The Value of a Specialized Program for the Management of Oral Anticoagulation

1997 ◽  
Vol 17 (03) ◽  
pp. 133-136 ◽  
Author(s):  
Jack Ansell
Keyword(s):  
United States ◽  
Oral Anticoagulation ◽  
New Technologies ◽  
Point Of Care ◽  
Cost Effective ◽  
International Normalized Ratio ◽  
The United States ◽  
Self Management ◽  
Anticoagulation Management ◽  
Self Testing

SummaryOral anticoagulation has proven to be an effective and useful therapy for over 50 years for patients at risk for thromboembolism, but recent evidence suggests that many patients are not only poorly managed, but therapy is withheld from a significant number of individuals because of the fear of complications and the labor intensiveness of treatment.Over the last decade several developments have occurred that may increase and improve the use of oral anticoagulation by effectively lowering the risk/benefit profile. Among these have been the standardization of the prothrombin time using the International Normalized Ratio leading to more appropriate and standardized therapy, and a number of consensus conferences in the United States and throughout the world focusing on indications for anticoagulation. Less has occurred in a coordinated fashion to substantially improve the management of oral anticoagulation until very recently. There is now accumulating evidence showing that a coordinated and focused approach to the management of therapy by specialized programs significantly improves clinical outcomes by improving therapeutic control, lessening the frequency of hemorrhage or thrombosis and decreasing the use of medical resources leading to more cost-effective therapy. Furthermore, with the development of new technologies for the measurement of prothrombin times (capillary whole blood PTs or point-of-care testing) allows for novel models of management including patient self-testing and patient self-management. These latter concepts are beginning to be popularized in several regions, especially Germany, Canada and the United States.The focus of the presentation will be to comment on the barriers to more effective and widespread use of anticoagulation and to summarize advances in the management of therapy including the concept of anticoagulation management services, patient self-testing and patient self-management.

Anticoagulation Clinics and Self-Testing

2006 ◽  
Author(s):  
Richard C. Becker ◽  
Frederick A. Spencer
Keyword(s):  
United States ◽  
Oral Anticoagulation ◽  
Vitamin K Antagonists ◽  
Anticoagulation Therapy ◽  
The United States ◽  
Anticoagulation Clinic ◽  
Record Keeping ◽  
Self Testing ◽  
Model Of Management ◽  
Patients At Risk

Oral anticoagulation is a time-tested and effective therapy for patients at risk for thromboembolism (Ansell, 1993). Because of the high risk–benefit ratio of oral vitamin K antagonists, physicians are sometimes reluctant to initiate therapy even for well-established indications (Kutner et al., 1991; McCrory et al., 1995). Furthermore, management is recognized as labor intensive. These factors can be minimized and the benefits of treatment maximized by implementation of an expert model of management that can be achieved with a coordinated and focused system of care known as a coordinated anticoagulation clinic (Ansell and Hughes, 1996). Patient self-testing (and management) may also foster more wide-scale and effective treatment of thromboembolic disorders. The concept of a coordinated anticoagulation clinic (ACC) is not new. Programs focusing on the management of oral anticoagulation have existed in the United States since the late 1950s, and several Scandinavian and other European countries are well known for their coordinated programs (Loeliger et al., 1984), some of which oversee the care of all anticoagulated patients in their respective countries. In the United States, ACCs are growing in number and diversity of services, spurred on by increasing evidence of improved clinical outcomes and cost-effectiveness. The basic elements of a coordinated ACC include (1) a manager or team leader (physician, pharmacist), (2) support staff (nurse practitioner, pharmacist, or physician assistant), (3) standardized record keeping and a computerized database, (4) a manual of operation and practice guidelines, and (5) a formal mechanism for communicating with referring physicians and patients. Currently, most oral anticoagulation therapy in the United States is managed by a patient’s personal physician. In essence, the monitoring and dose titration of patients with thromboembolic disease represents a relatively small proportion of the physician’s overall clinical practice. This approach can be characterized as “traditional” or routine medical care. There may be no specialized system or guidelines in place to track patients or ensure their regular follow-up. An ACC uses a focused and coordinated approach to managing anticoagulation (Ansell et al., 1997).

Implementation of SintromacWeb®, a new internet-based tool for oral anticoagulation therapy telecontrol: Study on system consistency and patient satisfaction

2010 ◽  
Vol 103 (05) ◽  
pp. 1091-1101 ◽  
Author(s):  
Yolanda Mira ◽  
María Teresa Contreras ◽  
Cristina Aguado ◽  
José Antonio Aznar ◽  
Fernando Ferrando
Keyword(s):  
Patient Satisfaction ◽  
Oral Anticoagulation ◽  
Point Of Care ◽  
Anticoagulation Therapy ◽  
International Normalized Ratio ◽  
Final Visit ◽  
Normal Range ◽  
Oral Anticoagulation Therapy ◽  
Self Testing ◽  
Anticoagulated Patients

