Research into whether medication regimen complexity is associated with nonadherence and hospitalization has produced inconsistent results. Moderate-quality evidence from four studies (two each for nonadherence and hospitalization) suggests that medication regimen complexity is associated with nonadherence and higher rates of hospitalization.

Background and Purpose-Warfarin is an effective drug for the prevention of thromboembolism in the elderly. The major risk for patients taking warfarin is bleeding. We aimed to assess the impact of psychosocial factors, including mood, cognition, social isolation, and health literacy on warfarin instability among community-based elderly patients. Methods-A case-control study was conducted between March 2008 and June 2009 in a community-based setting. Cases were patients previously stabilized on warfarin who recorded an international normalized ratio Ն6.0. Control subjects were patients whose international normalized ratio measurement was maintained within the therapeutic range. Patient interviews investigated potential predisposing factors to elevated International Normalized Ratio levels. Results-A total of 486 patients were interviewed: 157 cases and 329 control subjects, with an approximate mean age of 75 years. Atrial fibrillation was the most common primary indication. Adjusted multivariate logistic regression revealed impaired cognition (OR, 1.9; 95% CI, 1.0 to 3.6), depressed mood (OR, 2.2; 95% CI, 1.2 to 3.9), and inadequate health literacy (OR, 4.0;95% CI, 2.1 to 7.4) were associated with increased risk of an elevated International Normalized Ratio. Conclusions-This study identified impaired cognition, depressed mood, and inadequate health literacy as risk factors for warfarin instability. These had a similar impact to well-recognized demographic, clinical, and medication-related factors and are prevalent among the elderly. These findings suggest that elderly patients prescribed warfarin should be reviewed regularly for psychosocial deficits. (Stroke. 2011;42:2866-2871.)

Over the last decade, medical schools have been increasingly incorporating research methods and evidence-based medicine as part of their core teaching. 1 In addition to teaching research methods via coursework, numerous institutions have embraced scholarly experiences. 1,2 Globally, scholarly experiences differ between institutions and are often termed, scholarly placements, scholarly projects, scholarly intensives or scholarly concentrations. 1 We have used the term 'scholarly experiences', as an over-arching term to encompass the various terminologies used by different medical schools. These experiences aim to foster independent learning and develop

Objective: To identify potential weaknesses in the system of managing warfarin therapy. Design, participants and setting: A structured interview‐based study of 40 community‐dwelling patients taking warfarin and with an international normalised ratio ≥ 6.0 and 36 of their treating doctors (35 general practitioners and 1 specialist), conducted between July and November 2007. Patients all received services from and were recruited sequentially by a large, private metropolitan pathology provider in Melbourne. Main outcome measures: Patients’ demographic, clinical, cognitive and psychosocial characteristics, warfarin knowledge, medication complexity and adherence; and doctors’ experience with, approach to and involvement in warfarin management, and their perception of responsibility for warfarin management and patient education. Results: Interviews revealed multiple difficulties, including cognitive dysfunction, possible depression, and medication non‐adherence, in 30 of 40 patients. Of 36 doctors interviewed, 12 were unaware of these difficulties in their patients. Five doctors considered they had sole responsibility for their patients’ anticoagulation, while 15 confirmed a mutual relationship with the pathology service, and 16 deferred total responsibility to the pathology provider. Only 14/36 doctors reported conducting patient education at commencement of warfarin therapy, with the other 22 stating this was the responsibility of the initiating specialist, pathology service or dispensing pharmacist. Conclusions: There is a need for improved role clarification in coordinating warfarin management. We propose exploring the possibility of a Warfarin Suitability Score to assist better recognition of patients in whom treatment may be problematic, along with a model of care using practice nurses with GPs to facilitate optimal patient care.