title: Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation.
abstract: BACKGROUND
  Current guidelines recommend oral anticoagulation therapy for patients with atrial fibrillation who are at moderate-to-high risk of stroke, however anticoagulation control (time in therapeutic range (TTR)) is dependent on many factors. Educational and behavioural interventions may impact on patients' ability to maintain their International Normalised Ratio (INR) control.
  
  
  OBJECTIVE
  To evaluate the effects on TTR of educational and behavioural interventions for oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF).
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library (2012, Issue 7 of 12), MEDLINE Ovid (1950 to week 4 July 2012), EMBASE Classic + EMBASE Ovid (1947 to Week 31 2012), PsycINFO Ovid (1806 to 2012 week 5 July) on 8 August 2012 and CINAHL Plus with Full Text EBSCO (to August 2012) on 9 August 2012. We applied no language restrictions.
  
  
  METHODS
  The primary outcome analysed was TTR. Secondary outcomes included 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), and anxiety.
  
  
  METHODS
  The two review authors independently extracted data. Where insufficient data were present to conduct a meta-analysis, effect sizes and confidence intervals (CIs) of the included studies were reported. Data were pooled for two outcomes, TTR and decision conflict.
  
  
  RESULTS
  Eight trials with a total of 1215 AF patients (number of AF participants included in the individual trials ranging from 14 to 434) were included within the review. Studies included education, decision aids, and self-monitoring plus education.For the primary outcome of TTR, data for the AF participants in two self-monitoring plus education trials were pooled and did not favour self-monitoring plus education or usual care in improving TTR, with a mean difference of 6.31 (95% CI -5.63 to 18.25). For the secondary outcome of decision conflict, data from two decision aid trials favoured usual care over the decision aid in terms of reducing decision conflict, with a mean difference of -0.1 (95% CI -0.2 to -0.02).
  
  
  CONCLUSIONS
  This review demonstrated 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.
authors.affiliation: University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK. 2School of Life and Health Sciences,Aston University, Birmingham, UK.
authors.forename: Danielle E
authors.initials: DE
authors.lastname: Clarkesmith
authors.forename: Helen M
authors.initials: HM
authors.lastname: Pattison
authors.forename: Deirdre A
authors.initials: DA
authors.lastname: Lane
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000097:blood / Q000150:complications*; D002908:Chronic Disease; D003661:Decision Support Techniques; D016903:Drug Monitoring / Q000379:methods* / Q000592:standards; D006801:Humans; D019934:International Normalized Ratio / Q000592:standards; D055118:Medication Adherence; D008875:Middle Aged; D010353:Patient Education as Topic; D016032:Randomized Controlled Trials as Topic; D012648:Self Care / Q000379:methods; D020521:Stroke / Q000097:blood / Q000209:etiology / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants