Open Access Open Access  Restricted Access Subscription or Fee Access

Patients’ experiences with hospital outpatient anticoagulation services: dimensions and determinants

Syed Ghulam Sarwar Shah, Julie Barnet, Jasna Kuljis, Kate Hone, Richard Kaczmarski


OBJECTIVES: To characterise patients’ experiences with outpatient anticoagulation clinic services for testing blood coagulation intensity through the measuring of the international normalised ratio (INR) and to identify the latent dimensions and determinants of their experiences.

METHODS: A cross-sectional questionnaire survey of a convenience sample of patients (N=350) attending outpatient anticoagulation services at a district general hospital in London.

RESULTS: Response rate was 35.7% (n=125). The majority of patients were male (64%), aged ≥71 years (60%), and white / Caucasians (85%). Most of the respondents (55%) attended outpatient anticoagulation services several times in a month for INR testing, 97% of patients received INR test results by a letter and 78% of patients were very satisfied with the current method of getting test results. Eighty per cent of patients maintained a personal record of INR test results that was rated as ‘very useful’ by 77% of those who kept the record. The mean ratings of semantic differential items (SDI) used for characterising patients’ overall experience with outpatient anticoagulation services were detrimental-beneficial = 6.3 (±0.97), useless-useful = 6.2 (±1.01), worthless-valuable = 6.1 (±1.19), difficult-easy = 5.48 (±1.66), undesirable-desirable = 5.29 (±1.55), unpleasant-pleasant = 4.74 (±1.61), dislike-like = 4.71 (±1.42), unenjoyable-enjoyable = 4.28 (±1.61). Exploratory and confirmatory factor analyses of the SDI data determined two latent factors suggesting an ‘affective’ and a ‘value’ dimension of these patients’ experience with anticoagulation services. The duration that participants believed that they would continue to undergo INR testing was statistically a significant and negatively related predictor (β -0.306, P <0.05) of the affect dimension. The satisfaction with the current method of getting INR test results (β 0.362, P <0.001) and usefulness of keeping a personal record of results of INR tests (β 0.215, P <0.05) were statistically significant and positive predictors of the ‘value’ dimension.

CONCLUSION: The overall experience of outpatient anticoagulation service users has ‘affect’ and ‘value’ dimensions, which may determine their use of the service. Identification of these two significant dimensions of patients’ experiences can help in studying experiences of users of other types of outpatient services. There is however a need for identifying other dimensions and predictors of patients’ experiences with outpatient services.


oral anticoagulation therapy, INR testing, patient experience, outpatient services, questionnaire survey, statistical modelling, health service research

Full Text:



Bergbom, I. (2012). News, coming events and new steps. Scandinavian Journal of Caring Sciences 26 (1), 1-2.

Cornwell, J., Adeagbo, A., Cubbon, J. et al. (2010). The Intelligent Board 2010: Patient Experience. London: Dr Foster Intelligence.

Coulter, A., Fitzpatrick, R. & Cornwell, J. (2009). The Point of Care. Measures of patients’ experience in hospital: purpose, methods and uses. London: The King’s Fund.

International College of Person-centered Medicine. (2012). The Geneva Declaration on Person-centered Care for Chronic Diseases. International Journal of Person Centered Medicine 2 (2), 153-4.

Darzi, L. (2008). High quality care for all: NHS Next Stage Review final report. Richmond, Surrey (UK): Office of Public Sector Information, Department of Health. Report No. Cm 7432.

Downing, A., Rudge, G., Cheng, Y., Tu, Y.-K., Keen, J. & Gilthorpe, M. (2007). Do the UK government's new Quality and Outcomes Framework (QOF) scores adequately measure primary care performance? A cross-sectional survey of routine healthcare data. BMC Health Services Research 7 (1), 166.

Campbell, J., Smith, P., Nissen, S., Bower, P., Elliott, M. & Roland, M. (2009). The GP Patient Survey for use in primary care in the National Health Service in the UK - development and psychometric characteristics. BMC Family Practice 10 (1), 57.

GP Patient Survey. (2010). Questionnaires and Letters. London: Department of Health; [cited 2010 19 October]; Available from:

Raposo, M., Alves, H. & Duarte, P. (2009). Dimensions of service quality and satisfaction in healthcare: a patient’s satisfaction index. Service Business 3 (1), 85-100.

Jenkinson, C., Coulter, A., Bruster, S., Richards, N. & Chandola, T. (2002). Patients’ experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care. Quality and Safety in Health Care 11 (4), 335-9.

