1. Prepared for: The National Consumers League September 21, 2005 J23715 The Use of Oral Anticoagulant Medications PRESENTATION: Key Findings from Surveys of Patients, Caregivers, and Physicians

2. 2Background The National Consumers League (NCL), on behalf of the SOS Rx Coalition (The Coalition), is working on an outpatient medication safety campaign aimed at consumers, caregivers, and physicians. The initial focus of this campaign is on oral anticoagulant drugs. –Oral anticoagulants, or blood thinners, are highly effective at preventing blood clots and are used for numerous indications, including stroke and coronary event prevention. –Despite their benefit, these agents are known to be relatively difficult to manage, require frequent monitoring, and may be associated with a large number of potential interactions with other medications or food. –The SOS Rx Coalition would like to further explore these potential issues among patients, caregivers, and physicians in order to help design outreach and educational campaigns to help consumers and providers better manage this drug. Harris Interactive was commissioned to conduct a survey exploring use of and experiences with oral anticoagulants.

3. 3Objectives –Gain insight into the experiences of patients who are taking oral anticoagulants particularly issues around managing their medication regimen, adherence to recommendations, relationships and communications with their doctors, and sources used for information to help manage their regimen. –Gain insight into the experiences of caregivers who assist in the management of patients’ anticoagulant regimen. –Gain insight into the physician’s point of view on issues around the use and management of oral anticoagulant medication. –Identify opportunities for improving education and communication about oral anticoagulant treatment, which could improve patient compliance, safety, and outcomes.

4. 4Methodology Harris Interactive conducted surveys with patients, caregivers, and physicians about the use of oral anticoagulants. All three surveys were conducted online within the United States. Patients –A total of 426 patients were interviewed. –Patients were sampled from the Harris Interactive Chronic Illness Panel. –Eligible respondents have been taking an oral anticoagulant medication for at least 3 months and are at least 30 years of age. –Interviews conducted between April 4 -15, 2005. Caregivers –A total of 109 caregivers were interviewed. –Caregivers were sampled from the Harris Interactive Panel, prescreened as being the caregiver of someone who is chronically ill. –Eligible caregivers are taking care of a person who has been on an oral anticoagulant medication for at least 3 months and is at least 30 years of age. Further, caregivers must assist the patient in at least 2 out of 11 care- giving tasks around anticoagulant use. –Interviews conducted between May 19 - 26, 2005.

5. 5 Methodology, continued Physicians –A total of 101 physicians were interviewed. –Physicians were sampled from the Harris Interactive Physician Panel. –Eligible respondents are primary care providers (specializing in family practice, internal medicine or general medicine) and cardiovascular specialists, practicing for at least 5 years, spending at least 70% of their time in direct patient care and treating 5 or more patients who are on an oral anticoagulant medication. –Interviews conducted between August 11 - 18, 2005. –Eligible respondents received a $50 honorarium for completing the survey.

6. 6 Summary of Key Findings

7. 7 Summary of Key Findings: Patients 1.People on oral anticoagulants face complex health problems and have considerable health management needs. 2.Almost all patients on oral anticoagulants also take other prescription drugs and many take over-the-counter (OTC) drugs and vitamins/supplements. 3.According to patients, physicians are overall doing a good job educating new oral anticoagulant users, but there are gaps in education about dietary considerations, drug interactions, and possible side effects. 4.There are gaps in the management of the health care of patients on oral anticoagulants. 5.There is room for improvement in the relationship between oral anticoagulant users and their physicians. Continued >

8. 8 Summary of Key Findings: Patients, continued 6.Communication about blood test goals should be improved. 7.Patients are fairly knowledgeable about the things they should and should not do when taking an oral anticoagulant. However, actual behavior could be improved upon. 8.Patients have some difficulties and concerns about being on an oral anticoagulant. 9.Adverse reactions to oral anticoagulants are common. Many do not change their behavior or seek help. 10.Patients could use more assistance with management of their oral anticoagulant use. Such assistance is associated with improved awareness, behavior, and confidence around the management of oral anticoagulant use. 11.Doctors are the most used, perceived as being the most useful, and most trusted source of information about what patients should and should not do when taking an oral anticoagulant.

9. 9 Summary of Key Findings: Caregivers 1.Caregivers are assisting oral anticoagulant users who have considerable health management needs. 2.Caregivers are highly involved in helping their family members manage their oral anticoagulant regimen. 3.Caregivers are generally aware of the complexity of oral anticoagulant medication, knowledge of precautions could be improved. 4.Caregivers could use more assistance in helping their family members with management of their anticoagulant regimen. 5.Nearly one in four caregivers is less than very confident that their family members are taking the anticoagulant correctly; Family members need encouragement to follow recommendations for safe use of medication.

10. 10 Summary of Key Findings: Caregivers, continued 6.A small but troubling minority of caregivers report that their family members experienced adverse reactions to anticoagulant medications that led to an ER visit and/or hospital stay. 7.Caregivers rate physicians highly on their responsiveness to patients; However there is room for improvement in explanations of precautions both to caregivers and family members. 8.Doctors are the most used source of information on the dos and don’ts of managing and anticoagulant regimen.

11. 11 Summary of Key Findings: Physicians 1.Managing patients on anticoagulant medication is a challenge for physicians. 2.Most physicians feel that the effort to manage multiple conditions and medications is the main reason why oral anticoagulant patients experience difficulties with their regimen. 3.There is room for improvement in communication by physicians about oral anticoagulant regimen requirements and blood test results. 4.Physicians could be doing more to help their patients with ongoing management of their oral anticoagulant regimen. 5.Improving blood testing, communication, and involvement with health care professionals are seen as key components in helping patients comply with their oral anticoagulant regimen.

12. 12 Executive Summary

13. 13 Three Key Themes Across Groups 1.Oral anticoagulant use presents a challenge to patients, caregivers, and physicians. 2.There are gaps in education around oral anticoagulant use, both for patients and caregivers. 3.There are gaps in the health care management of oral anticoagulant patients.

14. 14 Key Theme #1 Oral anticoagulant use presents a challenge to patients, caregivers and physicians.

15. 15 Patients on oral anticoagulant medications have complicated health needs, use numerous medications, and see multiple doctors. 3 in 5 suffer poor or fair health Most suffer four or more conditions Almost all take multiple medications, and many take OTCs Almost all see multiple doctors, with 2 in 5 seeing 4 or more doctors Half of patients have been hospitalized or have gone to the ER past 12 months Generally, caregivers report even greater health management challenges among their family members Most caregivers care for someone memory impairment

16. 16 3 in 5 oral anticoagulant users suffer poor or fair health. Q310In general, how would you describe your own health? Base: Qualified respondents (n=426) 59% How would you describe your own health? Caregiver response in contrast: Fair/Poor: 69%

17. 17 More than half of oral anticoagulant users suffer four or more of these conditions. Q335Have you been told by a doctor that you have...? Base: Qualified respondents (n= 426) * Less than 1 percent Diagnosed with: % Any of these conditions 92 Four or more of these conditions 54 Hypertension, sometimes called high blood pressure 66 Heart disease, including heart attack 60 Atrial Fibrillation also known as “Afib” 51 Arthritis 47 Stroke or stroke-like symptoms 38 Diabetes 35 Depression 23 Blood clot, thromboembolism or pulmonary embolism 22 Heart valve replacement 20 Asthma, Emphysema, or any other chronic lung problems 19 A high red blood cell count (polycythemia) 2 Sickle cell anemia * In contrast: Caregivers reporting that their family member suffers from four or more of these conditions 43

18. 18 Most oral anticoagulant patients are taking multiple prescription medications and OTCs. Q500Including your blood thinning medication, how many different prescription medications do you take on a regular or ongoing basis? Q507In addition to anticoagulant, are you also taking Plavix on a regular basis? Q510Are you taking any over-the-counter medications such as aspirin, Motrin, Tylenol, Tagamet, or Zantac, on a regular or ongoing basis? Q512Are you taking any vitamins or supplements, such as ginkgo, ginseng or St. John’s Wort, on a regular or ongoing basis? Q508Are you taking aspirin as a blood thinning medication? Base: Qualified respondents (n=426) Rx and OTC Use: % Number of prescription medications taken on regular basis: 1 (anticoagulant only) 2 2-4 23 5-7 35 8 or more 38 Mean number of Rx: 7 Currently taking Plavix on a regular basis 6 Currently taking aspirin as a blood thinner 37 Currently taking any OTCs on regular basis (not including aspirin) 27 Currently taking vitamins or supplements on a regular basis 46

