The requirement to respect autonomy - The Royal New Zealand ...

improving performanceFigure 1. An example of an INR recordfrom practice management software. A MicrosoftOffice Excel spreadsheet could be produced easilywhich would allow the exercise to be reduced to asimple matter of data entry.AcknowledgmentsI would like toacknowledge the work ofmy son Kyle Wright whoperformed the statisticalanalysis for this study whilehe was an undergraduatestudent in mathematics.FundingNo funding was receivedfor this study.Conflict of interestNone declaredIndividual mean INRWith one patient showing a rise in mean INRand another a fall and the majority showingno change, it can be concluded that the changein method did not have a significant impact onmean INR.Lessons and messagesMachin suggests that a reasonable standard forgood control of warfarin therapy is an INRwithin the therapeutic range 60% of the time. 5The British guidelines for anticoagulation controlquote 50%. 6 It would appear that this standardcan be achieved in my practice either by using myad hoc approach (65.3%) or by my nurses usingthe ‘British Columbia Health Service’ standardisedprotocol (69.3%).This is a study with a small number of patientsin a single practice. Factors such as ethnic mix,educational status and socioeconomic status maylimit the ability for these results to be generalisedto other general practices in NZ.While it is likely that most doctors would followthe same general principles, the effectiveness ofan individual doctor’s ad hoc approach will beunknown unless the practice data is audited. Theraw data for a practice audit is easily obtainedThe switch in my practice away from the heavilydoctor-intensive ad hoc system to the entirelynurse-led system was motivated by a desire to improvepractice efficiency and free up doctor time.Our experience was that this was achieved. Thedoctor was liberated from any part in the process.The nurse’s time was used more efficiently by nolonger having to act as a liaison with the doctor.Patients were able to get their instructions morequickly and were able to discuss the adjustmentwith the nurse making the clinical decision.Nobody was more pleased by the change than ourreceptionist who no longer had to inform patients‘the doctor hasn’t had time to look at your resultsyet, can you phone back later?’. This improvedefficiency is likely to be even greater in a grouppractice where several doctors may be involved inthe warfarin adjustment process.Changing from one system to the other can bedone quickly and with a minimum of planning.While new anticoagulant drugs not requiringsuch rigorous monitoring are under trial elsewherein the world, it is likely that we in NZ arestill several years away from having a safe andeffective alternative to using warfarin.References1. Lafuente-Lafuente C, Mahe I, Extramiana F. Management ofatrial fibrillation. BMJ. 2010;340:40–45.2. New Zealand Guidelines Group. The management of peoplewith atrial fibrillation and flutter. 2005.3. Nair A, Hazell W, Sutton T, Pillai S. Antithrombotic therapy inatrial fibrillation: an assessment of compliance with guidelines.N Z Med J. 28 Jan 2005; 118(1208).4. Guidelines and Protocol Advisory Committee. Initiation andmonitoring of warfarin therapy. British Columbia Medical Association.2004;1–8.5. Machin SJ. Medico legal problems associated with oral anticoagulantservices. In: Fitzmaurice DA and Murray ET, editors.Oral anticoagulation management and stroke prevention:the primary care perspective. Newmarket: Hayward MedicalCommunications. 2002;50–57.6. Baglin T et al. Guidelines on oral anticoagulation. Br J Haematol.1998;101:374–387.322 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE