ANTICOAGULATION CLINICS - THE ITALIAN EXPERIENCE

Background and Objective. The clinical quality of oral anticoagulant t herapy (OAT) depends on how successful physicians and patients are in achieving and maintaining levels of anticoagulation capable of prevent ing thromboembolic events without increasing the risk of hemorrhagic c omplications. Concerning the patient, education and compliance are the major problems. As for the physician, on the other hand, the manageme nt of patients receiving OAT is a complex task that requires frequent laboratory testing, dosage regulation, prompt diagnosis and treatment of thromboembolic and hemorrhagic events. It requires educated and ski lled personnel and a well-organized framework of services. Anticoagula tion clinics, which provide patient education, close monitoring of pro thrombin time and continuous clinical surveillance, may help in improv ing the overall quality of OAT. Information sources. The authors have been working in this field contributing, original papers. In addition, the material examined in this article includes articles published in the journals covered by the Science Citation index(R) and Medline(R). State of art and Perspectives. The concept of a coordinated network of medical services specifically devoted to the control of OAT was devel oped in the Netherlands following the model created by the late Profes sor Jordan, who in 1949 founded the first thrombosis center at the Uni versity of Utrecht. Many other anticoagulant clinics were organized on a voluntary basis in the following decades in the Netherlands. The Du tch Federation of Thrombosis Centers was founded in 1971 and each affi liated Center is formally recognized and supported by the central Gove rnment. Today, there is a nation-wide system of regionally centralized anticoagulant control for outpatients and home patients that counts a pproximately 70 anticoagulant clinics (thrombosis centers), covering m ore than 90% of the country. Similar global approaches to the manageme nt of patients receiving OAT were proposed in other countries. In the 1950's, a group of internists and surgeons at the University of Michig an, USA, developed a unit specifically devoted to the diagnosis and tr eatment of thromboembolic disease, and proposed common strategies, tea ching and research programs. In 1959, Sevitt and Gallagher were the fi rst to propose a formal recognition of an anticoagulant unit in Great Britain. Finally, the Italian Federation of Centers for the Surveillan ce of Anticoagulant (FCSA) therapies was founded in 1989. Nowadays, It alian anticoagulation clinics operating in the framework of the FCSA a re still voluntary organizations which provide a specific medical serv ice by continuously reorganizing the personnel, structures and resourc es available to meet increasing demands. Since OAT has a profound soci al impact, its control should not be left to the good will of dedicate d people, but should instead represent a specific task of the public h ealth system. The achievement of a formal recognition of federated cen ters is essential for their growth, but the unavoidable increase of th e expenses needed to support anticoagulation clinics is difficult to b ear in a public care system which is currently facing a substantial re duction of financial resources. In a fixed health care budget, a redis tribution of existing resources is the only possible solution, but to achieve this goal, public authorities have to be convinced that the ma nagement of OAT in specific anticoagulation clinics is cost-effective. A more accurate estimate of costs is needed and should be performed b y the FCSA. Finally, the FCSA should strengthen its contacts with pati ent organizations and other scientific associations in order to develo p common action strategies for improving the quality of OAT. (C) 1997, Ferrata Storti Foundation.