Gary Tataronis

Dietary vitamin K variability affects international normalized ratio (INR) coagulation indices

BACKGROUND Changes in daily vitamin K intake may contribute to marked variations in the International Normalized Ratio (INR) coagulation index in patients receiving oral warfarin anticoagulant therapy, with potentially serious adverse outcomes. Thus, patients receiving warfarin therapy are routinely counseled regarding this drug-nutrient interaction and are instructed to maintain consistent vitamin K intakes, though little quantitative information about this relationship is available. OBJECTIVE To determine the quantitative impact of variability in dietary vitamin K(1) (phylloquinone) intake, assessed by a validated patient self-monitoring instrument, on weekly INR in patients receiving warfarin anticoagulant therapy. METHODS A prospective dietary assessment study was conducted at the Massachusetts General Hospital in Boston. Sixty outpatients (37 males and 23 females) were selected with a mean age 60.3 +/- 16.8 years, who began oral warfarin anticoagulant therapy within 14 days prior to their first clinic visit to an outpatient anticoagulation therapy unit. Exclusion criteria included more than 2 drinks of alcohol per day, inability to speak English, and concurrent disease states affecting warfarin therapy such as liver disease and terminal illness. Over the five-week study period, participants recorded daily intakes in specified amounts of all food items appearing on a validated dietary self-assessment tool. Concomitant use of prescription and/or non-prescription medications was also obtained. Concurrent daily warfarin dose and adherence to the drug regimen, concomitant use of prescription and/or non-prescription medications known to interact with warfarin, and weekly INR were obtained. Week-to-week changes in vitamin K intake, warfarin dose, and INR were determined and cross-correlated. RESULTS Forty-three patients (28 males and 15 females) completed the study and 17 dropped out. Pearsons correlation coefficient revealed the variability in INR and changes in vitamin K intake were inversely correlated (r = -0.600, p < 0.01). Multiple regression analysis (r = 0.848) indicated that a weekly change of 714 mug dietary vitamin K significantly altered weekly INR by 1 unit (p < 0.01) and a weekly change of 14.5 mg warfarin significantly altered weekly INR by 1 unit (p < 0.01) after adjustment for age, sex, weight, height, and concomitant use of medications known to interact with warfarin. CONCLUSIONS Patients taking warfarin and consuming markedly changing amounts of vitamin K may have a variable weekly INR with potentially unstable anticoagulant outcomes.

Assessment of Healthcare professionals' knowledge about warfarin-vitamin K drug-nutrient interactions

Objective: Dietary vitamin K can interact with oral anticoagulant drugs and interfere with their therapeutic safety and efficacy. Therefore, knowledge about drug-nutrient interactions involving vitamin K possessed by physicians, pharmacists, dietitians and nurses practicing anticoagulant therapy was assessed. Methods: Healthcare practitioners were surveyed using a 30-question, 98-item questionnaire on the most common and/or important food interactions with warfarin, drug interactions with warfarin and general drug-nutrient interactions involving vitamin K. The study sample included 160 randomly selected healthcare providers (40 physicians, pharmacists, dietitians and nurses) from 10 hospitals with 200 to 1000 beds from six Massachusetts regions. Random selection was conducted from a pool of selected healthcare providers practicing anticoagulant therapy who counsel patients receiving warfarin. Results: All surveys were completed within three months of the start of the study, and all participants provided usable data for statistical analysis. The mean scores (±SD) on the overall test were 72.5±9.0 for pharmacists, 62.5±10.6 for physicians, 56.9±8.8 for dietitians and 50.2±9.3 for nurses, with 100 being a perfect score. Pharmacists scored significantly higher in the area of drug interactions (75.9±11.3, p<0.05). Dietitians scored higher in the area of food interactions (73.0±10.3). No significant differences between physicians and pharmacists were evident on general drug-nutrient interactions. While over 87% of the healthcare professionals correctly identified some common foods containing large amounts of vitamin K, such as broccoli and spinach, fewer than 25% were able to identify others such as pea soup, coleslaw and dill pickles. Conclusions: Although the healthcare professionals surveyed in this study appear to have demonstrated some proficiency in their respective areas of expertise, they exhibited less knowledge in others. Therefore, additional training and integration of knowledge and expertise about drug-nutrient interactions among healthcare professionals are essential to provide appropriate patient counseling and optimal therapeutic outcomes.