19. 19 Oral anticoagulant users see multiple doctors, in addition to their regular doctor. Q410In addition to your regular doctor, how many other doctors, including specialists, have you seen in the past year? Base: Qualified respondents (n= 426) In the past year, number of doctors seen in addition to regular doctor; 41% Caregiver responses in contrast: 65% of their family members see for 4 or more doctors

20. 20 Most caregivers are caring for someone with memory impairment. 68% Q820 Does your family member suffer from memory impairment? If so, how severe is this impairment? Base: Qualified respondents (n=109)

21. 21 Following the oral anticoagulant treatment regimen is difficult for many. A substantial minority of patients are less than very confident that they are taking the oral anticoagulant medication correctly. 1 in 5 caregivers are less than very confident that their family member is taking the medication correctly. Assistance with following treatment recommendations is needed. 2 in 5 caregivers feel that family members need encouragement to follow recommendations. A small minority needs a great deal of encouragement (8%). Physicians report that patient non-compliance with medication regimen and recommended blood tests are the top challenges to treating anticoagulant patients. Physicians indicate that nearly half of patients are managing their anticoagulant regimen less than very well. They report that 1 in 4 patients have a difficult time following the recommendations.

22. 22 A substantial minority of patients are less than very confident that they are taking the oral anticoagulant correctly. Q645 Overall, how confident are you that you are taking the anticoagulant the correct way to ensure that the drug works at its best and does not cause any problems? Base: Qualified respondents (n=426) 17% Confidence that they are taking anticoagulant medication the correct way

23. 23 Nearly 1 in 4 caregivers are less than very confident that their family members are taking the oral anticoagulant medication correctly. Q530 Overall, how confident are you that you family member is taking his/her oral anticoagulant medication the correct way? Base: Qualified respondents (n=109) 22%

24. 24 Patients recognize the importance of safe behaviors; Compliance is more difficult. Q640As far as you know, how important is it for people who take anticoagulants to... ? Q610How often do you do the following? Base: Qualified respondents (n=426) Importance of and compliance with anticoagulant precautions

25. 25 Following an appropriate diet is difficult for many patients. Q910How easy or difficult is it for you to... ?” Base: All respondents (n=426)

26. 26 2 in 5 of caregivers feel that family members need at least some encouragement to follow instructions associated with taking the anticoagulant medication safely 40% Q520 How much encouragement does you family member need to follow all o the instructions associated with taking an oral anticoagulant medication? Base: Qualified respondents (n=109)

27. 27 Most caregivers report that their family members need at least some assistance following recommendations. 70% 67% 63% 69% 64% 59% 58% 54% 51% 60% Q510 How much assistance does your family member need to follow these recommendations related to taking his/her anticoagulant? Base: Qualified respondents (n=109)

28. 28 Physicians feel that patient non-compliance with medication regimen and recommended blood tests are the top challenges when dealing with oral anticoagulant patients. Q610 Thinking about your experiences managing patients who take oral anticoagulants, which would you say are the biggest challenges you face? Base: Qualified Respondents (n=101) Percent who indicated items as one of top 3 challenges

29. 29 Physicians report that almost half of patients are managing their anticoagulant regimen less than very well (Case Study) Q555 Overall, how well do you think this patient is managing his/her oral anticoagulant? Base: Qualified Respondents (n=101) 48% Percent of physicians indicating how well the patient is managing oral anticoagulant use:

30. 30 Physicians report that 1 in 4 patients have difficulty following recommendations (Case Study) Q560 To the best of your knowledge, how easy or difficult is it for this patient to follow all of your recommendations related to taking his/her oral anticoagulant? Base: Qualified Respondents (n=101) 26% Percent of physicians indicating how difficult it is for the patient to follow all of their recommendations:

31. 31 Adverse reactions due to oral anticoagulant use are not uncommon. Many patients do not change their behavior or seek help. Almost all patients have experienced at least one side effect to the anticoagulant medication. A troubling minority have been to the ER and/or the hospital because of problems related to their medication. Only about 2 in 5 patients contacted their doctor in response to a problem. Only about half say that they did anything to change their behavior in response to a problem. A majority of physicians report that, in the past 12 months, they have had anticoagulant patients who called or visited the office and/or went to the ER or hospital due to problems with their medication.

