Letters

Managing the increased workload in anticoagulant clinics

EDITOR,--F C Taylor and colleagues describe a method of managing the increasing number of patients seen in anticoagulant clinics by reducing the number of contacts with medical staff by using a screening process.¹ They show no improvements in clinical care in terms of the percentage of time for which patients' international normalised ratio is within the target range yet conclude that this is "a suitable method for managing the increasing numbers of patients without incurring additional costs, such as buying computer dosing systems or by shifting anticoagulant services to primary care."

As it has been shown that the percentage of time for which patients' international normalised ratio is within the therapeutic range can be consistently improved by use of computer dosage support^{2 3} it could be argued that improved control resulting in fewer attendances at the clinic would be a cheaper and more effective method of managing the increasing number of patients. Computer dosing also allows rapid identification of patients whose condition is poorly controlled and whose treatment requires medical input. For example, the 50 patients with the worst results identified by computer in south Warwickshire included 15 with recurrent deep vein thrombosis, 14 of whom were taking warfarin at the time of the recurrence. Such valuable clinical information would not be routinely available to anticoagulant clinics that did not use computer support.

A multicentre study is currently being undertaken in Birmingham to assess the usefulness of computerised decision support in association with near patient testing to manage patients being treated with warfarin. Far from leading to an increase in costs as suggested by Taylor and colleagues, this method of management could lead to a considerable cost saving, and it is much preferred by patients. Taylor and colleagues suggest that adequate clinical control can be achieved with reduced medical contact. The logical conclusion from this is that clinical control can be achieved with minimal if any medical contact, and, indeed, in south Birmingham patients attending the hospital based anticoagulant clinic see a doctor only on their first visit.

Several models of care will need to be available for patients receiving warfarin, and these will include traditional hospital based clinics, computerised decision support, and primary care clinics incorporating new technologies. It is important that these services are developed in partnership so that patients can receive personalised care that is suitable to both their physical health and their social environment.

Lecturer in general practice Consultant haematologist Medical audit officer Department of General Practice, Medical School, University of Birmingham, Birmingham B15 2TT

D A Fitzmaurice, P E Rose, M Gilbert 

1. Taylor FC, Ramsey ME, Renton A, Cohen H. Methods for managing the increased workload in anticoagulant clinics. BMJ 1996;312:286. (3 February.) [Free Full Text]
2. Ryan P, Gilbert M, Rose P E. Computer controlled anticoagulant dose of therapeutic range. BMJ 1989;299:1207-9.
3. Polar L, Wright D, Rowlands A. Prospective comparative study of computer programmes used for management of warfarin. J Clin Pathol 1993;46:299-303. [Abstract/Free Full Text]