Transitioning to routine breast cancer risk assessment and management in primary care: what can we learn from cardiovascular disease?

To capitalise on advances in breast cancer prevention, all women would need to have their breast cancer risk formally assessed. With ~85% of Australians attending primary care clinics at least once a year, primary care is an opportune location for formal breast cancer risk assessment and management. This study assessed the current practice and needs of primary care clinicians regarding assessment and management of breast cancer risk. Two facilitated focus group discussions were held with 17 primary care clinicians (12 GPs and 5 practice nurses (PNs)) as part of a larger needs assessment. Primary care clinicians viewed assessment and management of cardiovascular risk as an intrinsic, expected part of their role, often triggered by practice software prompts and facilitated by use of an online tool. Conversely, assessment of breast cancer risk was not routine and was generally patient- (not clinician-) initiated, and risk management (apart from routine screening) was considered outside the primary care domain. Clinicians suggested that routine assessment and management of breast cancer risk might be achieved if it were widely endorsed as within the remit of primary care and supported by an online risk-assessment and decision aid tool that was integrated into primary care software. This study identified several key issues that would need to be addressed to facilitate the transition to routine assessment and management of breast cancer risk in primary care, based largely on the model used for cardiovascular disease.

Uma metodologia multicritério construtivista de avaliação de alternativas para o planejamento de recursos hídricos de bacias hidrográficas

De acordo com a Lei Federal n° 9.433/97, que instituiu a Política e o Sistema Nacional de Gerenciamento dos Recursos Hídricos, o planejamento de recursos hídricos deve ter um enfoque sistêmico, de uso múltiplo das águas e descentralização das decisões, adotando a bacia hidrográfica como unidade de gestão. Dentro deste contexto, de descentralização de decisões e participação de grandes grupos no processo de tomada de decisão sobre a gestão dos recursos hídricos, os procedimentos clássicos de avaliação de alternativas para planejar o uso, controle e proteção das águas tornam-se limitados por sua impossibilidade de incluir outros critérios, além da minimização dos custos ou da maximização dos benefícios, e por não considerarem a subjetividade inerente ao processo de tomada de decisão, que corresponde ao sistema de valores dos atores envolvidos na tomada de decisões. Assim, este trabalho apresenta um Método Multicritério em Apoio à Decisão para o planejamento de recursos hídricos de bacias hidrográficas, que além de incorporar vários critérios na avaliação de alternativas, por adotar uma abordagem construtivista, propicia a participação de todos os atores envolvidos no processo de tomada de decisão. Para testar a aplicabilidade prática do método proposto foi escolhida a bacia hidrográfica do rio dos Sinos, localizada no estado do Rio Grande do Sul, sendo construído um Modelo Multicritério de Avaliação de Alternativas para o Plano da Bacia Hidrográfica do Rio dos Sinos. Os resultados do trabalho demonstraram a robustez da proposta que, ao possibilitar a geração e avaliação de alternativas para o Plano da Bacia Hidrográfica do Rio dos Sinos, a partir de diversos critérios, e levando em conta o sistema de valores dos decisores, se constituiu em um diferencial capaz de conferir maior legitimidade ao processo de tomada de decisões sobre o planejamento de recursos hídricos de bacias hidrográficas.

Emprego de uma metodologia multicritério na avaliação do estudo de impacto ambiental de hidrelétricas

