PHILADELPHIA –Patients who report receiving written and verbal instructions on the proper way to take the blood thinner warfarin are significantly less likely to suffer the serious gastrointestinal and brain bleeding problems that are associated with misuse of the drug, according to new research from the School of Medicine. The study, published in the October issue of the Journal of General Internal Medicine, also shows that patients who see only one physician and fill their prescription at a single pharmacy are less apt to experience serious bleeding events.
Lead author Joshua P. Metlay, MD, PhD, an Associate Professor in Penn’s division of General Internal Medicine and a Senior Scholar in the Center for Clinical Epidemiology and Biostatistics, found that patients who reported receiving medication instructions from a physician and a nurse plus a pharmacy worker were 60 percent less likely to experience a serious bleeding problem over the following two years. Since the serious side effects of warfarin use are often linked to hospitalizations, the Penn researchers theorize that improved patient communication — which can help clarify questions about dosing, other drugs to avoid while taking warfarin, and early symptoms of bleeding problems — could prevent a substantial number of injuries and resulting hospitalizations.
“While we do not know the specific mechanism linking the medication instructions to reduce bleeding risk, it is likely that improved communication about medications leads to increased drug adherence and earlier recognition of medication side effects,” Metlay says.
Metlay’s team, in collaboration with the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE), studied 2,346 older adults taking warfarin for problems including heart rhythm abnormalities, deep vein thrombosis, stroke, heart valve replacements and pulmonary embolism. Using data provided by the Pennsylvania Healthcare Cost Containment Council, the researchers identified hospitalizations that were tied to warfarin-related bleeding events among the patients in the study.
The findings also indicate that the way patients receive instruction about their medicine matters. Compared to receiving no instructions beyond those printed on the prescription bottle, patients who said they had been given written information or written information plus verbal instructions were less apt to suffer bleeding events. Reports of verbal instruction alone, however, were not associated with a decreased risk of bleeding problems compared to patients who received no instructions. The Penn researchers say the findings underscore previous studies showing that thorough, honest communication between health care providers and patients is an important contributor to compliance with recommended therapies.
Since only 55 percent of participants in the study reported receiving any type of medication instructions from a doctor or nurse, Metlay and his colleagues say the impact on bleeding events among warfarin users could be slashed further if similar communication models were adopted more widely by physicians and pharmacists. New regulations requiring that all patients filling warfarin prescriptions receive a Medication Guide could help, and since pharmacists are now able to be reimbursed for time spent providing medication counseling to Medicare recipients, the authors are hopeful more patients will get helpful information about this drug.
The new research may also have implications for the broader health care community. While warfarin is one of the highest-risk drugs routinely used in ambulatory care, these findings point to ways to improve provider-patient communication in ways that would encourage better drug adherence and patient safety for many other medications and chronic medical conditions.
“It is time that we recognize that patients and their caregivers bear a substantial burden in managing increasingly complex medical regimens and require more guidance in this area,” Metlay says.
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Penn Medicine is one of the world’s leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System, which together form a $7.8 billion enterprise.
The Perelman School of Medicine has been ranked among the top five medical schools in the United States for the past 20 years, according to U.S. News & World Report’s survey of research-oriented medical schools. The School is consistently among the nation’s top recipients of funding from the National Institutes of Health, with $405 million awarded in the 2017 fiscal year.
The University of Pennsylvania Health System’s patient care facilities include: The Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center — which are recognized as one of the nation’s top “Honor Roll” hospitals by U.S. News & World Report — Chester County Hospital; Lancaster General Health; Penn Medicine Princeton Health; Penn Wissahickon Hospice; and Pennsylvania Hospital – the nation’s first hospital, founded in 1751. Additional affiliated inpatient care facilities and services throughout the Philadelphia region include Good Shepherd Penn Partners, a partnership between Good Shepherd Rehabilitation Network and Penn Medicine, and Princeton House Behavioral Health, a leading provider of highly skilled and compassionate behavioral healthcare.
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