispersion according to diagnosis, and a predominance of Acenocoumarol use, especially 4 mg, as is mostly the case in Spain.[26,27] The results showed a statistically significant difference analyzing results before and after the intervention, both in the level of knowledge and the TTRr value (Table 2), and no statistically significant differences were found in the overall calculation according to sex, type of training session or origin of the patients (Table 3).
When analyzing the linear regression model, the second analysis showed a high influence of the first TTRr value in the model, perhaps due to the fact that most patients had increased their previous value, which makes it a variable with an estimable weight in the model and it exist a high correlation between first and second TTRr measure (R = 0.918). These results suggest that the possible differences between analyzed groups are due to the high value on Pearson R coefficient found in the paired analysis, and has a logical explanation, because almost all patients reach both a major level of knowledge and a better TTRr value after the sessions.
We would like to emphasize the important role of nurses in this field in our country, because the majority of the follow-up of anticoagulated patients was performed by nurses. As people with a chronic disease and a long-life treatment, nurses are in charge of them, providing high quality care and sustainability to our health system and others with similar characteristics.[28–30]
Although we worked with self-controlled patients, those not included in self-control programs, can also find some gaps in the knowledge of their treatment, so a need of assessing patient knowledge and for structured education programs is detected.[26] This gap might be corrected with periodic training programs which include all under OAT (with or without AVK) patients. We pretend to include nonself-controlled patients in formative sessions in the near future, looking for an integral care and a better management of clinical safety, adapting our learning sessions to their special features, and also estimate the possible cost saving of our self-control programme both for patients and our health system.
Acknowledgments
Authors would like emphasize the support of the Spanish National Nursing Council in the development of this study (Consejo General de Enfermería de España).
Author contributions
Conceptualization: Adolfo Romero-Arana, María José González-Rodríguez, Patricia Sánchez-Vega, Juan Gómez-Salgado, Adolfo Romero.
Data curation: Adolfo Romero-Arana, María José González-Rodríguez, Patricia Sánchez-Vega, Juan Gómez-Salgado, Adolfo Romero.
Formal analysis: Adolfo Romero-Arana, María José González-Rodríguez, Patricia Sánchez-Vega, Juan Gómez-Salgado, Adolfo Romero.
Investigation: Adolfo Romero-Arana, María José González-Rodríguez, Patricia Sánchez-Vega, Juan Gómez-Salgado, Adolfo Romero
Methodology: Adolfo Romero-Arana, María José González-Rodríguez, Patricia Sánchez-Vega, Juan Gómez-Salgado, Adolfo Romero.
Project administration: Adolfo Romero-Arana, Juan Gómez-Salgado, Adolfo Romero.
Resources: Adolfo Romero-Arana, María José González-Rodríguez, Patricia Sánchez-Vega, Juan Gómez-Salgado, Adolfo Romero.
Software: Adolfo Romero-Arana, María José González-Rodríguez, Patricia Sánchez-Vega, Juan Gómez-Salgado, Adolfo Romero.
Supervision: Adolfo Romero-Arana, María José González-Rodríguez, Patricia Sánchez-Vega, Juan Gómez-Salgado, Adolfo Romero.
Validation: Adolfo Romero-Arana, María José González-Rodríguez, Patricia Sánchez-Vega, Juan Gómez-Salgado, Adolfo Romero.
Visualization: Adolfo Romero-Arana, María José González-Rodríguez, Patricia Sánchez-Vega, Juan Gómez-Salgado, Adolfo Romero.
Writing – original draft: Adolfo Romero-Arana, María José González-Rodríguez, Patricia Sánchez-Vega, Juan Gómez-Salgado, Adolfo Romero.
Writing – review & editing: Adolfo Romero-Arana, María José González-Rodríguez, Patricia Sánchez-Vega, Juan Gómez-Salgado, Adolfo Romero.
Abbreviations:
- AF
- atrial fibrillation
- AVK
- antivitamin K anticoagulants
- INR
- International Normalized Ratio
- OAT
- oral anticoagulation treatment
- SD
- standard deviation
- TTR
- time on therapeutic rank
- TTRr
- Rosendaal time on therapeutic rank
The authors have no funding and conflicts of interest to disclose.
All data generated or analyzed during this study are included in this published article [and its supplementary information files].
How to cite this article: Romero-Arana A, González-Rodríguez MJ, Sánchez-Vega P, Gómez-Salgado J, Romero A. Effectiveness of a self-management program for anticoagulated patients to improve their knowledge about treatment and time in therapeutic range. Medicine 2024;103:44(e40258).
Contributor Information
Adolfo Romero-Arana, Email: adolforomeror@gmail.com.
María José González-Rodríguez, Email: mariajogonz@hotmail.com.
Patricia Sánchez-Vega, Email: patri_sv@hotmail.com.
Adolfo Romero, Email: adolforomeror@gmail.com.
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