Esta pesquisa parte da constatação expressa na literatura analisada de que os métodos e técnicas utilizados na elaboração do Estudo de Impacto Ambiental - EIA de empreendimentos hidrelétricos têm se mostrado inadequados para apoiar o complexo processo de tomada de decisão, tanto no âmbito das empresas de consultoria, que elaboram o Estudo, como no dos órgãos ambientais, que analisam o EIA. Para investigar e confirmar esta questão, foram analisados a legislação vigente, Termos de Referência para a elaboração de EIAs e nove EIAs de hidrelétricas. Dentre eles, foram selecionados dois para estudo de caso. Constatou-se que são necessários três processos de avaliação na elaboração do EIA: dos impactos, das medidas mitigadoras e dos programas. Na avaliação de impactos, a técnica mais utilizada é a Matriz de Leopold, aplicada de forma correta em apenas um dos EIAs. Tornou-se evidente que os pontos fracos dessa avaliação podem ser reduzidos e até eliminados desde que o órgão ambiental melhore algumas exigências no Termo de Referência, de tal forma que levem a consultora a utilizar a referida técnica de forma correta ou a adotar um método ou técnica mais adequada. As avaliações das medidas mitigadoras e dos programas não são realizadas, invariavelmente. As razões para esta situação podem ser atribuídas tanto aos órgãos ambientais como às empresas de consultoria. Os primeiros, porque nem sempre elaboram o Termo de Referência integralmente de acordo com a Resolução CONAMA nº 001/86, deixando de especificar que as avaliações devem ser realizadas com métodos e técnicas válidos e confiáveis. Os segundos, porque não tomam a iniciativa de atender à legislação vigente, independente das instruções expressas no Termo de Referência. Essas avaliações constituemse nos pontos fracos mais relevantes a serem melhorados por órgãos ambientais e consultores. Ao considerar a avaliação dos programas ambientais como a problemática prioritária, a pesquisa investiga e reconhece que as metodologias multicritério, em especial as de apoio à tomada de decisão, pertencentes ao grupo Multicriteria Decision Aid - MCDA, apresentam grande potencialidade para a solução da problemática detectada. A escolha recaiu sobre a abordagem proposta por Ensslin, Montibeller Neto e Noronha (2001), que foi adaptada e submetida a um teste para investigar a sua validade e exeqüibilidade na avaliação dos programas do EIA de duas hidrelétricas no rio Ijuí – RS. Para isso, foram envolvidos quatro especialistas da empresa consultora que elaborou o EIA, para atuarem como avaliadores. Os resultados foram submetidos à apreciação dos próprios avaliadores, de técnicos do órgão ambiental estadual e de técnicos do órgão ambiental federal, que se manifestaram favoráveis à metodologia, em sua maioria.

Employing the Components of the Human Development Index to Drive Resources to Educational Policies

A new form of composition of the indicators employed to generate the United Nations Human Development Index (HDI) is presented here. This form of composition is based on the assumption that random errors affect the measurement of each indicator. This assumption allows for replacing the vector of evaluations according to each indicator by vectors of probabilities of being the best or the worst according to such attribute. The probabilistic composition of such probabilities of preference according to each indicator into probabilities of being the best or the worst according to all of them generates indices that may unveil, on one hand, performances to be followed and, on the other hand, extreme conditions that an additive composition would hide. Differences between the results of application of the diverse forms of composition are examined in the case of the HDI and in the case of the districts version of the HDI employed to compare Brazilian municipalities. It is verified that the smallest correlation between the education.

Ranking de municípios para políticas públicas de educação: comparação entre avaliações multicritério a partir do IDH

Neste artigo se desenvolvem alternativas de abordagem multicritério visando à seleção de municípios para a implementação de políticas públicas de educação. Considerando que a situação da educação no Brasil apresenta grande variabilidade, o que impacta as demandas educacionais por políticas públicas de educação de forma diferente em diferentes regiões, verifica-se a necessidade de critérios objetivos para a seleção de pontos de aplicação de recursos para o combate a desigualdades nessa área. Em particular, se discute o emprego do Índice de Desenvolvimento Humano como fundamento para decisões na área educacional. Além disso, visa-se a estabelecer condições para a comparação dessas situações segundo diferentes critérios utilizados para fundamentar políticas públicas de educação.

