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improving performanceAn audit of two methods of anticoagulationmonitoring in a general practiceKerr R Wright MBChB, DRCOG, MRCGP, FRNZCGPABSTRACTBackground and context: Patients with atrial fibrillation (AF) and a five-year stroke risk >15%should be on long-term oral anticoagulant therapy with adjusted dose warfarin unless there is a clearcontraindication.Assessment of problem: Ad hoc adjustments of warfarin dose and anticoagulation monitoring bya general practitioner is less efficient than a standardised protocol administered by the practice nurses.This study was a retrospective audit of patient anticoagulation control before and after a change inmethod of warfarin adjustment. Measures were frequency of testing, time spent in the therapeutic rangeand mean International Normalised Ratio.Results: Thirty-two patients were studied over a 12-month period. The method change resulted inimportant improvements in practice efficiency while maintaining the standard of anticoagulation controlwith no significant increase in frequency of venesection.Strategies for improvement: General practices still using ad hoc adjustments of warfarin therapycan adopt a standardised nurse-managed protocol to achieve greater efficiency without adverselyaffecting patient care.Lessons: A move from the heavily doctor-intensive ad hoc system to the entirely nurse-led systemimproved practice efficiency. The doctor was liberated from the process. The nurse no longer had to actas liaison with the doctor. The receptionist did not have to ask patients to ring back once the doctor hadseen the results. Patients received their instructions more quickly and their care was not compromised.KEYWORDS: Anticoagulation monitoring; warfarin; family practice.CORRESPONDENCE TO:Kerr R WrightGeneral practitioner,44 Sedgwick Road,Opotiki, Eastern Bay ofPlenty, New Zealanddoctor@heritagehealth.co.nzBackgroundPatients with atrial fibrillation (AF) and a fiveyearstroke risk of over 15% should be on longtermoral anticoagulant therapy with adjusteddose warfarin unless there is a clear contraindicationto doing so. 1 The target InternationalNormalised Ratio (INR) is 2.5, range 2.0–3.0. 2The monitoring of anticoagulation representsa significant workload to general practices. ANew Zealand (NZ) study from 2005 suggeststhat less than half of eligible patients in NZreceive anticoagulation. 3 If these figures are tobe improved, then the workload associated withanticoagulation monitoring in general practice isset to increase. Efficient ways of managing thisworkload are required.Outline of local contextThis study took place in a rural Eastern Bay ofPlenty general practice. At the time of the audit,there was one full-time GP and two practicenurses working 1.2 full-time equivalents. The enrolledpopulation was 2430. Thirty-four percentof the practice was aged under 19 years and 20%aged 60 years or over. Forty-two percent of thepatients identified themselves as Maori.Assessment of problemsApproach takenThe traditional method of monitoring anticoagulationin our practice was similar to that used in318 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE
improving performancemany general practices—a system often describedin the literature as ‘ad hoc adjustments’. Resultsfrom the venesection were faxed from the lab tothe practice. The doctor decided if a dose adjustmentwas required and when the next test shouldbe. The practice nurse would then contact thepatient with the new instructions.As the doctor involved in the dose adjustments, Itook into considerations several factors other thanthe patient’s past INR results. These included myimpression of the patient’s ‘reliability in followinginstructions’, transport and mobility issues.In order to improve efficiency, we decided todevolve the clinical decision-making process tothe practice nurses by adopting a standardisedmethod for INR adjustment. Following an inhouseclinical education meeting, we decided toimplement the guideline produced by the BritishColumbia Health Service as this appeared wellvalidated and easily understood. 4 For the firstmonth of the new regime, all INR adjustmentsmade by the nurse following the anticoagulationguidelines were checked by the doctor and noerrors were found.The change from a method that was ‘tailor-made’by the doctor for each patient to a ‘one size fitsall’ nurse-led method had resulted in importantimprovements in efficiency. Gains in practice efficiencyare sometimes achieved at the expense ofpatient care. Our aim was to discover if any alterationhad occurred in the standard of anticoagulationcontrol or frequency of patient venesection.Measurement of problemUsing patients as their own controls, a retrospectiveaudit was performed for a period of sixmonths before (ad hoc arm) and six months afterthe change in practice (standardised arm). Patientswho commenced or discontinued warfarin duringthe study period were excluded. Only thosepatients whose target INR was 2.0–3.0 wereincluded. Only a small number of patients inthe practice had a target range higher than this.They were patients with mechanical heart valvesand, while they were managed using the sameguidelines, their numbers were too small to allowany meaningful analysis.WHAT GAP THIS FILLSWhat we already know: Most monitoring of anticoagulation occurswithin the primary care setting. Some practices use ad hoc methods ofwarfarin dose adjustment which can be time-consuming and of untestedeffectiveness.What this study adds: Switching from ad hoc adjustments to a standardisedprotocol improved our efficiency and maintained effectiveness.The dates of testing and the INR results for the12-month period were extracted from the practicemanagement software and analysed in order toanswer the following three questions:1. Has there been any change in the frequencyof testing of INRs? To establish this, thelength of time between tests was measuredfor each patient for both study periods. Amean was calculated with a standard deviationto establish whether a significant change inthe frequency of testing had occurred foreach individual and for the group as a whole.Ninety-five percent confidence intervals wereused in establishing significance.2. Has there been any change in the amountof time spent by the patients in thetarget range over the two study periods?Establishing length of time within thetherapeutic range is a complex issue. It canonly be known for sure whether someone iswithin or outside the range on a particularday when an INR test has been performed. Iftwo consecutive results are within the targetrange then an assumption is made that thepatient has been in range for the entire intervalbetween the tests. If consecutive results showone result in target and one out of target thena linear estimate is made of when the patiententered or exited the therapeutic range. Usingthese assumptions, the percentage of timewithin the therapeutic range was calculatedfor each patient for both study periods using95% confidence intervals in establishingsignificance. A mean and standard deviationwas calculated for the test group for bothstudy periods to establish whether or not asignificant change had taken place.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 319
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