Primary care oral anticoagulant management utilising computerised Decision Support (DSS) and Near Patient Testing (NPT)

Introduction: Increased numbers of patients receiving warfarin, particularly for non-rheumatic atrial fibrillation has increased pressure on GPs to undertake therapeutic articoagulation monitoring. This MRC sponsored study tested the effectiveness of utilising a combination of DSS and NPT in general practice to provide an effective warfarin management service in primary care. Method: 9 intervention and 3 control practices recruited from Birmingham run practice nurse anticoagulation clinics, using DSS and NPT (Thrombotrak). Patients were randomised to attend the practice based clinic or continue to attend hosptial clinics. Patients attending the practice clinic had a venous blood sample taken. INR estimation was tested using NPT and the result entered onto the DSS which recommends warfarin dosage and recall date. Patients were given hand held record containing this information. The venous sample was sent to the laboratory for quality control and results recorded centrally. Results: 368 patients were recruited (121 intervention, 103 intra-controls, 144 inter-controls). Improved INR control was seen win 85% of intervention patients in range compared with 62% and 67% for the intra and inter-controls (chi-squared p<0.05). There was also a reduction in the incidence of stroke in the intervention group (n.s.). The capital costs of the DSS and NPT were offset by the savings from patients not attending hospital clinics. Discussion: This study has shown that warfarin management can be undertaken efficiently, effectively and with overall cost savings for Health Services, in primary care, utilising DSS and NPT. With the increasing use of warfarin for stroke prophylaxis in atrial fibrillation this model of care represents a cost-effective method of ensuring maximum benefit, with minimum risk.