.jpg)
Win an iPod
Point-of-Care PT/INR Testing: A Better Choice For Your Patients and Your Practice
| Author: Michael Samoszuk |
| Company: Roche Diagnostics |
| Article Date: 1/31/2007 |
| For More Information |
This article is the first in a two-part series on systematic anticoagulation management at the point of care. In the February issue, Part 2 will discuss the practical components of a successful POC anticoagulation therapy program.
Point-of-care PT/INR testing: A better choice for your patients and your practice
Michael Samoszuk, MD
Dr. Michael Samoszuk currently holds the position of Chief Medical Officer with Roche Diagnostics Corporation, maker of CoaguChek® products. The views expressed herein are based upon his professional judgment and do not necessarily reflect the views of Roche Diagnostics Corporation.
Oral anticoagulant therapy with warfarin is generally used for the prevention and treatment of strokes related to atrial fibrillation, DVT and other vascular conditions. Under many conditions, the therapy can be highly effective.1,2
The management of that therapy, however, can be highly ineffective.
For example, one study reported that less than half of all patients on oral warfarin treatment are in their therapeutic range – which means the rest are at greater risk for serious complications, including bleeding and strokes.1,3
There are several reasons why therapy management can be problematic: a narrow therapeutic dosing range; the influence of medication, diet and liver function; and inefficient office workflow models that make it hard to manage warfarin patients cost-effectively.4,5,6 Those challenges help explain why only one out of four patients with indications for warfarin therapy actually receive the treatment.4,7,8,9
There is a solution, however – one that can benefit both patients and a physician practice.
A systematic focus on patient care
Systematic anticoagulation management (SAM) at the point of care shifts the focus in warfarin therapy from a very labor-intensive administrative process to personalized patient care.
Multiple studies have shown that a systematic approach to anticoagulation management, focused at the point of care, may increase the time patients are in range and reduce the risk of adverse events.5,10,11
In particular, they’ve shown that point-of-care PT/INR testing and anticoagulation management can be more cost-effective than traditional medical care. By putting patient, physician and test results in the same place at the same time, they facilitate timely and proper patient evaluation and education.2,4
Immediate access to results for better quality of care
Point-of-care anticoagulation management combines testing accuracy comparable to that of outside laboratories with the convenience of immediate access to test results.13,14 Thus, treatment decisions can be made and discussed with patients while they are still in the office (see Figure 1).
By establishing systematic anticoagulation management at the point of care, healthcare professionals have an ideal framework to:
Administer therapy more effectively
Ensure timely testing and dosage adjustments
Maximize patient compliance
Reduce the risk of adverse events
Studies have shown that point-of-care PT/INR testing enhances the quality of care – enabling faster and more consistent clinical turnaround time for warfarin dose adjustment and closer monitoring of patients on anticoagulation therapy.1,4,5
Improved patient satisfaction and compliance
Patients say they like the convenience of point-of-care testing, too. Results from the Prothrombin Office-Testing Benefit Evaluation (PROBE) study indicate that patients prefer fingerstick PT/INR tests with a portable monitor over venous lab draws.1,15
img src='http://www.physiciansofficeresource.com/images-article/figure10.JPG''width=400 height=300'>
That preference doesn’t have to come at the expense of accuracy. Extensive evaluation of the accuracy of the CoaguChek S portable, office-based monitor to test PT/INR, for example, indicates that the results are essentially equivalent to what would be expected from a central laboratory.1,13,14,16
Perhaps most importantly, office-based PT/INR testing can provide a greater degree of satisfaction to physicians, nurses, and patients than conventional lab-based testing – and “satisfaction” may be the most critical component in determining patient adherence to therapy and, therefore, outcomes.1
Greater efficiency for better office economics
Conventional lab-based care of anticoagulated patients can involve significant direct and indirect costs – often including extensive chart activity and follow-up phone contact with the laboratory and the patient.
There can also be additional medical costs and liability concerns if the office or clinic does not track patients accurately and perform timely follow-up.
Therefore, making anticoagulation patient evaluation and treatment easier and more efficient is important from both a financial and a practical standpoint.
Establishing systematic anticoagulation management at the point of care can have a significant impact on office efficiency because it can help eliminate the extra time-consuming steps involved in traditional lab-based care. For example, it may reduce or even potentially eliminate late-night calls to the emergency room to verify results, as well as other inconvenient, labor-intensive administrative tasks.
