RESEARCH TITLE:

PATIENTS’ KNOWLEDGE IN USAGE OF SUBLINGUAL GLYCERYL TRINITRATE

BY :

KAVITHA SATHASIVAN

AMAL MUSLIHA BINTI MOHD SIRAN

OCT 2012

INTRODUCTION

• Angina pectoris can be described a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back, or arms.

(ESC Guideline, 2006)

• Glyceryl trinitrate is used to treat and prevent chest pain, which is symptom of angina and other heart conditions.

• It widens the arteries that carry blood to the heart msucle and relax the vein that return blood from the body to the heart. (Micromedex, 2010)

INTRODUCTION

• It is important for the patients to know how to use the glyceryl trinitrate tablet because it helps one during a life-threatening situation

• Poor knowledge on SLGTN usage may lead to poor management of cardiac condition. (Ming-I Fan et. al, 2009)

• But there is no formal studies have been conducted to evaluate the patients’ understanding about it’s use.

BACKGROUND LITERATURE

• Patients showed a depressing lack of knowledge of their drug treatment, and many did not know how to take sublingual glyceryl trinitrate tablets correctly. (George R Bailie et. al, 1988)

• E.M. McGovern et. al, 2001 has studied on Pharmaceutical care needs of patients with angina.

Result:

1) GTN administration technique in almost one third of angina patients was poor

2) knowledge of when appropriate medical help should be sought was poor.

AIM & OBJECTIVES

AIM

• To increase Hospital Putrajaya patient’s awareness on the importance of knowledge on the proper way of using the GTN tablet prescribed to them.

 

OBJECTIVE OF STUDY

• To evaluate the significance of counseling on SLGTN among patients.

• To assess patient’s knowledge in usage of sublingual glyceryl trinitrate in Hospital Putrajaya.

• To identify the significance between the demographic characteristics and knowledge of the subjects on GTN.

METHODSTUDY DESIGN

Data obtained are then evaluated, organized and analyzed using paired T-Test, independent T-Test and one-way ANOVA in SPSS software

METHOD

• Type of study : Survey (questionnaire)

• Study design : Observational study

• Study area : Outpatient Pharmacy (OPD), Putrajaya

Hospital

• Study period : April - July 2012

METHOD

• Population sample : All OPD patients prescribed with SLGTN (first time users, partial medication or partial-partial medication)

• Sampling technique / procedure : Convenience Sampling

METHOD

• Data Collection Tools:

– 15 questionnaires

• Section A: Demographic of patients

• Section B : Knowledge of SLGTN

• Data analysis :

• SPSS 15

• Descriptive analysis

• Independent T-test

• Paired T-test

• One-way ANOVA Test

METHOD

METHOD

PATIENT SELECTION CRITERIA

INCLUSION CRITERIA

• Patients from OPD of HPJ who are prescribed with sublingual GTN.

EXCLUSION CRITERIA

• Patients who are not prescribed with GTN.

• Patients from other hospital who comes to collect their partial sublingual GTN tablets in Hospital Putrajaya.

• Patients who send their relatives or representatives to collect their partial GTN medication.

• 4) Patients who have not attempted first assessment of questionnaire.

• 5) Patients who collect their partial medication via ‘Sistem Perubatan Ubat Bersepadu’ and ‘Ubat Melalui Pos’.

Variables n Percentage (%)

Gender Male Female

3916

70.929.1

Age 31-4041-5051-6061-65>65

61019128

10.918.234.521.814.5

Status SingleMarriedDivorcedWidow

05032

090.95.53.6

Race MalayChineseIndianOthers

39772

70.912.712.73.6

Education level PrimarySecondaryTertiary

102322

18.241.840

Demographic Data

STATISTICAL ANALYSISBefore Intervention

• Descriptive analysis was done to analyze the demographic data.

• Independent T-Test was used to determine the significance of gender with the knowledge level regarding sublingual glyceryl trinitrate. (SLGTN)

• One-way ANOVA test was used to determine the significance between education level and the knowledge level regarding sublingual glyceryl trinitrate.

After Intervention

• Paired T-Test was used to compare the mean score of the participants before and after intervention.