Hospital Consumer Assessment of Healthcare Providers and Systems. (2010). CAHPS Hospital Survey. [cited 2010 19 October]; Available from:

Sizmur, S. & Redding, D. (2010). Key domains of the experience of hospital outpatients. Oxford: Picker Institute Europe. Discussion paper 2.

Care Quality Commission. (2010). Outpatient Department Survey 2009: Results. Newcastle upon Tyne, England.

Department of Health. (2006). Our health, our care, our say: A new direction for community services. London: The Stationery Office. Report No. Cm 6737.

Yang, D. T., Robetorye, R. S. & Rodgers, G. M. (2004). Home prothrombin time monitoring: A literature analysis. American Journal of Hematology 77 (2), 177-86.

Connock, M., Stevens, C., Fry-Smith, A., Jowett, S., Fitzmaurice, D., Moore, D. & Song, F. (2007). Clinical effectiveness and cost-effectiveness of different models of managing long-term oral anticoagulation therapy: a systematic review and economic modelling. Health Technology Assessment 11 (38), 1-86.

The Health and Social Care Information Centre.(2012). Outpatient data: Treatment Speciality. Leeds, England.

Shah, S. G. S. & Robinson, I. (2011). Patients' perspectives on self-testing of oral anticoagulation therapy: Content analysis of patients' Internet blogs. BMC Health Services Research 11 (1), 25.

Bjorholt, I., Andersson, S., Nilsson, G. & Krakau, I. (2007). The cost of monitoring warfarin in patients with chronic atrial fibrillation in primary care in Sweden. BMC Family Practice 8 (1), 6.

Fritschi, J., Raddatz-Müller, P., Schmid, P. & Wuillemin, W. A. (2007). Patient self-management of long-term oral anticoagulation in Switzerland. Swiss Medical Weekly 137, 252-8.

Garcia-Alamino, J. M., Ward, A. M., Alonso-Coello, P., Perera, R., Bankhead, C., Fitzmaurice, D. & Heneghan, C. J. (2010). Self-monitoring and self-management of oral anticoagulation. Cochrane Database of Systematic Reviews 2010 (4).

Schwartz, M. (2010). Home monitoring of INR using point-of-care testing is a viable option for patient involvement.: The International Self-Monitoring Association of oral Anticoagulated Patients (ISMAAP); [cited 2011 5th May]; Available from:

Gardiner, C., Williams, K., Mackie, I. J., Machin, S. J. & Cohen, H. (2005). Patient self-testing is a reliable and acceptable alternative to laboratory INR monitoring. British Journal of Haematology 128 (2), 242-7.

Einbinder, J. S., Rury, C. & Safran, C. (1995). Outcomes research using the electronic patient record: Beth Israel Hospital's experience with anticoagulation. Proceedings of the Annual Symposium on Computer Application in Medical Care 1995 819-23.

Car, J. & Sheikh, A. (2004). Email consultations in health care: 1—scope and effectiveness. BMJ 329 (7463), 435-8.

Silow-Carroll, S., Edwards, J. N. & Rodin, D. (2012). Using Electronic Health Records to Improve Quality and Efficiency: The Experiences of Leading Hospitals. New York: The Commonwealth Fund. Report No. 1608.

Davies, A., Buxton, M., Patterson, D. & Webster-King, J. (2000). Anti-coagulant monitoring service delivery: a comparison of costs of hospital and community outreach clinics. Clinical & Laboratory Haematology 22 (1), 33-40.

Batra, R. & Ahtola, O. T. (1991). Measuring the hedonic and utilitarian sources of consumer attitudes. Marketing Letters 2 (2), 159-70.

Osgood, C. E., Suci, G. J. & Tannenbaum, P. H.(1957). The Measurement of Meaning Urbana, IL.: University of Illinois Press.

Komorita, S. S. & Bass, A. R. (1967). Attitude differentiation and evaluative scales of the semantic differential. Journal of Personality and Social Psychology 6 (2), 241-4.

Brace, N., Kemp, R. & Snelgar, R.(2009). SPSS for psychologists. 4th ed. Bsingstoke, Hamps.: Palgrave Macmillan.

SPSS Inc.(2010). PASW Statistics 18. Chicago, IL.

Hair, J. F., Black, W. C., Babin, B. J. & Anderson, R. E.(2010). Multivariate data analysis. A global perspective. 7th ed. London: Pearson.

