EVALUATION OF COMPUTERIZED DECISION-SUPPORT FOR ORAL ANTICOAGULATION MANAGEMENT BASED IN PRIMARY-CARE

Background. Increasing indications for oral anticoagulation has led to pressure on general practices to undertake therapeutic monitoring. Co mputerized decision support (DSS) has been shown to be effective in ho spitals for improving clinical management. Its usefulness in primary c are has previously not been investigated. Aim. To test the effectivene ss of using DSS for oral anticoagulation monitoring in primary care by measuring the proportions of patients adequately controlled, defined as within the appropriate therapeutic range of International Normalise d Ratio (INR). Method. All patients receiving warfarin from two Birmin gham inner city general practices were invited to attend a practice-ba sed anticoagulation clinic. In practice A all patients were managed us ing DSS. In practice B patients were randomized to receive dosing advi ce either through DSS or through the local hospital laboratory. Clinic al outcomes, adverse events and patient acceptability were recorded. R esults. Forty-nine patients were seen in total. There were significant improvements in INR control from 23% to 86% (P>0.001) in the practice where all patients received dosing through DSS. In the practice where patients were randomized to either DSS or hospital dosing, logistic r egression showed a significant trend for improvement in intervention p atients which was not apparent in the hospital-dosed patients (P<0.001 ). Mean recall times were significantly extended in patients who were dosed by the practice DSS through the full 72 months (24 days to 36 da ys) (P = 0.033). Adverse events were comparable between hospital and p ractice-dosed patients, although a number of esoteric events occurred. Patient satisfaction with the practice clinics was high. Conclusion. Computerized DSS enables the safe and effective transfer of anticoagul ation management from hospital to primary care and may result in impro ved patient outcome in terms of the level of control, frequency of rev iew and general acceptability.