No abstract

CommentThe data show that the number of HIV related consultations in Dutch general practice is rather low. However, the increase observed in the number of these consultations during the study period and the differences in the numbers of consultations recorded between practices are remarkable. General practitioners can play an important role in reassuring their concerned patients providing that they can translate the general information about AIDS/HIV to the needs of the individual patients.Funding: Ministry of Welfare, Health and Culture, after nomination by the Dutch programme committee for AIDS research.Conflict ofinterest: None. (42) 73 (60) 41 (49) by calculating the interval between INR tests and dividing it equally between INR results at the beginning and end of each interval. After the baseline audit the clinic system was modified so that fewer patients were required to see the doctors: new attenders until control had been stabilised, patients whose INR was outside therapeutic limits, those asking to see the doctor, and those who had experienced five key events relating to anticoagulant control (bruising or bleeding; attendance at an accident and emergency department; admission to hospital; starting, stopping, or changing any medicines; notification of dental treatment or surgery due within two months). Health care assistants were trained to ask each patient about the five key events at each visit (excluding first attendance), to record the answers on the revised treatment card, and to refer to the doctors any patients who said they had experienced any of the events. All other patients had their doses determined by the doctors without consultation.In 1993 seven months after these changes were implemented we repeated the audit. Owing to an increase in the number of patients attending clinic, the second sample consisted of 206 patients: 122 patients in group 1 and 84 in group 2. The second audit included four patients in group 1 and 37 in group 2 from the first audit.

Safe levels of anticoagulation are normally considered to be achieved if patients are maintained within their therapeutic international normalized ratio (INR) range for 70% or more time, but evidence in the United Kingdom suggests that this is often not attained. Recently, alternative models in the management of out-patient anticoagulation have been investigated with favourable results. We report on a study which compared a consultant anticoagulant service (CAS) with a nurse specialist service (NSAS). A sequential design was used with data collected on the consultant run service (CAS), followed by similar data on a NSAS over two 6 month periods. Two patient groups were recruited: those newly referred (group A) and those on long-term treatment (group B). Outcomes were the proportion of time patients spent within INR range, documentation of relevant clinical details, number of drugs taken which may adversely interact with and/or inhibit haemostatic function and patient knowledge. The results indicate that the NSAS was as good as the CAS in maintaining therapeutic control and better at documenting relevant clinical details in reducing the number of drugs taken which may adversely interact with and/or inhibit haemostatic function and in improving some aspects of patient knowledge.

Aims-To determine the costs and effectiveness of an anticoagulant nurse specialist service compared with a conventional consultant service based on two hospital sites in northwest Hertfordshire. Methods-Sequential design comparing retrospectively the conduct and outcomes of a consultant service with a nurse specialist service over two six month periods. In each of the six month study periods, all new patients consecutively referred for anticoagulation over a three month period (group A) at the start of each study period and a random selection of patients who had already been attending the anticoagulant service for one year or more (group B) were included in the study. Group A patients were followed for up to three months and group B patients for six months. The main outcome measures were costs of service provision and effectiveness. Costs included those for the use of the anticoagulant service, those related to general practitioner (GP) visits and hospitalisations, and running costs (staff time, laboratory tests, patient transport). Measures of effectiveness were the mean proportion of time patients spend in the therapeutic range, the number of drugs being taken that could interact adversely and/or inhibit haemostatic function, and patient and GP satisfaction with service provision. Results-In the consultant service, for group A there were more patients aged 66-75 years (p = 0.004) and fewer patients aged more than 76 years (p = 0.001); and for group B, there were fewer patients on anticoagulation for cardiac conditions (p = 0.001), but more on anticoagulation for thromboembolic conditions (p = 0.02) than in the nurse specialist service. The clinic running costs of the nurse specialist service were £4.99 per attendance, compared with £4.75 in the consultant service. Including all other costs related to treatment, there was no statistically significant difference in cost per patient. There was no significant difference in the proportion of time patients spent in the therapeutic range between the consultant service and the nurse specialist service. In the nurse specialist service, fewer patients in group A were taking drugs that could interact adversely and/or inhibit haemostatic function (p = 0.01) and more patients were satisfied with service provision (p = 0.04) compared with the consultant service. There was no significant variation in GP satisfaction between the two services. Conclusion-In the provision of outpatient anticoagulation, the nurse specialist service was no more expensive than the consultant service and, using our primary outcome, at least as effective. The nurse specialist service has some clear advantages compared to the consultant service: provision of domicilliary care for housebound patients, fewer new patients taking drugs that could interact adversely and/or inhibit haemostatic function patients, it is preferred by newly referred patients to the consultant service, and it is as acceptable to their GPs.

F. Physicians' attitudes towards oral anticoagulants and antiplatelet agents for stroke prevention in elderly patients with atrial fibrillation. Arch Intern Med 1991;151:1950-3.