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Meta-Analysis
. 2017 Apr 5;4(4):CD008600.
doi: 10.1002/14651858.CD008600.pub3.

Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation

Danielle E Clarkesmith  1 , Helen M Pattison  2 , Phyo H Khaing  3 , Deirdre A Lane  1
Affiliations
Meta-Analysis

Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation

Danielle E Clarkesmith et al. Cochrane Database Syst Rev. .

Abstract

Background: Current guidelines recommend oral anticoagulation therapy for patients with atrial fibrillation (AF) with one or more risk factors for stroke; however, anticoagulation control (time in therapeutic range (TTR)) with vitamin K antagonists (VKAs) is dependent on many factors. Educational and behavioural interventions may impact patients' ability to maintain their international normalised ratio (INR) control. This is an updated version of the original review first published in 2013.

Objectives: To evaluate the effects of educational and behavioural interventions for oral anticoagulation therapy (OAT) on TTR in patients with AF.

Search methods: We updated searches from the previous review by searching the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library (January 2016, Issue 1), MEDLINE Ovid (1949 to February week 1 2016), EMBASE Classic + EMBASE Ovid (1980 to Week 7 2016), PsycINFO Ovid (1806 to Week 1 February 2016) and CINAHL Plus with Full Text EBSCO (1937 to 16/02/2016). We applied no language restrictions.

Selection criteria: We included randomised controlled trials evaluating the effect of any educational and behavioural intervention compared with usual care, no intervention, or intervention in combination with other self-management techniques among adults with AF who were eligible for, or currently receiving, OAT.

Data collection and analysis: Two of the review authors independently selected studies and extracted data. Risk of bias was assessed using the Cochrane 'Risk of bias' tool. We included outcome data on TTR, decision conflict (patient's uncertainty in making health-related decisions), percentage of INRs in the therapeutic range, major bleeding, stroke and thromboembolic events, patient knowledge, patient satisfaction, quality of life (QoL), beliefs about medication, illness perceptions, and anxiety and depression. We pooled data for three outcomes - TTR, anxiety and depression, and decision conflict - and reported mean differences (MD). Where insufficient data were present to conduct a meta-analysis, we reported effect sizes and confidence intervals (CI) from the included studies. We evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

Main results: Eleven trials with a total of 2246 AF patients (ranging from 14 to 712 by study) were included within the review. Studies included education, decision aids, and self-monitoring plus education interventions. The effect of self-monitoring plus education on TTR was uncertain compared with usual care (MD 6.31, 95% CI -5.63 to 18.25, I2 = 0%, 2 trials, 69 participants, very low-quality evidence). We found small but positive effects of education on anxiety (MD -0.62, 95% CI -1.21 to -0.04, I2 = 0%, 2 trials, 587 participants, low-quality evidence) and depression (MD -0.74, 95% CI -1.34 to -0.14, I2 = 0%, 2 trials, 587 participants, low-quality evidence) compared with usual care. The effect of decision aids on decision conflict favoured usual care (MD -0.1, 95% CI -0.17 to -0.02, I2 = 0%, 2 trials, 721 participants, low-quality evidence).

Authors' conclusions: This review demonstrates that there is insufficient evidence to draw definitive conclusions regarding the impact of educational or behavioural interventions on TTR in AF patients receiving OAT. Thus, more trials are needed to examine the impact of interventions on anticoagulation control in AF patients and the mechanisms by which they are successful. It is also important to explore the psychological implications for patients suffering from this long-term chronic condition.

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Conflict of interest statement

Dr Clarkesmith completed a PhD studentship that was funded by an Investigator‐Initiated Educational Grant from Bayer Healthcare and Aston University when the original review was conducted, but currently works as a post‐doctoral researcher with no conflicts of interest. Miss Khaing reports no conflicts of interest. Dr Lane was the principal grant holder for the 'TRial of an Educational intervention on patients' knowledge of Atrial fibrillation and anticoagulant therapy, INR control, and outcome of Treatment with warfarin' (TREAT). Dr Clarkesmith was the primary investigator for TREAT. Dr Lane and Professor Pattison were the educational supervisors of Dr Clarkesmith for the TREAT study. This review is not funded by Bayer Healthcare.

Figures

1
1
PRIMSA flow chart of included studies.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: self‐monitoring plus education versus usual care on time in therapeutic INR range.
5
5
Forest plot of comparison: education versus usual care on HADS anxiety.
6
6
Forest plot of comparison: education versus usual care on HADS depression.
7
7
Forest plot of comparison: decision‐aid versus usual care on decision conflict.
1.1
1.1. Analysis
Comparison 1 Self‐monitoring plus education versus usual care, Outcome 1 Time in therapeutic INR range.
2.1
2.1. Analysis
Comparison 2 Education versus usual care, Outcome 1 HADS anxiety.
2.2
2.2. Analysis
Comparison 2 Education versus usual care, Outcome 2 HADS depression.
3.1
3.1. Analysis
Comparison 3 Decision‐aid versus usual care, Outcome 1 Decision conflict.
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References to other published versions of this review

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