32. 32 Most patients have experienced adverse reactions to oral anticoagulant use. Q615How often, if at all, do you experience any of the following as a result of taking the anticoagulant? Base: All respondents (n=426) Ever experienced any of these adverse reactions as a result of taking their anticoagulant Note: Percentages shown are the sum of responses ‘always’, ‘most of the time’, ‘sometimes’, and ‘rarely’.

33. 33 A troubling minority of patients have been to the hospital or emergency room because of problems with their oral anticoagulant. Q630In the past 12 months, have you gone to the emergency room or been admitted to the hospital because of a problem related to taking the anticoagulant. Base: Qualified respondents (n=426) [NOTE: RECALCULATED TO BASE OF ALL QUALIFIED RESPONDENTS] No hospital/ER use due to anticoagulant: 92% Admitted to hospital due to anticoagulant problem: 3% Went to ER due to anticoagulant problem: 5% 8% Caregiver responses in contrast: 11% say their family member went to the ER or hospital due to anticoagulant problem

34. 34 Half of patients who experience adverse reactions do nothing to change their behavior. Q635After you have experienced side effects or other adverse reactions due to taking anticoagulant, what, if anything, are you doing differently now? Base: Qualified respondents who experienced at least 1 side effect (n=395) Change in behavior after experiencing side effects from anticoagulant use *Lifestyle changes: test regularly, changed/added medications, monitored health status, etc.

35. 35 Many patients who experience adverse reactions do not contact their doctor about the problem. Q620What did you do when you experienced side effects from taking anticoagulant? Please select all that apply. Base: Qualified respondents who experienced at least 1 side effect (n=395) Response to experiencing side effects from anticoagulant use

36. 36 Most physicians have anticoagulant patients who contact them with problems due to their anticoagulant use; Half have patients who end up in the ER or hospital. Q440 In the past 12 months, have any of your patients done any of the following because of a problem related to taking their oral anticoagulant medication? Base: Qualified respondents (n=101)

37. 37 Caregivers struggle to help manage the complex care needs of their loved ones. Many oral anticoagulant users have family members or friends assisting with their care, physicians report that more than 1 in 3 new anticoagulant patients are accompanied by a caregiver Caregivers are involved in a multitude of aspects related to their family members anticoagulant regimen, from accompanying them to the doctor to keeping track of all their medication Many of these caregivers feel that it is their responsibility to ensure that their family member takes their anticoagulant medication as prescribed Many caregivers find it difficult to assist with the oral anticoagulant regimen

38. 38 Q413B Proportion of patients who come to initial consultation for anticoagulant medication with a caretaker. Base: Respondents who have 5 or more patients on oral anticoagulants (n=94) 4%: Decline to answer According to physicians, 1 patient in 3 was accompanied by a caregiver when their oral anticoagulant treatment was initiated. Physician reports of proportion of patients with caregiver at initial appointment 34%

39. 39 Caregivers are involved in all aspects of anticoagulant management. Tasks: % Go with family member to the doctor who prescribes his/her oral anticoagulant medication 82 Help family member keep track of ALL of the medications that he/she is taking, including prescription drugs, OTC drugs, vitamins, and supplements 80 Pick up prescriptions for anticoagulant medications 76 Find out results of the blood tests (eg. INR level) that are part of family member’s regimen 74 Help monitor family member’s diet 68 Go with family member to have his/her blood tested as part of his/her regimen 64 Remind family member about the special things he/she needs to be careful about when taking his/her oral anticoagulant medication 57 Remind family member to take his/her oral anticoagulant medication 55 Assist with self-testing of blood to determine INR level 15 Q340 Do you assist your family member in any of the following ways? Base Qualified respondents (n=109)

40. 40 2 in 5 caregivers feel that they are primarily responsible for ensuring that their family member takes the oral anticoagulant correctly. Q630 Who do you think is primarily responsible for ensuring that your family member takes his/her oral anticoagulant medication as prescribed and follow all of the recommended actions related to taking this medication? Base: Qualified respondents (n=109) Patient responses in contrast: Patient himself/herself82% Doctor11% Spouse or Caretaker3% Pharmacist2% Nurse2% Percent of caregivers identifying who is primarily responsible for ensuring that family member follows recommendations:

41. 41 Many caregivers find it at least somewhat difficult to assist with their family member’s oral anticoagulant regimen. Q700 How difficult or easy do you find the following when assisting your family member managing his/her use of oral anticoagulant medication? Base Qualified respondents (n=109) Percent of caregivers finding it very difficult or somewhat difficult to…

42. 42 Physicians see care for oral anticoagulant patients as a challenge, requiring more time than patients with other chronic conditions According to physicians, oral anticoagulant patients require more time than other patients with other chronic diseases. The average anticoagulant patient visits the doctor 7 times a year, with more than 1 in 5 making 10 or more visits a year

43. 43 Anticoagulant patients require more of physicians’ time than other chronically ill patients. Q605 Compared to your patients on other medications for other chronic conditions (such as diabetes, arthritis, chronic lung disease, heart condition, or high blood pressure), do you find that your oral anticoagulant patients require more or less time from you or your staff for the following activities? Base: Qualified Respondents (n=101) Time anticoagulant patients require: Much less time % Somewhat less time % About the same amount of time % Some- what more time % Much more time % Net of more time % Amount of time adjusting medication1 317512879 The amount of time I need to review and relay their test results - 526482269 The amount of time I have to spend with the patient (both in person and on phone/email consultations) - 627531467 The amount of time that other staff in my practice need to spend with the patients - 434392260

44. 44 Q531How many times have you seen this patient in the past year? If you are not sure, your best estimate will do. Base: Qualified Respondents (n=101) According to physicians, the average anticoagulant patient visits the doctor 7 times a year (Case Study) Not sure: 2% Average number of visits a year: 7 Percent of physicians who report the number of times they have seen their most recent anticoagulant patient in the past year:

45. 45 Key Theme #2 There are gaps in education around oral anticoagulant use, both for patients and caregivers.

46. 46 Need for greater education, particularly around dietary considerations, drug interactions, and side effects. While most patients and caregivers recognize the importance of following the precautions, there are some gaps in knowledge, particularly around dietary concerns, potential interactions, and side effects. Troubling minorities of patients report that their doctor did not tell them about important elements of their anticoagulant regimen. Many physicians also admit that they do not tell all their patients this important information when they first start them on anticoagulant medication. Opportunities for education at initiation of treatment are being lost.

47. 47 Patients recognize the importance of safe behaviors, with some weaker areas. Q640As far as you know, how important is it for people who take anticoagulants to... ? Base: Qualified respondents (n=426) Importance of anticoagulant precautions

48. 48 There are some gaps in caregiver knowledge about dietary concerns, potential interactions, and side effects. Q500: Regarding your family member’s use of their oral anticoagulant, do you understand the following…? Base: Qualified respondents (n=109 ). Percent of caregivers who have no understanding or are unsure:

49. 49 A small but troubling minority of caregivers have had problems with a lack of information or conflicting information. Q710 How much of a problem has each of the following been for your or your family member? Base: Qualified respondents (n=109)

50. 50 There are gaps in education of new oral anticoagulant patients. Q520Thinking about the first time when the doctor prescribed the anticoagulant for you, did he or she...? Base: Qualified respondents (n=426) When your doctor first prescribed your anticoagulant, did he or she: Yes % No % Not Sure % Tell you about any special dietary considerations you should know while taking this medication 74215 Explain potential interactions between the anticoagulant and other prescription or over-the-counter medication, vitamins or supplements 76195 Explain any side effects you might experience when taking the anticoagulant 78175 Tell you symptoms to watch for and when to seek further care or treatment 79156 Give you clear instructions about how to take the medication 9441 Tell you how often you should have your blood tested 9621 Explain to you why you need to take the anticoagulant 9811

51. 51 Many physicians do not tell their patients important information when they first start patients on and anticoagulant medication. Q402First, please think about the situations when you start a patient on an oral anticoagulant or when you see a patient immediately after he or she has been started on an oral anticoagulant in a hospital. In these situations, how often do you talk to your patients about the following issues when you give them an oral anticoagulant prescription for the first time. Base: Qualified respondents (n=101) *1% not sure Issues that doctors talk about when initiating oral anticoagulant medication for the first time: Less than every time % Every time % Tell them about any special dietary considerations they should know while taking this medication 4447 Explain potential interactions between the oral anticoagulant and other prescription or over-the-counter medications, vitamins or supplements 4259 Explain any side effects they may experience 3466 Tell them about symptoms to watch for and when to seek further care or treatment 2874 Give them specific instructions about how to take the medication 2872 Tell them about how often they should have their blood tested 2080 Explain why they need to take it 1585 Advise them to wear a medical information emblem (bracelet or identifier) or carry a piece of paper that indicates the name of their anticoagulant medication 8316

52. 52 Key Theme #3 There are gaps in the health care management of oral anticoagulant patients.