Modelagem da decisão por pacotes de viagem: um estudo usando processo de hierarquia analítica AHP

The objective of this dissertation is to propose a Multi Criteria Decision Aid Model to be used by the costumers of the travel agencies and help them to choose the best package travel. The main objective is to contribute for the simplification of the travel package decision choice from the identification of the models of values and preference of the customers and applying them to the existing package. It is used the Analytic Hierarchy Process (AHP) method to structuralize a decision hierarchic model composed by six criteria (package cost, hotel category, security of the city, travel time, direct flight and position in ranking of the 10 most visited destination) and five real alternatives of packages for a holiday of three days created from travel agency data. The decision analysis was realized for the choice of a travel package by a group composed by two couples that regularly travels together, to which was asked to do a pairwise judgment of the criteria and the alternatives. The mains results show that, although been a group that travels together, there are different models of values in the weights of the criteria and a certain convergence in the scales of preferences of the alternatives in the criteria. It was not pointed a dominant alternative for all the members of the group separately, but an analysis of a total utility of the group shows a classification and an order of the travel packages and an alternative clearly in front of the others. The sensitivity analysis revels that there are changes in the ranking, but the two alternatives best classified in the normal analysis are the same ones in the sensitivity analysis, although with the positions changed. The analysis also led to a simplification of the process with the exclusion of alternatives dominated for the others ones. As main conclusion, it is evaluated that the model and method suggested allow a simplification of the decision process in the choice of travel packages

Modelagem de decisão na seleção de equipamento: um estudo usando o processo analítico hierárquico na contratação de sondas de perfuração de poços de petróleo

The main goal of this dissertation is to develop a Multi Criteria Decision Aid Model to be used in Oils and Gas perforation rigs contracts choices. The developed model should permit the utilization of multiples criterions, covering problems that exist with models that mainly use the price of the contracts as its decision criterion. The AHP has been chosen because its large utilization, not only academic, but in many other areas, its simplicity of use and flexibility, and also fill all the requirements necessary to complete the task. The development of the model was conducted by interviews and surveys with one specialist in this specific area, who also acts as the main actor on the decision process. The final model consists in six criterions: Costs, mobility, automation, technical support, how fast the service could be concluded and availability to start the operations. Three rigs were chosen as possible solutions for the problem. The results reached by the utilizations of the model suggests that the utilization of AHP as a decision support system in this kind of situation is possible, allowing a simplifications of the problem, and also it s a useful tool to improve every one involved on the process s knowledge about the problem subject, and its possible solutions

Modelo de previsão de priorização de peça de reposição

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Aplicação de métodos com múltiplos critérios em uma empresa petroquímica

The corporate world is increasingly competitive, and companies need to go deep into the routines and work them in order to understand them fully. The market is demanding more than simple improvements that bring advances - of small or great expression; however, in a longer term it will no longer meet the ideology of the market. Companies aimed at the world class must focus on projects that will continually bring returns to the company. As previously mentioned, understanding the processes in minute details is of paramount importance, as this knowledge can be acquired by analyzing the decisions that are necessary during the process. Once the complexity increases, the quantity and difficulty of the criteria that influence them grow accordingly. At this time, methods and tools that assist decisionmaking processes can be used as, besides being able to provide the best decision methods of MCDA (Multiple Criteria Decision Aid), they provide clear and assertive understanding of the whole decision process. In developing this study, we sought to explore the AHP (Analytic Hierarchy Process) method (a MCDA method) in the choice of access service, featured by the support service used to reach and be the basis of repairs in places of difficult access. This work proposes a study of the quantitative modeling approach in a real routine activity for a Brazilian petrochemical company. Decision-making processes are explored when we seek to analyze not only the decision makers but also what directly influences them on the use of the AIJ method. Once this is achieved, the understanding of decision-making is substantiated

Aplicação de métodos com múltiplos critérios em uma empresa petroquímica

The corporate world is increasingly competitive, and companies need to go deep into the routines and work them in order to understand them fully. The market is demanding more than simple improvements that bring advances - of small or great expression; however, in a longer term it will no longer meet the ideology of the market. Companies aimed at the world class must focus on projects that will continually bring returns to the company. As previously mentioned, understanding the processes in minute details is of paramount importance, as this knowledge can be acquired by analyzing the decisions that are necessary during the process. Once the complexity increases, the quantity and difficulty of the criteria that influence them grow accordingly. At this time, methods and tools that assist decisionmaking processes can be used as, besides being able to provide the best decision methods of MCDA (Multiple Criteria Decision Aid), they provide clear and assertive understanding of the whole decision process. In developing this study, we sought to explore the AHP (Analytic Hierarchy Process) method (a MCDA method) in the choice of access service, featured by the support service used to reach and be the basis of repairs in places of difficult access. This work proposes a study of the quantitative modeling approach in a real routine activity for a Brazilian petrochemical company. Decision-making processes are explored when we seek to analyze not only the decision makers but also what directly influences them on the use of the AIJ method. Once this is achieved, the understanding of decision-making is substantiated

