Oral anticoagulation management in primary care with the use of computerized decision support and near-patient testing - A randomized, controlled trial

Background: There is increased pressure on primary care physicians to monit or oral anticoagulation. Objective: To test the null hypothesis that oral anticoagulation care can h e provided at least as well in primary care through a nurse-led clinic, inv olving near-patient testing and computerized decision support software, com pared with routine hospital management based on a variety of clinical outco me measures. Methods: A randomized, controlled trial in 12 primary care practices in Bir mingham, England (9 intervention and 3 control). Two control populations we re used: patients individually randomly allocated as controls in the interv ention practices (intrapractice controls) and all patients in control pract ices (interpractice controls). Intervention practices' patients were random ized to the intervention (practice-based anticoagulation clinic) or control (hospital clinic) group. The main outcome measure was therapeutic control of the international normalized ratio. Results: Three hundred sixty-seven patients were recruited (122 interventio n patients, 102 intrapractice control patients, and 143 interpractice contr ol patients). Standard measures of control of the international normalized ratio (point prevalence) showed no significant difference between the inter vention and control groups. Data on proportion of time spent in the interna tional normalized ratio range showed significant improvement for patients i n the intervention group (paired t test, P=.008). Conclusions: Nurse-led anticoagulation clinics can be implemented in novice primary care settings by means of computerized decision support software a nd near-patient testing. Care given by this model is at least as good as ro utine hospital follow-up. The model is generalizable to primary health care centers operating in developed health care systems.