53. 53 Improvement is needed in communication between doctors and patients about the management of their treatment regimen. Many physicians do not always contact patients with reminders about blood test results, appointments, or to check on health status. Patients and physicians do a good job managing multiple prescriptions; Could improve management of OTCs. During physician visits, many patients are not being asked about compliance, problems they may be having, and diet. Serious gaps in the management of and communication around blood testing.

54. 54 Good communication and information are seen by physicians as most effective in increasing patients’ compliance with oral anticoagulant medication. Physician ratings of the following approaches: Very Effective % Extremely effective % Net 4/5 % Improve the speed and accuracy of blood testing 292150 Improving communication about blood results – consistent feedback loop, regardless of whether INR results are good or bad 421859 Better information available to patients about what they should or should not do 331850 Having more patients visit anticoagulant clinics for routine care 311647 Nurses or other health-care professionals providing ongoing disease management for patients 371551 Physicians spending more time with patients to provide counseling and support 411151 Providing rewards to patients who show perfect compliance with their medication regimen 241135 Patient self-testing their blood for INR level26935 Pharmacists spending more time educating and counseling patients 26733 Q620 How effective do you think the following approaches to increasing patient oral anticoagulant compliance would be? Base: Qualified Respondents (n=101)

55. 55 The majority of physician offices do not contact their patients every time to remind them about their next appointment or to have their blood tested. Follow-up contact Every time % Less than every time % Remind them of their next appointment4356 Remind them to have their blood tested4555 To check how well they are doing2176 Q416 How often, if ever, do you or your office staff contact your oral anticoagulant patients to….? Base: Qualified respondents (n=101)

56. 56 Patients and physicians do a good job managing multiple prescriptions; Could improve management of OTCs. Q505 In the past year, have any of the following people reviewed with you all of the prescription drugs you are taking? Base:Respondents taking more than one prescription medication (n=424) Q440Do all of the doctors you see know that you are taking the anticoagulant? Base:Respondents seeing more than one doctor (n=398) Q515Does the doctor who prescribes your anticoagulant know that you are taking these over-the-counter medications, vitamins, or supplements? Base: Respondents who take OTCs/Vitamins (n=323) Less than 1 percent ** Includes decline to answer (2%) Medication management: Yes % No % Not Sure % In the past year, has a doctor, nurse, or other health care professional reviewed with you all of the prescription medication you take 964* Do all of the doctors you see know that you are taking an anticoagulant 9811 Does your doctor know you are taking OTCs, vitamins, or supplements in addition to the anticoagulant 8757 **

57. 57 While physicians are doing well with reviewing medication, many patients are not being asked about compliance, problems, and diet. (Case Study) On this patient’s most recent visit did you…? Yes % No % Not sure % Review the patient’s latest blood test results964- Review all of the patient’s medications, including over-the- counter medications, vitamins and supplements 84142 Ask the patient whether he/she is taking the oral anticoagulant as prescribed 8317- Ask the patient whether he/she is having any problems related to taking the oral anticoagulant 79201 Ask the patient about his/her diet50491 Q529On this patient’s most recent visit did you…? Base: Qualified respondents (n=101)

58. 58 There are considerable gaps in knowledge and communication about the blood test goals. Q830Has a health care professional ever told you what your “number” should be? Q840Does your ”number” usually stay within the desired range? Base:Qualified respondents (n=426) Blood test goals: Yes % No % Not Sure % Has a health care professional ever told you what your “number” should be? 79147 Does you number usually stay in the desired range? 6133*7 *includes respondents saying “it fluctuates”

59. 59 Many patients do not know their latest PT/INR number. Q835What was your “number” when you were last tested? Base: Respondents who were told of INR (n=426) PT/INR number last time they had their blood tested 4%: Decline to answer