Validación de sistemas constructivos de los cerramientos de la edificación mediante la aplicación de los métodos de decisión multicriterio : aplicación al catálogo de elementos constructivos del Código Técnico de la Edificación

Como punto de partida para el desarrollo de la Tesis, se mantiene la hipótesis de que es posible establecer métodos de evaluación global sobre el grado de utilidad de los sistemas constructivos correspondientes a los cerramientos de la edificación. Tales métodos habrían de posibilitar, de entre una serie finita de sistemas alternativos, cuáles de ellos son los objetivamente más adecuados para su selección en un entorno de decisión concreto, y habrían de permitir fundamentar la justificación objetiva de tal decisión. Paralelamente a esta hipótesis de carácter general, se planteó desde el inicio la necesidad de comprobación de una hipótesis de partida particular según la cual los sistemas constructivos basados en la utilización de componentes prefabricados, o procesos de puesta en obra con un alto grado de industrialización arrojarían valores de utilidad mayores que los sistemas tradicionales basados en la albañilería. Para la verificación de estas dos hipótesis de partida se ha procedido inicialmente a la selección de un conjunto coherente de doce sistemas de cerramientos de la edificación que pudiese servir como testigo de su diversidad potencial, para proceder a su valoración comparativa. El método de valoración propuesto ha entrado a considerar una serie de factores de diversa índole que no son reducibles a un único parámetro o magnitud que permitiese una valoración de tipo lineal sobre su idoneidad relativa, ni que permitiese establecer un grado de prelación entre los distintos sistemas constructivos alternativos de manera absoluta. Para resolver este tour de force o desafío metodológico se ha acudido a la aplicación de metodologías de valoración que nos permitiesen establecer de forma racional dicha comparativa. Nos referimos a una serie de metodologías provenientes en primera instancia de las ciencias exactas, que reciben la denominación de métodos de ayuda a la decisión multicriterio, y en concreto el denominado método ELECTRE. Inicialmente, se ha planteado la aplicación del método de análisis sobre doce sistemas constructivos seleccionados de tal forma que representasen de forma adecuada las tres categorías establecidas para caracterizar la totalidad de sistemas constructivos posibles; por peso, grado de prefabricación y grado de ventilación. Si bien la combinación de las tres categorías básicas anteriormente señaladas produce un total de 18 subcategorías conceptuales, tomamos finalmente doce subcategorías dado que consideramos que es un número operativo suficiente por extenso para el análisis propuesto y elimina tipos no relevantes. Aplicado el método propuesto, a estos doce sistemas constructivos “testigo”, se constata el mayor grado de utilidad de los sistemas prefabricados, pesados y no ventilados. Al hilo del análisis realizado en la Parte II de la Tesis sobre los doce sistemas constructivos “testigo”, se ha realizado un volcado de los sistemas constructivos incluidos en el Catalogo de Elementos Constructivos del CTE (versión 2010) sobre las dieciocho subcategorías definidas en dicha Parte II para caracterizar los sistemas constructivos “testigo”. Posteriormente, se ha procedido a una parametrización de la totalidad de sistemas constructivos para cerramientos de fachadas incluidos en este Catálogo. La parametrización sistemática realizada ha permitido establecer, mediante el cálculo del valor medio que adoptan los parámetros de los sistemas pertenecientes a una misma familia de las establecidas por el Catálogo, una caracterización comparativa del grado de utilidad de dichas familias, tanto en lo relativo a cada uno de los parámetros como en una valoración global de sus valores, de carácter indicativo. Una vez realizada una parametrización completa de la totalidad de sistemas constructivos incluidos en el Catálogo, se ha realizado una simulación de aplicación de la metodología de validación desarrollada en la Parte II de la presente Tesis, con el objeto de comprobar su adecuación al caso. En conclusión, el desarrollo de una herramienta de apoyo a la decisión multicriterio aplicada al Catálogo de Elementos constructivos del CTE se ha demostrado técnicamente viable y arroja resultados significativos. Se han diseñado dos sistemas constructivos mediante la aplicación de la herramienta desarrollada, uno de fachada no ventilada y otro de fachada ventilada. Comparados estos dos sistemas constructivos