Computer control of anticoagulant dose for therapeutic management.

Ryan, Patricia; Gilbert, Martin; Rose, P.

doi:10.1136/bmj.299.6709.1207

Cited by 76 publications

(39 citation statements)

References 6 publications

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“…The Coventry paper (Ryan et al, 1989) described an improvement in therapeutic INR control following the introduction of CDSS. It was not possible to ascertain the level of performance before the introduction of CDSS and whether the reported improvement was a true effect or reflected the learning curve associated with the introduction of new technology.…”

Section: Resultsmentioning

confidence: 99%

“…In general terms, two main types of expert system are available: rule-based systems, where operations are performed subject to a set of rules obtained from a single or group of specialists in a given field; and probabilistic systems where evidence is weighed and then the best option calculated according to Bayes Theorem (Lundsgaarde, 1987). Anticoagulation systems are also essentially of two further types, being concerned either primarily with initiation of warfarin therapy (Sun & Chang, 1995;Svec et al, 1985) or with maintenance therapy (Wilson & James, 1984;Mariani et al, 1990;Ryan et al, 1989). Initiation modules tend to use Bayesian predictions allied with pharmacodynamic modelling.…”

Section: Discussionmentioning

confidence: 99%

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Review of computerized decision support systems for oral anticoagulation management

et al. 1998

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Summary. Computerized decision support systems (CDSS)are available to assist clinicians in the therapeutic management of oral anticoagulation. We report the findings relating to CDSS for oral anticoagulation management of a primary-care-based systematic review which largely focused on near-patient testing. Seven papers were reviewed which covered four different systems. The methodology of these papers was generally poor, although one randomized controlled trial showed improved therapeutic control associated with computerized management compared with human performance.Keywords: computerized decision support system, oral anticoagulation.Therapeutic monitoring of warfarin therapy requires two key elements to be undertaken if it is to be successful: the measurement of the INR and an interpretation of the result in order to advise on dosage of warfarin and when the next test should be performed. The element of interpretation has traditionally been the consultant haematologist's role, with primary care physicians expressing concern at their perceived lack of clinical knowledge to undertake this service (Taylor et al, 1993).Computerized decision support systems (CDSS) can be defined as 'programmes designed to give advice about significance of results and their implications for subsequent patient management ' (Hobbs et al, 1997). The principle underlying the utilization of CDSS within any clinical environment is that a reproducible decision will be made given a certain set of data. Many clinical situations have been investigated to ascertain the utility of CDSS; however, few have demonstrated enduring effect. One area where success has been reported is the field of oral anticoagulation management.The principle advantages to CDSS are deemed to be reproducibility of interpretation within centres, standardization between centres, and ease of performance assessment. If these features are present, CDSS could enable non-specialist clinicians to undertake tasks which have previously been the domain of the specialist. Anticoagulation CDSS has been reported as enabling non-specialist staff to undertake therapeutic monitoring within hospital clinics, and also to provide accurate data for audit (Hobbs et al, 1997).This paper reports on the literature identified as part of a systematic review which reported on near-patient testing, CDSS and rapid transit systems relevant to or within primary care (Hobbs et al, 1997). METHODSAs part of a systematic review of near-patient tests in primary care (Hobbs et al, 1997), computer searches were undertaken covering the period 1986-95 using the following literature databases: Medline; BIDS (Bath-ISI-DataService); Science Citation Index; Index to Scientific and Technical Proceedings, Department of Health; EMBASE; GP Lit Data Base, Royal College of General Practitioners; and CINHAL. The key words used for CDSS were: computerized decision support, expert systems, electronic data interchange and computer communication networks; in combination with: family practice, primary (health) care, physician...

