Managed Care - October 2008 - (Page OA5) term anticoagulant therapy (warfarin PI 2007). Other patients who stand to benefit from PST include those with conditions or circumstances that make accessing usual care difficult; physical disabilities and financial constraints may limit a patient’s transportation options, for instance, or the patient may live far from the practitioner or clinic, preventing the patient from receiving INR monitoring at the frequency needed for optimal warfarin management. Patients who spend significant periods of time traveling from home or who have demanding work schedules also may benefit from the availability of PST programs. Likewise, caregivers who may have to make special work or child care arrangements to accompany the patient to office visits may welcome the flexibility that PST offers. Implementing PST as part of a comprehensive management plan offers patients and their caregivers an option to achieve or maintain high-quality care and may be more practical for some patients than the traditional model. The panel did not recommend an upper age limit for patient selection, but advised that practitioners evaluate each patient individually for clinical appropriateness to perform weekly self-testing. The panel recommends that physicians and other practitioners offer PST to any patient who meets the following criteria: • Willingness to participate in training on the proper use of PST in the context of a comprehensive management plan • Ability to attend face-to-face training and follow all procedures for testing, communicating results, complying with dose adjustments, and attending follow-up office visits • Reliability with regard to the practitioner’s assessment of the patient’s trustworthiness to adhere to all instructions • Access to a telephone or other devices to communicate with the practitioner • The presence of a caregiver or proxy who meets the above criteria if the patient does not Practitioners might consider a contract-based arrangement with patients who begin PST so that expectations are clear, and the patient understands that PST is based on medical necessity. All patients and/or caregivers should understand that participating in PST can continue only if adherence is consistently high, and that termination of PST will be implemented if adherence is inadequate. Such a contract might include specific elements that define compliance, including frequency of testing, timeliness of reporting results, and following all prescribed instructions regarding care. Panel members reported that some patients with chronic conditions become even more motivated to improve their health when offered the opportunity to take on more responsibility for their own care. “[Practitioners] should not underestimate the ability of patients to take care of their own problems as long as we give them the tools and guidelines.” — DAVID GREEN, MD, PHD Communication between practitioners and patients Effective, clear, consistent communication between practitioners and patients is a critical component of any high-quality oral anticoagulant management system. With the implementation of PST, there must be an easily accessible system for patients to report their weekly INR results and for practitioners to communicate dose adjustments or other instructions to the patient. There are several ways to set up a reliable system for patients to report their weekly INR results, and health care practitioners may choose from several options, depending on their preferences and needs. An answering machine phone line may be dedicated to PST patients calling in results, or e-mail or fax may be used if the retrieval system is reliable. An alternative method is to use a third-party patient management vendor who would receive results from patients and communicate them in real time to the practitioner. Health care practitioners implementing PST may schedule different patients for testing on different days of the week or all on the same day, depending on the office schedule and number of patients performing PST. There should be a protocol for contacting patients for whom a result is not received on the day it was expected, and the practitioner should review the INR results within a reasonable time frame and develop an individual office protocol for contacting patients regarding dose adjustments. Alternatively, the practitioner may prescribe INR-based dose adjustment instructions for patients. Patients and practitioners should maintain appropriate documentation of communication with each other, and to the extent possible, redundancy should be built into the program so that patient records can be crosschecked periodically. Voice-response software is available to facilitate the collection and real-time transmission of results without an increase in telephone activity. With these systems, patients call a toll-free number and enter a unique identifier and their weekly INR result. The system then asks the patient to confirm the data, and promptly transmits the information to the practitioner’s designated system. The many options for communications systems enable practitioners to select one that will allow their offices to function efficiently and prevent an increase in nonurgent SUPPLEMENT / ORAL ANTICOAGULATION 5
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