mejorados con otros sistemas constructivos analizados Se comprueba el alto grado de utilidad objetiva de los dos sistemas diseñados en relación con el resto. La realización de este ejercicio de diseño de un sistema constructivo específico, que responde a los requerimientos de un decisor concreto viene a demostrar, así pues, la utilidad del algoritmo propuesto en su aplicación a los procesos de diseño de los sistemas constructivos. La tesis incorpora dos innovaciones metodológicas y tres innovaciones instrumentales. ABSTRACT The starting point for the thesis is the hypothesis that it is possible to devise suitability degree evaluation methods of building enclosure systems. Such methods should allow optimizing appraisal, given a specific domain of decision, among a finite number of alternative systems, and provide objective justification of such decision. Along with the above mentioned general assumption, a second hypothesis whereby constructive systems based on the use of prefabricated components, or high industrialization degree work processes, would throw efficiency values higher than traditional masonry systems needed to be tested. In order to validate these two hypothesis a coherent set of twelve enclosure systems that could serve as a reference sample of their potential diversity was selected and a comparative evaluation was carried out. The valuation method proposed has considered several different factors that are neither reducible to a single parameter or magnitude that would allow a linear evaluation of their relative suitability nor allow to establishing an absolute priority ranking between different alternative constructive systems. In order to resolve this tour de force or methodological challenge, valuation methodologies that enable use establishing rational assessments were used. We are referring to a number of methodologies taken from the exact sciences field, usually known as aid methods for multi-criteria decision, in particular the so-called ELECTRE method. Even though the combination of the mentioned three basic categories result in eighteen conceptual sub categories, we are finally considering just twelve since we deem it adequately extended for the our intended purpose and eliminates non relevant instances. The method of analysis was initially applied to the set of twelve selected constructive systems is a way that they could represent adequately the three previously established categories set out to characterize all possible enclosure systems, namely weight, prefabrication degree and ventilation degree. Once the proposed method is applied to the sample systems, the higher efficiency of the prefabricated, heavy and not ventilated systems was confirmed. In line with the analysis in Part II of the thesis on the twelve chosen enclosure systems, it has done an uploading data of construction systems listed in the Catalogue of constructive elements of the CTE (version 2010) according the eighteen subcategories used in this part II to characterize the construction systems taken as sample. Subsequently, a parameterization of all enclosure facade systems included in this catalog has been undertaken. The systematic parameterization has allowed to set, by means of calculating the average values of the parameters of the systems belonging to the same family of those established by the Catalog, a comparative characterization of the efficiency degree of these families, both in relation to each parameter as to an overall evaluation of its values, in a indicative way. After the parameterization of all enclosure systems included in the Catalog, a simulation of validation methodology application developed in Part II of this Thesis has been made, in order to assess its consistency to the referred case. In conclusion, the development of a multi-criteria decision aid tool, applied to the CTE Catalog of constructive elements, has proved to be technically feasible and yields significant results. Two building systems through the application of the developed tool, a non-ventilated façade and a ventilated façade have been designed. Comparing these two improved construction systems with other building systems analyzed, we were able to assess the high degree of objective efficiency of the two systems designed in relation to the rest. The exercise of designing a specific enclosure system that meets the requirements of a particular decision-maker hence shows the suitability of the proposed algorithm applied to the process of enclosure systems design. This Thesis includes two methodological innovations and three instrumental innovations.