*Performed by using SPSS 16.0, Chicago, IL. For all tests, a p < 0.05 was defined as statistically significant.

RESULT ANALYSIS

• Scoring system was used.

• Total score of 11 and above were considered the patient has a good knowledge.

• Comparison of the score between the results of pre-intervention and post-intervention.

Pre & Post Intervention ResultComparison of level of SLGTN knowledge in patients in pre and post intervention

Discussion • From the data, there was significance difference after the intervention is done which indicates that the participants’ knowledge was improved significantly. • It is known that repetition of patient counseling increases patients’ recall of education advice (Jowett and Thompson ,2003).n Mean (+SD) P value

Pre -intervention 55 8.36 (+2.4) P ≤ 0.01

Post-intervention 55 12.41 (+1.15)

QuestionPre Post

Pvaluef(n) (%) f(n) (%)MOA GTN 38 69.1 52 94.5 P≤0.01When to take GTN 50 90.9 55 100 P=0.02Can GTN prevent chest pain? 30 54.5 42 76.4 P=0.02Right way to consume GTN 51 92.7 55 100 P=0.04Appropriate body position when taking GTN 35 63.6 55 100 P≤0.01GTN Storage 36 65.5 51 92.7 P=0.01GTN onset action 6 10.9 38 69.1 P=0.01GTN Duration of action 4 7.3 6 10.9 P=0.53Action when first dose GTN ineffective 36 65.5 54 98.2 P≤0.01Gap time before another tablet 22 40 54 98.2 P≤0.01Max GTN dose over 15 min 24 43.6 49 89.1 P≤0.01Action if 3 doses ineffective 50 90.9 55 100 P=0.02GTN side effects 9 16.4 19 34.5 P=0.01Expiry awareness 49 89.1 55 100 P=0.01Expiry date 20 36.4 43 78.2 P≤0.01

Knowledge Description

Knowledge Description

All showed significance difference except for duration of action P=0.53

RESULT ANALYSIS

n=6(10.9%)

n=38(69.1%)

post-pre= 58.2%

RESULT ANALYSIS

N=5

9.1%

N=28

50.9%

Wrong answer– 60% Right answer – 40%

n=6(10.9%)

n=4(7.3%)

RESULT ANALYSIS

N=2 3.6%

Wrong answer– 83.6% Right answer – 16.4%

n=22 (40%)

n=54(98.2)

post-pre= 58.2%

RESULT ANALYSIS

N=20

36.4%

Wrong answer– 63.4% Right answer – 36.4%

•Patients who do not understand dose limitations are at risk of using SLGTN ineffectively while having chest pain.•Thus decrease their enabling skills to manage their chronic cardiac condition (Timmins and Kaliszer, 2003).

n=24(43.6%)

n=49(89.1%)

post-pre= 45.5%

RESULT ANALYSIS

N=20

36.4%

Wrong answer– 63.4% Right answer – 36.4%

n=9(16.4%)

n=19(34.5%)

post-pre= 18.1%

•This finding is similar to a study where 33% of the patients do not know the new expiry date after opening the bottle. •Possibility of patients using medication with reduced potency. Thus, being ineffective in improving myocardial oxygen supply for symptom control immediately (Ming-I Fan et.al, 2009).

RESULT ANALYSIS

n=20(36.4%)

n=43(78.2%)

post-pre= 41.8%

Result: Education Level • Significance between education level and level of SLGTN

knowledge in pre intervention

Comparison of education level P value

Primary Tertiary 0.641

Secondary Primary 0.783

Tertiary Secondary 1.0

Discussion•From the data, there was no significant difference between groups of different education background. •This shows education level does not effect the knowledge of patient on SLGTN usage.•This is contradicting with finding of a study stating that the more educated do appear to be better informed, and appear to make use of health related information (Cutler et al. 2006)

Result: GenderSignificance between gender and level of SLGTN knowledge in pre intervention

Discussion

•As of the gender, there was no significant difference between the male and female participants’ knowledge of SLGTN.

•This result is similar to a study conducted in a hospital in Australia (Ming-I Fan et al, 2009) which concludes that there is no significant difference between gender differences on SLGTN knowledge.

