1001-14 A new approach to anticoagulation therapy: The fiscal and quality impact of computerized decision support and point of care testing

Point-of-care testing (POCT) in haemostasis has shown a steady state increase in the range of tests available with an exponential increase in the number of tests that are performed annually. The most commonly performed test remains the out of hospital measurement of the international normalised ratio (INR). The INR is used to monitor oral anticoagulation therapy (OAT) with vitamin K antagonists. Such drugs include some of the following: warfarin (Coumadin®), phenprocoumon (Marcumar®) and acenocoumarol (Sintrom®, also sold as other brand names). Contrary to laboratory testing, POCT is often performed by general practitioners (GPs), nurses, pharmacists, patients and other healthcare professionals. In many cases these individuals do not have access to the same support mechanisms that exist in the clinical laboratory regarding strict quality control programmes. When an INR test is performed in the clinical laboratory, it has to be accredited, monitored and inspected. Accreditation is also advisable and part of these requirements is to be involved in external quality assessment (EQA). In the case of POCT haemostasis assays, EQA programmes do exist, however these programmes are still relatively few in number. Over the last decade there has been a significant increase in the scope of POCT, particularly in the field of haemostasis. This brief review summarises POCT in haemostasis, highlighting some of its benefits, challenges and future perspectives, especially with regard to the measurement of the INR.

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Precision and accuracy of point-of-care testing coagulometers used for self-testing and self-management of oral anticoagulation therapy

Journal of Thrombosis and Haemostasis ◽

10.1111/j.1538-7836.2011.04568.x ◽

2012 ◽

Vol 10 (2) ◽

pp. 251-260 ◽

Cited By ~ 67

Author(s):

T. D. CHRISTENSEN ◽

T. B. LARSEN

Keyword(s):

Oral Anticoagulation ◽

Point Of Care ◽

Anticoagulation Therapy ◽

Self Management ◽

Point Of Care Testing ◽

Oral Anticoagulation Therapy ◽

Self Testing ◽

Precision And Accuracy

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Abstract 18842: Point of Care Testing Overestimates INR in CF-LVAD Patients

Circulation ◽

10.1161/circ.130.suppl_2.18842 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Marija Dionizovik-Dimanovski ◽

Allison P Levin ◽

Kanika P Mody ◽

Erica Simonich ◽

Justin Fried ◽

...

Keyword(s):

Large Scale ◽

Scale Validation ◽

Point Of Care ◽

Venous Blood ◽

Anticoagulation Therapy ◽

Home Monitoring ◽

Liver Function Tests ◽

Correlation Study ◽

Point Of Care Testing ◽

Blood Samples

Background: Long-term anticoagulation therapy with warfarin is used in pts. with continuous-flow LVAD (CF-LVAD) to minimize the occurrence of thromboembolic events. Patient self-testing (PST) of INR with home monitoring devices has been shown to improve time within therapeutic INR range as well as patient satisfaction in other settings. However, PST devices have never been tested in pts. with CF-LVADs. The purpose of this study was to determine the reliability of PST devices in patients supported with CF-LVADs. Methods: A correlation study was performed in 50 CF-LVAD pts. who were on stable warfarin therapy for a minimum of 3 weeks. Simultaneous INR values were determined from capillary whole blood samples using the Alere home monitoring PST device and venous blood samples processed in the core laboratory at a large volume CF-LVAD center. Hematocrit, liver function tests, TSH, and amiodarone use were also recorded on patients due to their propensity to affect warfarin metabolism and INR results. Results: Fifty LVAD pts with a mean age of 60 (±14) years were included in the study. Forty-one (82%) were male, and the mean time on CF-LVAD support at the time of INR measurement was 12 months, ranging from 1 to 56 months. There was a moderate correlation between the venous and capillary INR values with a correlation coefficient of 0.83 (r 2 =0.68, p<0.001; Fig 1a). The median difference between the methods was 0.39, with 44/50 pts. having higher INRs with Alere (Fig 1b). Results remained the same after controlling for the use of amiodarone, abnormal hematocrit and liver enzymes, creatinine and TSH. Conclusion: Point of care testing with Alere consistently overestimates INR when compared to conventional laboratory testing in CF-LVAD patients. While our data requires large scale validation, similar results have been reported with point of care testing in other patient populations. Once validated, failure to adjust for this difference may lead to unintentional subterapeutic INR.

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Clinical Decision Support and Optional Point of Care Testing of Renal Function for Safe Use of Antibiotics in Elderly Patients: A Retrospective Study in Community Pharmacy Practice

Drugs & Aging ◽

10.1007/s40266-017-0497-z ◽

2017 ◽

Vol 34 (11) ◽

pp. 851-858 ◽

Cited By ~ 7

Author(s):

Mette Heringa ◽

Annemieke Floor-Schreudering ◽

Peter A. G. M. De Smet ◽

Marcel L. Bouvy

Keyword(s):

Renal Function ◽

Decision Support ◽

Retrospective Study ◽

Elderly Patients ◽

Clinical Decision Support ◽

Point Of Care ◽

Pharmacy Practice ◽

Clinical Decision ◽

Point Of Care Testing ◽

Community Pharmacy Practice

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COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients

Scandinavian Journal of Pain ◽

10.1016/j.sjpain.2017.07.016 ◽

2017 ◽

Vol 17 (1) ◽

pp. 99-106 ◽

Cited By ~ 5

Author(s):

Sunil X. Raj ◽

Cinzia Brunelli ◽

Pål Klepstad ◽

Stein Kaasa

Keyword(s):

Information Technology ◽

Decision Support ◽

Pain Management ◽

Cancer Patients ◽

Point Of Care ◽

Management Strategies ◽

Symptom Assessment ◽

Clinical Decision ◽

Computerized Decision Support ◽

Support Tool

AbstractBackground and aimsThe prevalence of pain in cancer patients are relatively high and indicate inadequate pain management strategies. Therefore, it is necessary to develop new methods and to improve implementation of guidelines to assess and treat pain. The vast improvement in information technology facilitated development of a computerized symptom assessment and decision support system (CCDS) - the Combat system - which was implemented in an outpatient cancer clinic to evaluate improvement in pain management.MethodsWe conducted a controlled before-and-after study between patient cohorts in two consecutive study periods: before (n = 80) and after (n = 134) implementation of the Combat system. Patients in the first cohort completed questionnaires with the paper-and-pencil method and this data was not shown to physicians. Patients in the latter cohort completed an electronic questionnaire by using an iPad and the data were automatically transferred and presented to physicians at point of care. Additionally, the system provided computerized decision support at point of care for the physician based on the electronic questionnaires completed by the patients, an electronic CRF completed by physicians and clinical guidelines.ResultsThe Combat system did not improve pain intensity and there were no significant alterations in the prescribed dose of opiates compared to the cohort of patients managed without the Combat system.ConclusionThe Combat system did not improve pain management. This may be explained by several factors, however, we consider lack of proper implementation of the CCDS in the clinic to be the most important factor. As a result, we did not manage to change the behaviour of the physicians in the clinic.ImplicationsThere is a need to conduct larger prospective studies to evaluate the efficacy of modern information technology to improve pain management in cancer patients. Before introducing new information technology in the clinics, it is important to have a well thought out implementation strategy. The trial is registered at Clinialtrials.gov, number NCT01795157.

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