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Anticoagulation Management in the Physician Office
Management of the patient undergoing oral anticoagulation therapy, such as warfarin, requires the physician office to have an established system for test tracking and order management. Diligence in following established processes is key in avoiding potential impact on patient care due to over or under anticoagulation. Systematic follow-up enhances patient care by decreasing the likelihood of significant complications.
Warfarin has a very narrow therapeutic window. Failure to adequately monitor a patient or provide appropriate dosing could lead to serious, potentially life threatening complications. The patient may become supratherapeutic and have a serious bleeding event or subtherapeutic and be at risk for a clotting episode. An INR result that is outside the therapeutic range and becomes “lost in the shuffle” in a physician’s office can lead to life threatening complications.
Establishing a tracking system is the first step in effectively managing patients who are on warfarin for anticoagulation. A tracking system is implemented to assure that patient testing is completed when ordered, results are received and evaluated and adjustments are made to the patient’s medication regime (if necessary).
Tracking systems do not have to be complex or high tech. If the office has an electronic medical record (EMR), maximize the utilization of the system to include test tracking. This provides an electronic method that promotes timely communication and documentation.
In practices that do not have an EMR, examples of a tracking system include:
- Developing a simple flow sheet with the patient’s current dose, INR results and previous data allows for quick access to the necessary information.
- Using your electronic scheduling system to alert you that INR results are due on a patient. This will assist in assuring that the patient had the test performed.
- Creating a tickler file by date of those patients who are to have INRs performed to assure that test results are received as expected.
In addition to a tracking system, protocols need to be developed to address the process for patients who fail to show for an appointment/lab test. This process should include a review by the medical provider to determine what follow-up is necessary. Establish a process outlining how to manage a patient who cannot be contacted with results or who fails to respond to attempts to contact. If a patient demonstrates repeated non-compliance with the recommended testing and follow-up, schedule an appointment with the provider. This will provide the opportunity to discuss the importance of close monitoring and the potential risks of non-compliance. Clear, timely documentation in the medical record is essential.
Beyond tracking of test results and appointments, managing the patient’s INR effectively requires a knowledgeable, experienced practitioner to follow established guidelines in dose determination. Assessment of the patient to determine noncompliance, dietary impact or changes in medications needs to occur. Making warfarin dose adjustments based solely on “experience” or “history” with the patient can lead to challenges if the patient suffers a bad outcome due to anticoagulation management. Using an established algorithm is an objective, systematic way to manage warfarin therapy.
If your patient has multiple providers, establish and clearly document which provider will be responsible for prescribing, monitoring and adjusting the warfarin dose for the patient. For those patients receiving anticoagulation management in your practice, communicate the patient’s status with any other providers involved in their care. If you refer your patient to another provider, assure that information regarding the anticoagulation status is communicated.
Provide patients with clear, understandable educational material. Document patient education and understanding of their responsibilities regarding follow-up and ongoing monitoring as well as the expectation of compliance.
Some practices with a high volume of patients on warfarin may consider providing point-of-care testing using an FDA approved handheld device. These testing systems are CLIA-waived. Using a fingerstick instead of a blood draw, these machines provide INR results in less than two minutes. By using a point-of-care testing device, the physician receives test results in a timely manner and can make immediate changes to the medication dose. Additionally, the patient is physically present in the office, allowing an opportunity for face-to-face discussion regarding the patient’s anticoagulation management.
Recent changes to Medicare reimbursement have expanded coverage for home INR monitoring. Certain patients, based on medical history and reliability, obtain a home monitoring device and perform the fingerstick test for INR at home. They then call the results into the office for the provider to assess and make appropriate dose changes when indicated. If your practice has patients using a home monitoring device, a tracking system needs to be in place to assure that the patient is calling in with the results when expected.
Algorithms, Guidelines and Flowsheets
These are provided as reference only and require professional review to determine appropriateness to the clinical setting.
Commercially available systems such as webINR (www.webinr.com) can assist in managing patients on warfarin.
The American Academy of Family Physicians published in the American Family Physician, Volume 71, Number 10, an algorithm and flowsheet that can be seen by clicking here.
Additional algorithms and resources for anticoagulation management can be found at the following links.
Partnering with patients who are anticoagulated with warfarin is essential to assure safe patient care. Making test tracking a priority will reduce the risk of harm to patients from complications of anticoagulation therapy.
Medical Mutual Insurance Company of Maine's "Practice Tips" are offered as reference information only and are not intended to establish practice standards or serve as legal advice. MMIC recommends you obtain a legal opinion from a qualified attorney for any specific application to your practice.