Educational intervention improves anticoagulation control in atrial fibrillation patients:the TREAT randomised trial

Background: Stroke prevention in atrial fibrillation (AF), most commonly with warfarin, requires maintenance of a narrow therapeutic target (INR 2.0 to 3.0) and is often poorly controlled in practice. Poor patient-understanding surrounding AF and its’ treatment may contribute to patient’s willingness to adhere to recommendations. Method: A theory-driven intervention, developed using patient interviews and focus groups, consisting of a one-off group session (1-6 patients) utilising an ‘expert-patient’ focussed DVD, educational booklet, self-monitoring diary and worksheet, was compared in a randomised controlled trial (ISRCTN93952605) against usual care, with patient postal follow-ups at 1, 2, 6, and 12-months. Ninety-seven warfarin-naïve AF patients were randomised to intervention (n=46, mean age (SD) 72.0 (8.2), 67.4% men), or usual care (n=51, mean age (SD) 73.7 (8.1), 62.7% men), stratified by age, sex, and recruitment centre. Primary endpoint was time within therapeutic range (TTR); secondary endpoints included knowledge, quality of life, anxiety/depression, beliefs about medication, and illness perceptions. Main findings: Intervention patients had significantly higher TTR than usual care at 6-months (76.2% vs. 71.3%; p=0.035); at 12-months these differences were not significant (76.0% vs. 70.0%; p=0.44). Knowledge increased significantly across time (F (3, 47) = 6.4; p<0.01), but there were no differences between groups (F (1, 47) = 3.3; p = 0.07). At 6-months, knowledge scores predicted TTR (r=0.245; p=0.04). Patients’ scores on subscales representing their perception of the general harm and overuse of medication, as well as the perceived necessity of their AF specific medications predicted TTR at 6- and 12-months. Conclusions: A theory-driven educational intervention significantly improves TTR in AF patients initiating warfarin during the first 6-months. Adverse clinical outcomes may potentially be reduced by improving patients’ understanding of the necessity of warfarin and reducing their perception of treatment harm. Improving education provision for AF patients is essential to ensure efficacious and safe treatment.

The snakes and ladders of user involvement:moving beyond Arnstein

For 35 years, Arnstein's ladder of citizen participation has been a touchstone for policy makers and practitioners promoting user involvement. This article critically assesses Arnstein's writing in relation to user involvement in health drawing on evidence from the United Kingdom, the Netherlands, Finland, Sweden and Canada. Arnstein's model, however, by solely emphasizing power, limits effective responses to the challenge of involving users in services and undermines the potential of the user involvement process. Such an emphasis on power assumes that it has a common basis for users, providers and policymakers and ignores the existence of different relevant forms of knowledge and expertise. It also fails to recognise that for some users, participation itself may be a goal. We propose a new model to replace the static image of a ladder and argue that for user involvement to improve health services it must acknowledge the value of the process and the diversity of knowledge and experience of both health professionals and lay people.

Network effects, network structure and consumer interaction in mobile telecommunications in Europe and Asia

This paper estimates the importance of (tariff-mediated) network effects and the impact of a consumer's social network on her choice of mobile phone provider. The study uses network data obtained from surveys of students in several European and Asian countries. We use the Quadratic Assignment Procedure, a non-parametric permutation test, to adjust for the particular error structure of network data. We find that respondents strongly coordinate their choice of mobile phone providers, but only if their provider induces network effects. This suggests that this coordination depends on network effects rather than on information contagion or pressure to conform to the social environment.

Scenario-based preparedness plan for floods

The increasing trend of disaster victims globally is posing a complex challenge for disaster management authorities. Moreover, to accomplish successful transition between preparedness and response, it is important to consider the different features inherent to each type of disaster. Floods are portrayed as one of the most frequent and harmful disasters, hence introducing the necessity to develop a tool for disaster preparedness to perform efficient and effective flood management. The purpose of the article is to introduce a method to simultaneously define the proper location of shelters and distribution centers, along with the allocation of prepositioned goods and distribution decisions required to satisfy flood victims. The tool combines the use of a raster geographical information system (GIS) and an optimization model. The GIS determines the flood hazard of the city areas aiming to assess the flood situation and to discard floodable facilities. Then, the multi-commodity multimodal optimization model is solved to obtain the Pareto frontier of two criteria: distance and cost. The methodology was applied to a case study in the flood of Villahermosa, Mexico, in 2007, and the results were compared to an optimized scenario of the guidelines followed by Mexican authorities, concluding that the value of the performance measures was improved using the developed method. Furthermore, the results exhibited the possibility to provide adequate care for people affected with less facilities than the current approach and the advantages of considering more than one distribution center for relief prepositioning.