Variable n Mean (+SD) P value

Male 39 12.41 (+1.19) P ≤ 0.75

Female 16 12.44 (+ 1.09)

DISCUSSION

• In this study most of the participants have lack of knowledge regarding the onset time (10.9% ,n=6), expiry date (36.4% ,n=20), gap time in between tablets of SLGTN (40.0% ,n=22), duration of action (7.3% ,n=4), and the side effects of this medication (16.4% ,n=9).

• Findings suggested patients need to improve their knowledge level in using and management which may further support self-care of their cardiac condition (Lehne, 2004).

DISCUSSION

• Before the intervention, the minimum score was 2.00. This depicted that the patients do not understand about the SLGTN.

• This can be very dangerous since the deficit in patients’ knowledge may cause poor management of their cardiac condition and more frequent episodes of angina (Adams et al 2005).

LIMITATION

• Small samples size

–number of patients taking SLGTN in Hospital Putrajaya is small in size.

• Sampling errors

- biased (partial users also included)

• Counseling by pharmacist was not standardized

- counseling points differ

• Knowledge reassessment

- was conducted via phone call , not conducted face to face to really ensure that the same person has been interviewed.

CONCLUSION

1) There is improvement in patient’s knowledge on SLGTN usage after they were given counseling (P ≤ 0.01).

2) Patients need to improve their knowledge on the administration and dose of GTN, side effects and expiry of GTN.

3) There is no significant difference of education level and gender on patients’ knowledge on SLGTN usage.

RECOMMENDATION

• To develop a checklist comprising of a standard guideline of counseling points on SLGTN usage

• Written information is beneficial in increasing patients’ knowledge on their medicines especially when combined with oral information. (George R Bailie et. al, 1988)

REFERENCES

• Amal, N.M. et al., 2011. Prevalence of Chronic Illness and Health Seeking Behaviour in Malaysian Population ( NHMS III ) 2006. Med J Malaysia, 66(1), p.36-41.

• Cheah W.L. et al., 2010. A Preliminary Study on the Prevalence of Cardiovascular Disease Risk Factors in Selected Rural Communities in Samarahan and Kuching Division, Sarawak, Malaysia Malaysian J Med Sci, 18(2), p.58-6

• World health Organization. The Basic Document, 32th edition. Geneva, Switzerland: World Health Orgnization; 1982. 

REFERENCES

•  Guidelines on The Management of Angina Pectoris, European Heart Journal, 2006 http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-angina-FT.pdf Accesed on 18 February 2012 at 7.00 pm

• Maclean, F.K. et al., 1980. An assessment of the clinical use of glyceryl trinitrate in a hospital outpatient population. Australian and New Zealand journal of medicine, 10(1), p.12-14.

• Ingram N., 1999. Cardiac patients' perceived education and use of sub-lingual glyceryl trinitrate on commencement of outpatient cardiac rehabilitation. Coronary Health Care (3)3, P. 128–134

REFERENCES

• Fang M., 2006. Cardiac patients’ knowledge and use of sublingual glyceryl trinitrate (SLGTN). Australian Journal of Advanced Nursing, 26(3), p.32-38

• Manufacturer's PIL, Glyceryl Trinitrate Tablets, Actavis UK Ltd, electronic Medicines Compendium http://www.medicines.org.uk/emc/document.aspx?documentId=18092 Accessed on 18 February 2012 at 9.00 pm

• MIMS USA online

• http://www.mims.com/USA/drug/info/glyceryl%20trinitrate/glyceryl%20trinitrate?type=full Accessed on 18 February 2012 at 9.10 pm

REFERENCES

 

• Jowett, N. and Thompson, D. 2003. Comprehensive coronary care (3rd ed). Bailliere Tindail: London, UK

• Lehne, R. 2004. Pharmacology for cursing care (5th ed). W.B. Saunders, St. Louis, Missouri, USA.

• Timmins, F. and Kaliszer, M. 2003. Information needs of myocardial infarction patients. European Journal of Cardiovascular Nursing, 2 (1), p.57-65.

APPENDIXSLGTN Counseling Guideline