High quality patient management
Monitoring Your Warfarin Patients:
VKAs require close monitoring because of individual variations, drug-drug or food-drug interactions. Therefore, balancing the risks and benefits of warfarin therapy requires keeping careful track of PT/INR. Studies have shown that increasing a patient’s time in therapeutic range maximizes the benefits of anticoagulation therapy and minimizes the risk.
Models of Patient Monitoring
A variety of models exists for managing patients on warfarin therapy.
- Model 1: Traditional or Usual Care (UC)
In UC, patient testing is performed by a conventional laboratory. Results can take hours if not overnight to be returned to the physician.
The Health Care Professional (HCP) interprets the result and, if needed, changes the patient’s dosage. The patient may have to wait for the results, or even return to the physician after the result is delivered.
The challenges that UC presents to doctors and patients are:
- Resources and time needed for patient and healthcare provider
- Multiple contacts with the doctors for dose adjustments
- Separate visit by patients to the outpatient lab to get blood drawn and wait for the result
- Patient stress to manage daily life (lack of control, lack of knowledge)
- Little patient-independence (no self-responsibility)
- Delayed therapy management can result in non-therapeutic coagulation levels, putting the patient at risk of thromboembolism
- Potential errors in (pre-)analytics, e.g., variability between test systems 7
- Model 2: Alternative Site Testing (AST) – A Systematic Anticoagulation Management approach
There is now increasing evidence that better outcomes can be achieved if patients are managed by a specialized anticoagulation management service. Specialized management tends to occur at a site separate from the patient’s GP or hospital outpatient clinic and is therefore often called Alternative Site Testing (AST). The role of an Anticoagulation Clinic (AC) is to provide consistent, systematic and protocol-driven care13. AC clinics may perform testing using Point of Care (POC) INR devices in order to streamline the clinic workflow17
Improve patient care
Studies have shown that this type of systematic anticoagulation management can significantly improve patient care.8,17
Improve medical practice workflow efficiency
A systematic anticoagulation management approach can greatly improve your practice’s workflow efficiency.
Figure 1: Systematic Anticoagulation Management (SAM) can improve workflow efficiency*
Anticoagulation Clinics (ACs) which utilize POC testing and Clinical Decision Support System (CDSS) can develop a streamlined approach to managing patient care, whereas the Usual Care model is generally quite time-consuming for both patient and HCP.
Number of consultations reduced. In AST, INR testing and dose adjustment can be achieved in a single visit. For Usual Care, two consultations are typically required18
Obtaining patient clinical records. AST administrative staff only need to obtain a patient’s clinical records once, whereas for UC, clinical records are often obtained on at least two separate occasions17
Dose adjustment ‘on the spot’. In AST the patient is usually given their dose adjustment recommendation before they leave their appointment. With UC the physician or physician’s representative must contact the patient to relay the dose adjustment guidance. This can be particularly time consuming if multiple attempts are required before the patient is reached17
Risk of errors reduced. With AST near patient testing significantly reduces the risk of laboratory or communication errors. With UC blood samples can be lost en route to the laboratory or there may be communication errors which prevent the sample being analyzed or the result being conveyed back to the physician. This may require the patient to re-attend for another blood draw17
Physician time saved. In AST routine visits can be handled by nurses or pharmacists, freeing up physician time for other work. With UC physicians monitor all patients regardless of the complexity of the case17
Improve patient satisfaction and compliance
In an AST model, patients have shown to be more satisfied with being tested on a PC device than visiting the lab. This leads to increased engagement and compliance, which leads to improved outcomes.
To learn more about adopting a SAM approach through Alternative Site Testing, download this brochure.
SAM can improve satisfaction, the most critical component in determining patient compliance, and therefore, outcomes.*
Systematic Anticoagulation Management with a CoaguChek system is preferred over lab testing by most patients*
1. Levi et al (2009). Sem Thromb Hem 35:527-542
2. Connolly et al (2008). Circulation 118:2029-2037
3. Guyatt et al (2012). Chest 141:7S-47S
4. Connolly et al (2009). N Engl J Med 361:1139-1151
5. Heneghan C et al (2012) Lancet 379:322-334
6. Bloomfield HE et al (2011) Ann Int Med 154:472-482
7. Lind SE, Pearce LA, Feinberg WM, Bovill EG. Clinically significant differences in the International Normalized Ratio measured with reagents of different sensitivities. SPAF Investigators. Stroke Prevention in Atrial Fibrillation. Blood Coagul Fibrinolysis 1999; 10:215-227.
8. Heneghan C, Alonso-Coello P, Garcia-Alamino JM, Perera R, Meats E, Glasziou P. Self-monitoring of oral anticoagulation: a systematic review and meta-analysis. Lancet 2006; 367:404-411.
9. Phillips KW, Ansell J. Outpatient management of oral vitamin K antagonist therapy: defining and measuring high-quality management. Expert Rev Cardiovasc Ther 2008; 6:57-70
10. Heneghan et al (2012). Lancet 379:292-293
11. Wurster, M. Doran, T. Anticoagulation Management: a new approach. Disease Management 2006;9:201-209
12. Nichol, M.B., Knight, T.K., Dow, T., Wygant, G., Borok, G. et al. (2008). Quality of anticoagulation monitoring in nonvalvular atrial fibrillation patients:comparison of anticoagulation clinic versus usual care. Ann Pharmacother 42(1), 62-70.
13. Ebell, M.H. (2005). A systematic approach to managing warfarin doses. Fam Pract Manag 12(5), 77-83.
15. Gardiner C, Williams K, Mackle JJ, Machin SJ, Cohen H. Patient self-testing is a reliable and acceptable alternative to laboratory INR monitoring. British Journal of Haematology. 2004;1829:242-247
16. Giles T and Roffidal L. Results of the prothrombin office-testing benefit evaluation (PROBE). Cardiovascular Reviews and Reports. 2002;23:27-33
17. Gilles T and Roffida L. Results of the prothrombin office-testing benefit evaluation (PROBE). Cardiovascular Reviews and Reports. 202;23:27-33
18. Campbell PM, Radenskly PW, Denham CR. Economic analysis of systematic anticoagulation management vs. routine medical care for patients on oral warfarin therapy. Dis Manage Clin Outcomes. 2000;2:1-8.