60. 60 Many patients are not always getting clear and timely feedback about blood test results. Q815After having a blood test, how often, if ever, does someone contact you to give you your blood test results? Base: Qualified respondents who get blood checked (n=419) Q825Last time you had your blood tested, did someone explain the results in a way that you could understand? Base:Qualified respondents who get blood checked (n=419) Q818If nobody from your doctor’s office contacts you to give you your blood test results, do you usually contact the doctor’s office yourself? Base: Qualified respondents who do not get contacted every time (n=73) [NOTE: SMALL BASE] Contacting about blood test results: % Frequency of contact about blood test results: Every time 83 Less than always (NET) 17 (Usually 12%; Rarely/Never 5%) The last time he/she had their blood tested: Results were not explained/Respondent was not contacted 5 Results were explained, but not clearly 6 Of those who are not contacted about blood tests, frequency of contacting the doctors’ office oneself: Every time 18 Less than always (NET) 82 (Usually 33%; Rarely/Never 49%)

61. 61 Q425Which of the following best describes your office’s general approach to contacting patients regarding their INR results? Base: Qualified Respondents (n=101). Note: Multiple responses question, respondents could say that they phone and send letters. One in four physicians do not always call or mail the patients to inform them about their INR test results.

62. 62 Q435What terminology do you generally use to describe INR test results to your oral anticoagulation patients? Base: Qualified Respondents (n=101) When informing their patients about their INR test results, many physicians do not tell their patients their actual numeric INR value.

63. 63 Caregivers also need better ongoing communication with physicians to help assist patients manage their treatment. Many caregivers find it difficult to speak to their family members’ doctor. Caregivers see areas for improvement in communication between themselves and their family members doctor, particularly around education about treatment requirements.

64. 64 Many caregivers find it difficult to speak with somebody in the doctor’s office when they have questions about the use of the anticoagulant; Pharmacists are more accessible. How easy or difficult is it for you to… Q620 When you or your family member have questions about the use of anticoagulant, how difficult or easy is it to reach someone at his/her doctor’s office who can answer questions about the use of the anticoagulant? Q625 When you or your family member have questions about the use of the anticoagulant, how difficult or easy is it to reach a pharmacist who can answer questions about the use of the anticoagulant? Base: Qualified respondents (n=109)

65. 65 Caregivers see areas for improvement in communication with their family members’ physician. Q610 How would you rate your family member’s physician on each o the following criteria? Base: Qualified respondents (n=109)

66. 66 Assistance is needed to remain compliant with treatment requirements and goals. Caregivers need assistance in helping their loved ones to do so. 2 in 5 patients do not have the assistance of a health care professional, in addition to their doctor, to help them manage their blood thinning medication. Almost 2 in 5 physicians do not have a nurse or other health care professional in their office to help patients manage their oral anticoagulant. Many patients and caregivers do not receive written instructions about all of the things they need to do when taking an oral anticoagulant. Better health care management is associated with improved awareness, behavior, and confidence around the management of oral anticoagulant use.

67. 67 2 in 5 respondents do not have an additional health care professional to help manage oral anticoagulant use. Q435In addition to the doctor who prescribes your blood thinning medication, is there a nurse, a pharmacist or another health care professional who helps you manage your blood thinning medication? Base: Qualified respondents (n=426) 58% Note: Multiple responses allowed % indicating another health care professional, in addition to their doctor, helps manage anticoagulant

68. 68 Nearly 2 in 5 physicians do not have a nurse or other health care professional in their office to help patients manage their oral anticoagulant. Q410 Is there a nurse or another health-care professional in your office who helps patients manage their oral anticoagulant? This may include calling them regularly to check how well they are doing, reminding them about appointments for blood testing, reviewing their blood test results with them, etc. Please do not include a receptionist calling the patient about appointments. Base: Qualified respondents (n=101)

69. 69 Most caregivers feel they would benefit from having someone in the doctor’s office they could call for information. Other solutions could also be of help. Q720 How much do you think you and your family member would benefit from the following supports to help you manage your oral anticoagulant use? Base Qualified respondents (n=109) 72% 67% 65% 61%

70. 70 Q705 Please specify any particularly good methods you use or are aware of to communicate to your patients the “rules and guidelines” they should follow because they are on an oral anticoagulant therapy. Base: All respondents (n=101) Written communication is seen by many physicians as a good method of relaying information.

