Commentary

The growing number of patients receiving long term oral anticoagulation has created a substantial primary care management burden. To achieve benefit-risk ratios similar to those reported in randomised controlled trials, patients' INRs must be maintained in a narrow therapeutic range. However, primary care providers have difficulty in replicating the success observed in the trial setting. Approximately 50% of the time, patients who are receiving anticoagulants are not within the therapeutic range.¹ For patients with atrial fibrillation, the combined rate of major bleeding complications and stroke is 2 to 3 times higher in the “usual” care setting than in special anticoagulation clinics.² Anticoagulation management clinics are more likely than usual care settings to achieve optimal anticoagulation because of dedicated providers, appropriate follow up, access to INR monitoring, decision support systems, and patient education.^{2, 3} Specialised ambulatory anticoagulation management services may be provided in a hospital environment and are often delivered by non-physician providers or pharmacists who are directed by a physician who has no responsibility for the primary care of the patients. With appropriate restructuring, optimal long term anticoagulation may be achieved within a primary care setting with improved overall continuity of care.

The stratified randomised controlled trial by Fitzmaurice et al shows the effectiveness of primary care anticoagulation management that is delegated to a nurse with access to on site INR testing and computerised decision support. Consequently, this study supports the notion that the special features of anticoagulation management services can be incorporated into primary care.² Promising strategies include patient self monitoring and self management.³