Development of a Self-Assessment Instrument to Determine Daily Intake and Variability of Dietary Vitamin K

Objective: To develop and validate a brief, self-assessment instrument (K-Card) to determine daily variations in dietary vitamin K1 (phylloquinone) intake for use in patients receiving oral warfarin anticoagulant therapy. Methods: The K-Card was designed to include a checklist of selected common foods and beverages providing ≥ 5 μg vitamin K per serving in American diets and items with lower vitamin K content typically consumed in quantities which contribute significantly to total vitamin K intake. The K-Card was validated against records of weighed food intake from thirty-six healthy volunteers, 20 to 40 and 60 to 80 years of age, whose phylloquinone intakes and plasma concentrations had been previously measured by the Metabolic Research Unit, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA USA. Future use of the K-Card by patients was simulated by a single investigator using 108 one-day weighed food records to estimate phylloquinone intakes. Dietary phylloquinone calculated from the K-Card was compared to the values of phylloquinone intake from the diet records collected on the same days, and to fasting plasma phylloquinone concentrations obtained from the same individuals on the following day. Results: The mean dietary phylloquinone intake (± SEM) was 138.8 ± 15.7 μg for the K-Cards compared to 136.0 ± 15.8 μg for the diet records (p = 0.067). Bland-Altman limits of agreement between quantities of dietary phylloquinone calculated from the K-Card and values obtained from the weighed food records were ± 38 μg. Conclusion: In this simulation, the K-Card provided an accurate estimate of dietary phylloquinone intake and therefore deserves further testing for use by patients receiving coumarin-based anticoagulant therapy to determine whether variability in dietary patterns contributes to disruptions in anticoagulant drug efficacy and safety.

Students’ Attitudes, Academic Performance and Preferences for Content Delivery in a Very Large Self-Care Course Redesign

Objective. To evaluate students’ performance/attitudes toward a flipped team-based learning (TBL) format in a “very large” self-care course based on student content delivery preference. Design. Third-year students enrolled in the course were surveyed regarding elements of redesign and homework completion. Additionally, their performance and incoming grade point average were evaluated. Assessment. A survey was completed by 286 of 305 students. Nineteen percent of respondents preferred traditional content delivery, whereas 30% preferred flipped TBL, 48% preferred a mixed format, and 3% had no preference. The grades achieved in the course were: A (49%), B (48%), C (3%) and D (0%). The majority completed “all” or “most” of the homework, appreciated attributes of course redesign, felt home preparation and in-class activities engaged them, and reported improved communication/evaluation skills. Content delivery preference significantly affected attitudes. Conclusion. Students positively received a flipped team-based learning classroom format, especially those who preferred flipped TBL or mixed content delivery. A minority with preference for traditional teaching style did not enjoy the new format; however, their academic performance did not differ significantly from those who did.

Comparison of long-term knowledge retention in lecture-based versus flipped team-based learning course delivery

OBJECTIVES To determine whether team based learning (TBL) is superior to traditional lecture -based learning in confidence and knowledge retention one year later. DESIGN A survey was administered 17 months after a completion of a required over-the-counter /self-care (OTC) course to two different cohorts of students. The survey assessed confidence and knowledge related to OTC topics. The lecture group had a traditional lecture based classroom experience; the intervention group experienced a TBL format throughout the entire course. ASSESSMENT One hundred forty-seven students of 283 enrolled (51.9%) in the lecture group and 222 of 305 (72.8%) students in the TBL group participated in the knowledge assessment and survey. Demographic data including student grade point averages (GPA) and confidence were similar in both groups. Mean assessment scores (±SD) on OTC knowledge was significantly higher in the traditional lecture based group versus the TBL group; 62.9±19.3 vs. 54.9±15.7 (p=0.001). CONCLUSION Although TBL is thought to improve student engagement and mastery of material, after an initial implementation of TBL, knowledge retention in the long term appears to be lower than lecture based learning.

Hospital reimbursement for adult Patients with severe sepsis treated with drotrecogin alfa (activated)

Purpose Patients with severe sepsis are critically ill and use a high level of health care resources. The high resource utilization and lack of a specific diagnosis related group may lead to a significant loss in revenue for health care organizations secondary to inadequate reimbursement. The primary objective of this study is to quantify the difference in total cost and reimbursement in patients with severe sepsis treated with drotrecogin alfa (activated) (DAA) at our institution. Methods All patients between December 2001 and December 2003 diagnosed with severe sepsis and treated with DAA were evaluated. Demographic data, primary payer, diagnosis related group, hospital length of stay, length of medical/surgical stay, length of Intensive Care Unit stay, days on mechanical ventilation, total costs, and total reimbursement were determined by chart review and our institutions information systems. Results Data from a total of 71 patients were included. The total treatment cost was

The Impact of an Urban Telepharmacy on Patient Medication Adherence in a Federally Qualified Health Center

6,294,590, and the total reimbursement received was

Statin-Related Adverse Events: A Meta-Analysis

4,295,950. This represents a loss of

Impact of a pharmacist on drug costs in a coronary care unit.

1,998,640 or

Pharmacist Assisted Medication Program Enhancing the Regulation of Diabetes (PAMPERED) study

28,150 per patient. The primary factor contributing to this loss was Intensive Care Unit length of stay (P = 0.011). Conclusion Management of patients with severe sepsis is costly and strains hospital resources. The current reimbursement system does not allow for appropriate compensation. Therefore, in addition to efforts directed toward improved treatment strategies for severe sepsis, health care practitioners must target interventions to reduce hospital length of stay and maximize reimbursement.