71. 71 Just over half of patients received written instructions about taking the oral anticoagulant. Q528Has a doctor, nurse or other health care professional ever prepared for you written instructions about taking the anticoagulant, including what you should and should not do, such as following a specific diet, not taking certain prescription and over-the-country medications, getting your blood test regularly, etc.? Please do not include being given an informational insert that comes with your medication or from the drug maker. Base: Qualified respondents (n=426) Received written instructions: 55% Did not receive written instructions: 40% Not sure: 5% Caregiver responses in contrast: 24% did not receive written instructions 64% received written instructions 12% were not sure

72. 72 Q407 Do you or does someone else in your office give written instructions about taking anticoagulant medications to your patients? These written instructions may inform patients about what they should and should not do with regard to diet, concomitant prescription and over-the-counter medication use, blood tests, etc. Please do not include the informational insert that comes with the medication or from the drug maker. Base: Qualified respondents (n=101) 1 in 3 physicians does not provide any of their oral anticoagulant patients with written instructions.

73. 73 Patients with access to another health care professional have better management of blood testing. Q815After having a blood test, how often, if ever, does someone contact you to give you your blood test results? Q825Last time you had your blood tested, did someone explain the results in a way that you could understand? Base: Qualified respondents who get blood checked (n=419) Q830Has a health care professional ever told you what your “number” should be? Base: Qualified respondents (n=426) Q835What was your number when you were lasted tested? Base: Respondents who were told of INR (n=338) Access to Another Health Care Professional Managing blood testing: Yes % No % Frequency of reminders about blood testing: Always6040 Never2039 Were told what PT/INR “number” should be8473 Knows what PT/INR number was the last time they were tested7656 Frequency of contact about blood test results: Every time8677 Less than always (NET)1323 The last time he/she had blood tested, results were explained clearly9185

74. 74 Health Care Management Score Health care management score% Have a health care professional, in addition to the doctor, helping to manage oral anticoagulant use (1 point) 58 The first time doctor prescribed the oral anticoagulant, did he/she…. (% yes) Explain to you why you need to take anticoagulant98 Tell you how often you should have your blood tested96 Give you clear instructions about how to take the medication94 Tell you about symptoms to watch for and when to seek further care79 Explain any side effects you might experience78 Explain potential interactions between anticoagulant and other Rx or OTC76 Tell you about any special dietary considerations74 Received ALL of the above (1 point)37 Patient was provided written instructions about anticoagulant precautions (1 point)55 The last time he/she had blood tested, results were explained clearly (1 point)88 Health Care Management Score Health Care Management Score (total of 4 points) Poor/Fair health care management (0-2 point)43 Good health care management (3-4 points)57

75. 75 Patients with better health care management are more aware of the importance of oral anticoagulant precautions. Q640As far as you know, how important is it for people who take anticoagulants] to... ? Base: Qualified respondents (n=426) % who believe that behavior is extremely or very important

76. 76 Patients with better health care management are more compliant with oral anticoagulant precautions. Q610How often do you do the following? Base: Qualified respondents (n=426) % who indicate they always do the following…

77. 77 Patients with better health care management are more confident that they are taking the medication correctly. Q645 Overall, how confident are you that you are taking the anticoagulant the correct way to ensure that the drug works at its best and does not cause any problems? Base: Qualified respondents (n=426) Confidence that they are taking anticoagulant medication the correct way

78. 78 Patients with better health care management find it easier to follow the precautions of oral anticoagulant use. Q910How easy or difficult is it for you to… Base: Qualified respondents (n=426) % indicating it is very easy to follow the following precautions…

79. 79 Preliminary Conclusions

80. 80 Education, ongoing communication, and assistance with health care management are key to improving oral anticoagulant treatment. It is important to strengthen the education provided by physicians (and/or nurses in physician offices), both at the time of first prescription and ongoing. Doctors are the first line of education, but nurses, pharmacists and other health professionals can take on some of the burden. Patients and caregivers need more resources for information and counseling. Pharmacists and designated nurses at physician offices could be important resources. Written information about the precautions associated with anticoagulant use would be a simple and effective educational tool, yet many patients do not receive this. Educating patients about the importance of blood testing and the meaning of blood test results is key to improving compliance and positive outcomes. Caregivers need to be educated and recognized for their role in provision of care for anticoagulant patients. Physicians, nurses, pharmacists and other health care professionals involved in patient’s care need to be accessible to caregivers.