Resource consumption and management associated with monitoring of warfarin treatment in primary health care in Sweden.

Gunnar H Nilsson,Ingela Björholt,Ingvar Krakau,Stina Andersson

doi:10.1186/1471-2296-7-67

Abstract

BackgroundWarfarin is used for the prevention and treatment of various thromboembolic complications. It is an efficacious anticoagulant, but it has a narrow therapeutic range, and regular monitoring is required to ensure therapeutic efficacy and at the same time avoid life-threatening adverse events. The objective was to assess management and resource consumption associated with patient monitoring episodes during warfarin treatment in primary health care in Sweden.MethodsDelphi technique was used to systematically explore attitudes, demands and priorities, and to collect informed judgements related to monitoring of warfarin treatment. Two separate Delphi-panels were performed in three and two rounds, respectively, one concerning tests taken in primary health care centres, involving 34 GPs and 10 registered nurses, and one concerning tests taken in patients' homes, involving 49 district nurses.ResultsIn the primary health care panel 10 of the 34 GPs regularly collaborated with a registered nurse. Average time for one monitoring episode was estimated to 10.1 minutes for a GP and 21.4 minutes for a nurse, when a nurse assisted a doctor. The average time for monitoring was 17.6 minutes for a GP when not assisted by a nurse. Considering all the monitoring episodes, 11.6% of patient blood samples were taken in the individual patient's home. Average time for such a monitoring episode was estimated to 88.2 minutes. Of all the visits, 8.2% were performed in vain and took on average 44.6 minutes. In both studies, approximately 20 different elements of work concerning management of patients during warfarin treatment were identified.ConclusionMonitoring of patients during treatment with warfarin in primary health care in Sweden involves many elements of work, and demands large resources, especially when tests are taken in the patient's home.

Highlights

Warfarin is used for the prevention and treatment of various thromboembolic complications
International Normalized Ratio (INR) tests taken at a primary health care (PHC) centre The objective of panel I was to assess resource consumption associated with INR monitoring episodes in patients during warfarin treatment when the INR test was taken at a PHC centre
INR tests taken at a PHC centre Of the 50 general practitioners (GPs) invited to the study, 35 participated in the first round, 15 were primary respondents, 9 were first stand-ins and 11 were second stand-ins

Summary

Introduction

Warfarin is used for the prevention and treatment of various thromboembolic complications It is an efficacious anticoagulant, but it has a narrow therapeutic range, and regular monitoring is required to ensure therapeutic efficacy and at the same time avoid life-threatening adverse events. Oral ACs, i.e. vitamin K-antagonists, are used for the prevention and treatment of various thromboembolic complications Their efficacy has been demonstrated in a broad range of indications. The standard oral AC in Sweden is warfarin It is an efficacious anticoagulant, but it has a narrow therapeutic range, and interacts with a number of common drugs as well as with food and alcohol. If under-coagulated the patient is at risk of a thromboembolic event, while if over-coagulated there is a risk of bleeding complications Patients on such treatment require regular monitoring of International Normalized Ratio (INR) values, in order to ensure therapeutic efficacy and at the same time avoid lifethreatening adverse events. In Sweden such monitoring episodes are either managed by hospital anticoagulation clinics, in PHC, or in the patient's home

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