SummaryMost computer- or internet-assisted systems for oral anticoagulation therapy (OAT) telemanagement have limitations when it comes to implementation within a healthcare center. It was the objective of this study to evaluate convenience and patient satisfaction with the use of SintromacWeb→, a new OAT telecontrol system, compared with the conventional control. SintromacWeb® consists of a point-of-care device for patient international normalized ratio (INR) self-testing and software that allows internet mediated interaction with physicians. Patients initiated the use of SintromacWeb→ and were followed up during a three-month period. A score-based questionnaire was completed in three controlled visits, and data were subsequently analysed. A total of 102 patients were enrolled. At first visit, 55.7% of the patients had their INR within normal range, and 64.9% at the final visit. Internal consistency of the questionnaire was good (Cronbach‘s α: 0.79). Scores in the questionnaire were independent of patient’s age, education level, working status and INR value. The most valued features of SintromacWeb® were: fewer visits to the hospital, simplicity and convenience of the system, and time administration for control tasks (86.7%, 82.7% and 77.6% of very satisfied patients, respectively). Also, patients showed indifference or were dissatisfied with the conventional system. At the final visit, 99% of patients declared that they were satisfied with their OAT control. Moreover, all patients continued using Sintrom -acWeb→ after completion of the study. In conclusion, SintromacWeb→ telecontrol is a new model for management of anticoagulated patients. It was highly accepted and can be used by all patients regardless of their sociodemographic characteristics.

Point-of-care testing INR: an overview

2017 ◽  
Vol 55 (6) ◽  
pp. 800-805 ◽  
Author(s):  
Doris Barcellona ◽  
Lara Fenu ◽  
Francesco Marongiu
Keyword(s):  
Point Of Care ◽  
Cost Effective ◽  
International Normalized Ratio ◽  
Point Of Care Testing ◽  
Mechanical Valves ◽  
Self Testing ◽  
Periodic Monitoring ◽  
Monitoring Test ◽  
Pros And Cons

Abstract Oral anticoagulant therapies with the anti-vitamin K drugs (AVK), warfarin, acenocoumarol and phenprocoumon, are employed in primary and secondary anti-thrombotic prophylaxis in patients with venous thromboembolism, atrial fibrillation and cardiac mechanical valves. However, a monitoring test such as the International Normalized Ratio (INR) is required. The periodic monitoring of this therapy entails discomfort for the patients. Telemedicine and telecare can provide significant aid in the management of this therapy allowing patients to perform the test at home or anywhere else with a portable device, i.e. point-of-care testing (POCT), and to send the result to a thrombosis (TC) via web. Patients can receive dose adjustment sent back by the TC. The effectiveness of this type of management is equal or superior to the traditional AVK monitoring in terms of hemorrhagic and thrombotic events. Analysis of the costs with a horizon of 10 years reveals that both self-testing and self-management are cost-effective. The aim of this overview is to describe the pros and cons of the use of POCT as an alternative in the monitoring of AVK. In particular, description of the POCT, decentralization, quality of the therapy, safety and costs will be examined.

scholarly journals Point-of-Care Testing of International Normalized Ratios for People on Oral Anticoagulants: A Rapid Qualitative Review

2021 ◽  
Vol 1 (3) ◽  
Author(s):  
Elijah Herington ◽  
Danielle MacDougall
Keyword(s):  
Point Of Care ◽  
Oral Anticoagulants ◽  
Community Pharmacists ◽  
International Normalized Ratio ◽  
Health Needs ◽  
Point Of Care Testing ◽  
Anticoagulation Management ◽  
Personalized Care ◽  
Ongoing Training ◽  
Self Testing

The opportunity to engage in self-testing can be experienced as simultaneously liberating and constraining. While self-testing may be appreciated as a form of point-of-care testing for international normalized ratio (INR) levels, some people engaged in self-testing were concerned with the limited amount of personalized care they received. People using oral anticoagulants described community pharmacist-led anticoagulation management services (CPAMS) as a convenient way of testing INR levels and learning about their health needs. Community pharmacists felt they were well-situated to provide care through CPAMS, but acknowledged the importance of ongoing training, oversight, and appropriate levels of resourcing.

scholarly journals The clinical effectiveness and cost-effectiveness of point-of-care tests (CoaguChek system, INRatio2 PT/INR monitor and ProTime Microcoagulation system) for the self-monitoring of the coagulation status of people receiving long-term vitamin K antagonist therapy, compared with standard UK practice: systematic review and economic evaluation

2015 ◽  
Vol 19 (48) ◽  
pp. 1-172 ◽  
Author(s):  
Pawana Sharma ◽  
Graham Scotland ◽  
Moira Cruickshank ◽  
Emma Tassie ◽  
Cynthia Fraser ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Point Of Care ◽  
Clinical Effectiveness ◽  
Cost Effective ◽  
Risk Of Bias ◽  
Self Management ◽  
Thromboembolic Events ◽  
Self Monitoring ◽  
Self Testing

BackgroundSelf-monitoring (self-testing and self-management) could be a valid option for oral anticoagulation therapy monitoring in the NHS, but current evidence on its clinical effectiveness or cost-effectiveness is limited.ObjectivesWe investigated the clinical effectiveness and cost-effectiveness of point-of-care coagulometers for the self-monitoring of coagulation status in people receiving long-term vitamin K antagonist therapy, compared with standard clinic monitoring.Data sourcesWe searched major electronic databases (e.g. MEDLINE, MEDLINE In Process & Other Non-Indexed Citations, EMBASE, Bioscience Information Service, Science Citation Index and Cochrane Central Register of Controlled Trials) from 2007 to May 2013. Reports published before 2007 were identified from the existing Cochrane review (major databases searched from inception to 2007). The economic model parameters were derived from the clinical effectiveness review, other relevant reviews, routine sources of cost data and clinical experts’ advice.Review methodsWe assessed randomised controlled trials (RCTs) evaluating self-monitoring in people with atrial fibrillation or heart valve disease requiring long-term anticoagulation therapy. CoaguChek®XS and S models (Roche Diagnostics, Basel, Switzerland), INRatio2®PT/INR monitor (Alere Inc., San Diego, CA USA), and ProTime Microcoagulation system®(International Technidyne Corporation, Nexus Dx, Edison, NJ, USA) coagulometers were compared with standard monitoring. Where possible, we combined data from included trials using standard inverse variance methods. Risk of bias assessment was performed using the Cochrane risk of bias tool. A de novo economic model was developed to assess the cost-effectiveness over a 10-year period.ResultsWe identified 26 RCTs (published in 45 papers) with a total of 8763 participants. CoaguChek was used in 85% of the trials. Primary analyses were based on data from 21 out of 26 trials. Only four trials were at low risk of bias. Major clinical events: self-monitoring was significantly better than standard monitoring in preventing thromboembolic events [relative risk (RR) 0.58, 95% confidence interval (CI) 0.40 to 0.84;p = 0.004]. In people with artificial heart valves (AHVs), self-monitoring almost halved the risk of thromboembolic events (RR 0.56, 95% CI 0.38 to 0.82;p = 0.003) and all-cause mortality (RR 0.54, 95% CI 0.32 to 0.92;p = 0.02). There was greater reduction in thromboembolic events and all-cause mortality through self-management but not through self-testing. Intermediate outcomes: self-testing, but not self-management, showed a modest but significantly higher percentage of time in therapeutic range, compared with standard care (weighted mean difference 4.44, 95% CI 1.71 to 7.18;p = 0.02). Patient-reported outcomes: improvements in patients’ quality of life related to self-monitoring were observed in six out of nine trials. High preference rates were reported for self-monitoring (77% to 98% in four trials). Net health and social care costs over 10 years were £7295 (self-monitoring with INRatio2); £7324 (standard care monitoring); £7333 (self-monitoring with CoaguChek XS) and £8609 (self-monitoring with ProTime). The estimated quality-adjusted life-year (QALY) gain associated with self-monitoring was 0.03. Self-monitoring with INRatio2 or CoaguChek XS was found to have ≈ 80% chance of being cost-effective, compared with standard monitoring at a willingness-to-pay threshold of £20,000 per QALY gained.ConclusionsCompared with standard monitoring, self-monitoring appears to be safe and effective, especially for people with AHVs. Self-monitoring, and in particular self-management, of anticoagulation status appeared cost-effective when pooled estimates of clinical effectiveness were applied. However, if self-monitoring does not result in significant reductions in thromboembolic events, it is unlikely to be cost-effective, based on a comparison of annual monitoring costs alone. Trials investigating the longer-term outcomes of self-management are needed, as well as direct comparisons of the various point-of-care coagulometers.Study registrationThis study is registered as PROSPERO CRD42013004944.FundingThe National Institute for Health Research Health Technology Assessment programme.

Epidemiology of Technology Use and Mental Health in the United States

2020 ◽  
pp. 41-56
Author(s):  
Seth W. Whiting ◽  
Rani A. Hoff
Keyword(s):  
Mental Health ◽  
United States ◽  
Technology Use ◽  
New Technologies ◽  
Role Playing ◽  
The United States ◽  
Mass Scale ◽  
Online Gambling ◽  
Health Issues ◽  
Mental Health Issues

Advancements in technologies and their mass-scale adoption throughout the United States create rapid changes in how people interact with the environment and each other and how they live and work. As technologies become commonplace in society through increased availability and affordability, several problems may emerge, including disparate use among groups, which creates divides in attainment of the beneficial aspects of a technology’s use and coinciding mental health issues. This chapter briefly overviews new technologies and associated emerging applications in information communication technologies, social media networks, video games and massively multiplayer online role-playing games, and online gambling, then examines the prevalence of use among the general population and its subgroups and further discusses potential links between mental health issues associated with each technology and implications of overuse.

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