A prospective study of the use of alternative therapies by men with localized prostate cancer

Although the use of alternative therapies is highly prevalent amongst men with prostate cancer, research about the predictors of such use is limited. The current study aimed to describe prospectively the use of alternative therapies by men diagnosed with localized prostate cancer and identify predictors of alternative therapy use. In all, 111 men newly diagnosed with localized prostate cancer (93% response) were recruited to the study prior to treatment. Men's use of alternative therapies and psychological variables including: psychological distress, orientation to health care, decisional conflict, and health locus of control, were assessed at three time points-(1) before treatment; (2) 2 months after completion of treatment; and (3) 12 months after completion of treatment. Demographic information was also obtained. The percentage of men using alternative therapies was 25, 17 and 14% before treatment, 2 and 12 months after treatment, respectively. In general, the most commonly used therapies were dietary changes, vitamins and herbal and nutrient remedies. Alternative therapy use was not related to final treatment choices. Before treatment, men who used alternative therapies were more uncertain about prostate cancer compared to men who were not using these therapies. Men who were using alternative therapies 12 months after treatment were less psychologically distressed that men who were not using these therapies. Health locus of control and orientation to health care were not found to be related to men's use of alternative therapies. In conclusion, men's use of alternative therapies after localized prostate cancer varied across time in terms of the incidence of use, the types of therapies used, and the psychological correlates of therapy use. Informational support that targets uncertainty about prostate cancer may assist men at diagnosis who are considering alternative therapy use. The potential for alternative therapies to have a supportive function in patient care requires further investigation. (C) 2003 Elsevier Ireland Ltd. All rights reserved.

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

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. Objectives To evaluate the effects on TTR of educational and behavioural interventions for oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF). Search 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. Selection criteria 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. Data collection and analysis 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. Main 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). Authors' 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.

Development and trialling of a behavioural intervention for patients with atrial fibrillation initiating oral anticoagulation:the 'treat' study

Purpose: Atrial fibrillation (AF) is the most common heart arrhythmia and is associated with an increased risk of stroke. Stroke risk is commonly treated with oral anticoagulation (OAC) with a narrow therapeutic range (INR 2.0 to 3.0); which is poorly controlled in practice. Barriers to adherence include poor knowledge, and inaccurate perceptions surrounding illness and medications. Trial registration: ISRCTN93952605. Systematic review: Seven trials of educational, self-monitoring and decision aid interventions were included in a systematic review. Pooled analysis suggested education OR, 95% CI 7.89 (5.54-10.24) and self monitoring OR (95% CI) 5.47(2.55-8.39) significantly improve TTR; whereas decision aids are no more effective in reducing decision conflict than usual care, OR (95% CI) -0.10 (-0.17 to -0.02). Intervention development: The intervention was theoretically-driven (utilising the common sense and beliefs about medication models) and developed with expert patient feedback. Described using behavioural change techniques, the one-off group session included an educational booklet, ‘expert-patient’ focussed DVD, and worksheet. Methods: Ninety seven warfarin-naïve AF patients were randomised to receive the intervention (n=43), or usual care (n=54). The primary endpoint was time within therapeutic range (TTR), secondary endpoints included knowledge, quality of life (AF-QoL-18), beliefs about medication (BMQ), illness perceptions (IPQ-B), and anxiety and depression (HADS). Results: Intervention group had significantly higher TTR than usual care (78.5% vs. 66.7%; p=0.01). Knowledge changed significantly across time (F (3, 47) = 6.4; p<0.01), but not between groups (F (1, 47) = 3.3; p = 0.07). At six months knowledge predicted TTR (r=0.245; p=0.04). Illness concern negatively correlated with TTR (r= - 0.199; p=0.05). General Harm scores at one month predicted TTR (F (1, 72) = 4.08; p=0.048). There were significant differences in emotional representations (F (3, 49) = 3.3 (3, 49); p= 0.03), anxiety (F (3, 46) = 25.2; p<0.01) and depression (F (3, 46) = 37.7; p<0.01) across time. Conclusion: A theory-driven educational intervention can improve TTR in AF patients and potentially reduce the risk of adverse clinical outcomes. Improving education provision for AF patients is essential to ensure efficacious treatment.

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

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. Objectives To evaluate the effects on TTR of educational and behavioural interventions for oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF). Search 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. Selection criteria 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. Data collection and analysis 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. Main 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). Authors' 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.