Managed Care - October 2008 - (Page OA8) edgeable health care practitioner for patient assessment and follow-up, ongoing patient education regarding anticoagulant therapy and the patient’s disease state, and oversight of the therapy in the context of any comorbidities. Ongoing, age-appropriate patient education during regular office visits should include basic principles of coagulation that pertain to anticoagulation therapy, the effects of foods and medications on therapy, symptoms of bleeding and thrombotic events, and topics related to travel, nutrition, and other issues that may arise. Periodically, the practitioner may choose to observe the patient perform INR testing during an office visit to ensure continued correct use of the device. responding to emerging evidence-based guidelines and the changing requirements of accrediting organizations, and to the increasing demand by patients to participate more fully in their own care. References Albers GW, Dalen JE, Laupacis A, et al. Antithrombotic therapy in atrial fibrillation. Chest. 2001;119:194S–206S. Ansell J, Hirsh J, Poller L, et al. The pharmacology and management of the vitamin K antagonists: The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004;126:204–233. Ansell J, Jacobson A, Levy J, et al. Guidelines for implementation of patient self-testing and patient self-management of oral anticoagulation. International consensus guidelines prepared by International Self-Monitoring Association for Oral Anticoagulation. Int J Cardiol. 2005;99:37–45. Ansell JE, Patel N, Ostrovsky D, et al. Long-term patient selfmanagement of oral anticoagulation. Arch Intern Med. 1995; 155:2185–2189. Beyth RJ, Quinn L, Landefeld CS. A multicomponent intervention to prevent major bleeding complications in older patients receiving warfarin. A randomized, controlled trial. Ann Intern Med. 2000;133:687–695. CMS (Centers for Medicare and Medicaid Services). Decision Memo for Prothrombin Time (INR) Monitor for Home Anticoagulation Management (CAG-00087R) [Memorandum]. Decision memo for prothrombin time (INR) monitor for home anticoagulation management (CAG-00087R). March 19, 2008. Heneghan C, Alonso-Coello P, Garcia-Alamino JM, et al. Selfmonitoring of oral anticoagulation: a systematic review and meta-analysis. Lancet. 2006;367:404–411. Horstkotte D, Piper C, Wiemer M. Optimal frequency of patient monitoring and intensity of oral anticoagulation therapy in valvular heart disease. J Thromb Thrombolysis. 1998;5 (3 suppl 1):19–24. Joint Commission. Accreditation Program: Long Term Care. National Patient Safety Goals. «http://www.jointcommission. org/NR/rdonlyres/BD44F7AA-84D6-45ED-A0C5-33D3118 CF973/0/09_NPSG_LTC.pdf». Accessed Aug. 20, 2008. Körtke H, Körfer R. International normalized ratio self-management after mechanical heart valve replacement: is an early start advantageous? Ann Thorac Surg. 2001;72:44–48. Koertke H, Zittermann A, Wagner O, Koerfer R. Self-management of oral anticoagulation therapy improves long-term survival in patients with mechanical heart valves. Ann Thorac Surg. 2007;83:24–29. Lafata JE, Martin SA, Kaatz S, Ward RE. Anticoagulation clinics and patient self-testing for patients on chronic warfarin therapy: a cost-effectiveness analysis. J Thromb Thrombolysis. 2000;9:S13–S19. Sawicki PT. A structured teaching and self-management program for patients receiving oral anticoagulation: a randomized control trial. JAMA. 1989;281:145–150. Völler H, Glatz J, Taborski U, et al. Self-management of oral anticoagulation in nonvalvular atrial fibrillation (SMAAF study). Z Kardiol. 2005;94:182–186. Warfarin [package insert]. Princeton, N.J.: Bristol-Myers Squibb Company. August 2007. «http://www.fda.gov/cder/foi/ label/2007/009218s105lblv2.pdf». Accessed Aug. 20, 2008. White RH, McCurdy SA, von Marensdoff H, et al. Home prothrombin time monitoring after the initiation of warfarin therapy: a randomized, prospective study. Ann Intern Med. 1989;111:730–737. White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107(23 Suppl 1):I4–I8. A call to action PST has been shown to result in significant benefits for patients and their families, health care practitioners, and health care systems. Although effective, warfarin therapy has been associated with an increased risk of bleeding complications that can be reduced by implementing evidence-based programs, such as PST and PSM, that facilitate optimum INR control. The 2008 Joint Commission National Patient Safety Goals include reducing the likelihood of harm associated with the use of anticoagulants. The Goals specifically state that the implementation of standardized practices that include patient involvement may be useful in reducing the risk of anticoagulant therapy. To comply with the requirements, the Joint Commission has set a year-long implementation period during which organizations must phase in standardized programs to reduce the risk of complications with anticoagulant therapy. Complete implementation is expected by Jan. 1, 2009. Elements of such a program include the use of a defined anticoagulant management program that allows for the provision of individualized care; use of approved dosing protocols for initiation and maintenance; provision of education about anticoagulation therapy to staff, patients, and their families; and evaluation of anticoagulation practices (Joint Commission 2008). Implementing PST may fulfill the Joint Commission requirements for standardizing oral anticoagulant therapy to reduce the likelihood of bleeding or thrombotic complications associated with over- or under-dosing of warfarin. PST also provides a way to improve patients’ lives, reduce costs to the health care system, and allow practitioners a more efficient and effective way to manage their patients. The growing clinical evidence supporting PST and the changing landscape of health care delivery are driving a paradigm shift in the management of patients receiving oral anticoagulant therapy. Many practitioners view PST as an important tool to help them respond to these changes and improve the standard of care for their patients. They also understand the importance of PST in 8 MANAGED CARE / SUPPLEMENT http://www.jointcommission.org/NR/rdonlyres/A552F1C7-071C-4927-B2B8-1789FCABB974/0/LTC_NPSG_Outline.pdf http://www.jointcommission.org/NR/rdonlyres/A552F1C7-071C-4927-B2B8-1789FCABB974/0/LTC_NPSG_Outline.pdf http://www.jointcommission.org/NR/rdonlyres/A552F1C7-071C-4927-B2B8-1789FCABB974/0/LTC_NPSG_Outline.pdf http://www.fda.gov/cder/foi/label/2007/009218s105lblv2.pdf http://www.fda.gov/cder/foi/label/2007/009218s105lblv2.pdf
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