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Review of computerized decision support systems for oral anticoagulation management

et al. 1998

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“…The blood sample was tested using a Thrombotrak near-patient testing device (Nycomed, UK) and Coventry' computer decision support software helped to provide the dosage (Ryan et al, 1989). Patients received their dosage information before leaving the clinic.…”

Section: Methodsmentioning

confidence: 99%

Anticoagulation management in primary care: a trial‐based economic evaluation

2000

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Summary. The demand for anticoagulation management is increasing because of a widening of the indications of treatment. A primary care clinic using near-patient testing and computer decision support software is one model of care to meet this increased demand. The study aimed to determine the cost and cost-effectiveness of primary carebased anticoagulation management in comparison with traditional' hospital care-based provision by means of a cost-effectiveness analysis using data from a Birminghambased multicentre randomized controlled trial. The costs per patient per year in primary care were £170 [95% confidence interval (CI) £149±190] vs. £69 (95% CI £57±81). Sensitivity analysis demonstrated that the cost in primary care could be reduced to under £100 per patient per year under plausible changes in the variables. Primary care provides similar levels of control to secondary care for patients on anticoagulation therapy. There is an increased cost of managing patients in primary care and at no point did primary care become a lower cost option than secondary care. Local decision-makers need to assess the increased cost of primary care anticoagulation management in terms of the potential reductions in high-cost serious adverse events.Keywords: economic evaluation, anticoagulation, warfarin, primary care, secondary care.The continuing expansion of clinical indications for warfarin (particularly non-rheumatic atrial fibrillation) has greatly increased the pressure on hospital anticoagulation management services (Sudlow et al, 1995;Sweeney et al, 1995). In response, various efforts have been undertaken to provide care in non-hospital settings. Studies have demonstrated that care within non-hospital settings can be at least as good as hospital care in terms of International Normalized Ratio (INR) control and the incidence of adverse events (Pell et al, 1993;Radley, 1995;Fitzmaurice et al, 1997). There has been little research, however, into the cost implications of devolving anticoagulation care into the community. This paper provides a report of an economic evaluation of one new model of care: a practice nurse-led, primary care clinic utilizing nearpatient testing for INR testing combined with a computerized decision support system to assist with warfarin dosing (hereafter primary care) which was compared with conventional hospital management. METHODSThe economic evaluation used data from a Birminghambased multicentre randomized controlled trial which is reported in full elsewhere (Fitzmaurice et al, 2000). Patients were randomized either to the primary care intervention arm or to the hospital control arm. The clinical study was powered to detect a 20% difference in INR control at 5% significance, and analysis was on an intention-to-treat basis. For the economic evaluation power calculation, a £25 difference in the cost per patient per annum was taken to be a significant cost difference, which at 80% power and 5% significance required 63 patients in each arm of the trial. Effectiveness was measured by the proportion ...

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“…The significance of this issue for all healthcare systems with aging populations can be estimated from data showing that of patients with identified atrial fibrillation, only one third are currently receiving anticoagulation [4]. Furthermore, in the absence of screening programs, possibly 60% of patients with AF remain unidentified [7]. Based on these data, the service requirements for anticoagulation monitoring may be predicted to increase by a factor of 5.…”

Section: Introductionmentioning

confidence: 97%

Oral Anticoagulation Control: The European Perspective

Fitzmaurice

2006

J Thromb Thrombolysis

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We describe the results of a novel complete care package using point-of-care INR testing and computerized decision support for the management of oral anticoagulation by nurse-led primary care clinics in the United Kingdom. We found such therapy to be as safe and effective as traditional hospital-based care for oral anticoagulation in the UK as determined by adverse events or International Normalized Ratio (INR) time in range. We then review the literature as it pertains to the safety, efficacy, and cost effectiveness of patient self-management with point-of-care INR testing at home and discuss the implications for such care in the UK.

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Computer control of anticoagulant dose for therapeutic management.

Abstract: Objective-To improve the standard of managing anticoagulant treatment and provide a basis for therapeutic quality control.Design-Implementation of a comprehensive computerised system for decision support.Setting-Three anticoagulation clinics in South Warwickshire.

Cited by 76 publications

References 6 publications

Review of computerized decision support systems for oral anticoagulation management

Review of computerized decision support systems for oral anticoagulation management

Anticoagulation management in primary care: a trial‐based economic evaluation

Oral Anticoagulation Control: The European Perspective

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