Anticoagulation Clinics and Self-Testing

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).