New approaches to the delivery of anticoagulant services

Quality of oral anticoagulation in patients with atrial fibrillation: A cross-sectional study in general practice

OBJECTIVE

To evaluate the quality of management of oral anticoagulation among patients on oral anticoagulation for atrial fibrillation, and to verify the relation between patient performance and the risk of an event due to therapy.

METHODS

In a retrospective cross-sectional study involving 66 general practices, international normalized ratio (INR) values obtained over a 6-mo period were analysed. All INR values were determined by a single clinical laboratory, and additional medical information was provided by GPs.

RESULTS

395 patients were included in the study, with a mean age of 74+/-9.6 y. In total, 3111 INR values were obtained. The mean number of tests/month per patient was 2.7+/-4.3. A total of 49 728 d of therapy was evaluated. Fifty-three per cent of the day values were within 0.5 INR units of the target (and 69% within 0.75 INR units of the target). The incidence rate for major bleeding was 4.4/100 patient years (and 2.9/100 patient years for thromboembolic events). There was a significant relation between patient performance and the presence of an event (p=0.017), with an odds ratio of 2.8 (95% CI 1.3-6.3).

CONCLUSION

The quality of oral anticoagulation in patients with atrial fibrillation is suboptimal. This is significantly related to an increased risk of haemorrhagic events.

The Belgian Improvement Study on Oral Anticoagulation Therapy: a randomized clinical trial

AIMS

In Belgium, general practitioners (GPs) mainly manage oral anticoagulation therapy. To improve the quality of oral anticoagulation management by GPs and to compare different models and interventions, a randomized clinical trial was performed.

METHODS AND RESULTS

Stratified randomization divided 66 GP-practices into four groups. A 6-month retrospective analysis assessed the baseline quality. In the prospective study, each group received education on oral anticoagulation, anticoagulation files, and patient information booklets (groups A, B, C, and D). Group B additionally received feedback every 2 months on their anticoagulation performance; group C determined the international normalized ratio (INR) with a CoaguChek device in the doctor's office or at the patient's home; and group D received Dawn AC computer assisted advice for adapting oral anticoagulation. For the different groups, the time spent in target INR range (Rosendaal's method) and adverse events related to anticoagulation were determined and compared with the same quality indicators at baseline. There was a significant increase in per cent of time within 0.5 INR from target, from 49.5% at baseline to 60% after implementing the different interventions. However, neither the per cent in target range nor the event rates differed among the four groups.

CONCLUSION

The interventions significantly improved the quality of management of oral anticoagulation by Belgian GPs, mainly as a result of an education and support programme.

Primary care anticoagulant management using near patient testing

BACKGROUND

Indications for anticoagulant treatment are increasing and new approaches to anticoagulant services require a shift from hospital to primary care.

AIM

To pragmatically test the validity and effectiveness of primary care anticoagulant management using near patient testing.

METHODS

Twelve CoaguCheck monitors were supplied to 16 rural practices that had previously provided supervision of anticoagulant therapy. Practices were required to record data for eligible patients from September 1998 to April 1999 and to forward one blood sample per week to the regional hospital laboratory for parallel testing.

RESULTS

Nine practices returned data on 122 patients. Indications for anticoagulation Included atrial fibrillation (n = 56), valve replacement (n = 12) and deep venous thrombosis or pulmonary embolus (n=12). Regression of the mean of 185 paired readings against their difference confirmed the validity of the CoaguCheck monitor (r2 = 0.00 [95% CI -0.38 to 0.38]). There were 692 International Normalised Ratio (INR) tests performed representing an average of 5.7 tests per patient. The desired therapeutic range was provided for 609 (88%) of these tests; 294 (48.3%) were within the desired therapeutic range. Results differed significantly between practices.

CONCLUSIONS

This study confirmed the validity of anticoagulant management using the CoaguCheck monitor in primary care.

Cardiac markers: point of care testing

Point-of-care (POC) or "near-patient" testing allows diagnostic assays to be performed in locations such as the emergency department or intensive care unit where treatment decisions are made and care is delivered based on the results of these assays. Presently, there exist POC immunoassays for several cardiac markers including creatine kinase MB (CK-MB), myoglobin, troponin I, and troponin T that yield qualitative and quantitative results comparable to traditional central lab assays. In the evaluation of emergency room patients with chest pain, POC cardiac markers may improve triage and clinical outcomes. Existing POC assays combining myoglobin and CK-MB have high sensitivity and specificity for diagnosing acute myocardial infarction and may provide the earliest identification of myocardial injury. POC Troponin T assays are the most studied POC cardiac marker assays. Along with POC troponin I assays, these tests provide more sensitive identification of myocardial injury and valuable prognostic information. Prior studies of POC cardiac marker assays have not addressed whether POC testing affects patient outcome or process of care. In situations in which caregivers base triage, treatment and monitoring decisions on time-sensitive diagnostic results, POC tests linked with improved triage and treatment strategies may improve resource utilization and clinical outcomes.