Byrne, B. M.(2010). Structural equation modelling with AMOS: Basic concepts, applications, and programming. 2nd ed. New York: Routledge.

SPSS Inc.(2010). IBM SPSS AMOS 19. Chicago, IL.

Fornell, C. & Larcker, D. F. (1981). Evaluating Structural Equation Models with Unobservable Variables and Measurement Error. Journal of Marketing Research 18 (1), 39-50.

Farrell, A. M. (2010). Insufficient discriminant validity: A comment on Bove, Pervan, Beatty, and Shiu (2009). Journal of Business Research 63 (3), 324-7.

Field, A.(2009). Discovering statistics using SPSS. 3rd ed. Los Angeles: Sage.

Wu, J.-H., Shen, W.-S., Lin, L.-M., Greenes, R. A. & Bates, D. W. (2008). Testing the technology acceptance model for evaluating healthcare professionals' intention to use an adverse event reporting system. International Journal for Quality in Health Care 20 (2), 123-9.

Gurwitz, J. H., Avorn, J., Ross-Degnan, D., Choodnovskiy, I. & Ansell, J. (1992). Aging and the Anticoagulant Response to Warfarin Therapy. Annals of Internal Medicine 116 (11), 901-4.

White, P. J. (2010). Patient Factors That Influence Warfarin Dose Response. Journal of Pharmacy Practice 23 (3), 194-204.

Blann, A. D., Fitzmaurice, D. A. & Lip, G. Y. H. (2003). Anticoagulation in hospitals and general practice. BMJ 326 (7381), 153-6.

McCahon, D., Murray, E. T., Jowett, S., Sandhar, H. S., Holder, R. L., Hussain, S., O’Donoghue, B. & Fitzmaurice, D. A. (2007). Patient self management of oral anticoagulation in routine care in the UK. Journal of Clinical Pathology 60 (11), 1263-7.

Stevenson, F. A., Cox, K., Britten, N. & Dundar, Y. (2004). A systematic review of the research on communication between patients and health care professionals about medicines: the consequences for concordance. Health Expectations 7 (3), 235-45.

Redding, D. (2008). Communication and PCTs. British Journal of Healthcare Management 14 (11), 514.

Trafimow, D.(2004). Attitude Measurement. In: Encyclopedia of Applied Psychology. Charles, S., editor., pp. 233-43. New York: Elsevier.

Killeen, M. B.(2007). Development and initial testing of atheory of patient satisfaction with nursing care. In: Middle range theory development using King's conceptual system. Sieloff, C. L. & Frey, M. A., editors., pp. 138-63. New York: Springer.

Paterson, B. L., Charlton, P. & Richard, S. (2010). Non-attendance in chronic disease clinics: a matter of non-compliance? Journal of Nursing and Healthcare of Chronic Illness 2 (1), 63-74.

National Patient Safety Agency.(2007). Actions that can make anticoagulant therapy safer - Patient Safety Alert. London: National Patient Safety Agency.

Steinbrook, R. (2008). Personally Controlled Online Health Data -The Next Big Thing in Medical Care? New England Journal of Medicine 358 (16), 1653-6.

Lober, W. B., Zierler, B., Herbaugh, A., Shinstrom, S. E., Stolyar, A., Kim, E. H. & Kim, Y. (2006). Barriers to the use of a Personal Health Record by an Elderly Population. AMIA Annual Symposium Proceedings 2006 514–8.

Kaelber, D. C., Jha, A. K., Johnston, D., Middleton, B. & Bates, D. W. (2008). A Research Agenda for Personal Health Records (PHRs). Journal of the American Medical Informatics Association 15 (6), 729-36.

Patel, V. N., Abramson, E., Edwards, A. M., Cheung, M. A., Dhopeshwarkar, R. V. & Kaushal, R. (2011). Consumer Attitudes Toward Personal Health Records in a Beacon Community. American Journal of Managed Care 17 (4), E104-E20.

Yamin, C. K., Emani, S., Williams, D. H., Lipsitz, S. R., Karson, A. S., Wald, J. S. & Bates, D. W. (2011). The Digital Divide in Adoption and Use of a Personal Health Record. Archives of Internal Medicine 171 (6), 568-74.

De Boer, D., Delnoij, D. & Rademakers, J. (2010). Do patient experiences on priority aspects of health care predict their global rating of quality of care? A study in five patient groups. Health Expectations 13 (3), 285-97.



  • There are currently no refbacks.