In one workflow process flow analysis, median turnaround time (from initial blood draw to patient notification of test results) was 8 minutes for clinics doing PT/INR testing with a point-of-care device, compared to 498 minutes (8+ hours, with a range of 22 minutes to 23 days) for clinics using outside laboratories.4 In the PROBE study, switching to point-of-care testing significantly reduced the nursing time required for each patient, as well as the workload in medical records.1
Potentially lower costs, higher revenue capture
By streamlining both the data management and the patient care components of warfarin therapy, systematic anticoagulation management may reduce the indirect costs of patient management (see Figure 2).5
In addition, it may actually increase revenue. In one study, for example, managing patients with computerized decision support and an optimized workflow at the point of care enabled a university-affiliated primary care clinic to:
Capture additional revenue of more than $320 per patient per year
Reduce labor-related overhead costs by approximately 75%5
Because systematic anticoagulation management can be more effective than routine care, the costs of care for patients can be reduced as well. One extensive economic analysis estimated that the total cost associated with routine medical care for atrial fibrillation patients on oral warfarin therapy was nearly twice as high as the cost under systematic anticoagulation management, in part due to the costs related to adverse events.2
A closer connection to patients
Adopting systematic anticoagulation management at the point of care allows healthcare professionals to potentially lower their costs for managing patients on oral warfarin therapy, increase their revenue, and improve patient satisfaction
It also can give them the time and information they need to focus on specific patient needs and manage anticoagulant therapy effectively, resulting in fewer adverse events and a higher level of patient care.
References
1.Giles TD, Roffidal L. Results of the Prothrombin Office-Testing Benefit Evaluation (PROBE). CVR&R. 2002;23:27-28, 30, 32-33.
Multicenter, prospective design study with 1951 patients (up to 50 consecutive) to assess patient, physician and physician office staff satisfaction with an office-based finger-stick method of PT testing vs. the usual method of testing in an outside laboratory.
2. Campbell P, Radensky P, Denham C. Economic analysis of systematic anticoagulation management vs. routine medical care for patients on oral warfarin therapy. Disease Management and Clinical Outcomes, 2000;2.
Economic analysis of cost impact of systematic anticoagulation management vs. routine medical care for 1000 atrial fibrillation patients on warfarin therapy.
3. Rosenstock IM. Patient-physician communications and adherence. In: Panky GA, Kalish GH, eds. Outpatient Antimicrobial Therapy. Fort Lee, NJ: Health Care Communications, Inc.; 1989:9-23.
4. Jacobson A, Guilloteau F, Campbell P, Denham C. Comparison of point-of-care testing and standard reference laboratory testing for PT/INR measurements in patients receiving routine warfarin therapy: an engineering work process flow study. Disease Management and Clinical Outcomes, 2000;2.
Comparison of prospective analysis of workflow and operational costs of PT/INR testing and retrospective analysis of the utilization of anticoagulation management strategies for two point of care clinics and two control clinics that used standard reference laboratories.
5. Wurster M, Doran T. Anticoagulation management: A new approach. Disease Management, 2006;4:201-209.
6. Spandorfer JM, Merli GJ. Outpatient anticoagulation issues for the primary care physician. Med Clin North Am. 1996;80:475-491.
7. Bath PMW, Prasad A, Brown MM, et al. Survey of use of anticoagulation in patients with atrial fibrillation. BMJ. 1993;307:1045
8. Kutner M, Nixon F, Silverstone F. Physicians’ attitudes toward oral anticoagulants and antiplatelet agents for stroke prevention in elderly patients with atrial fibrillation. Arch Intern Med. 1991;151:1950-1953.
9. McCrory DC, Matchar DB, Samsa G, et al. Physician attitudes about anticoagulation for nonvalvular atrial fibrillation in the elderly. Arch Int Med. 1995;155:277-281.
10. Ansell JE, Buttaro ML, Thomas OV, et al., and the Anticoagulation Guidelines Task Force. Consensus guidelines for coordinated outpatient oral anticoagulation therapy management. Ann Pharmacother. 1997;31:604-615
11. Singer DF. Anticoagulation for atrial fibrillation: Epidemiology informing a difficult clinical decision. Proc Assoc Am Physicians. 1996:8(1):29-36
12. Jacobson AK. In: Ansell JE et al., eds. Managing Oral Anticoagulation Therapy. 2nd ed. St. Louis, Mo: Facts and Comparisons; 2003:45:1-6.
13. Bussey HI, Chiquette E, Bianco TM, et al. A statistical and clinical evaluation of fingerstick and routine laboratory prothrombin time measurements. Pharmacotherapy. 1997;17(5): 861-866.
14. Kaatz SS, White RH, Hill J, et al. Accuracy of laboratory and portable monitor international normalized ratio determinations. Comparison with a criterion standard. Arch Intern Med. 1995;155:1861-1867.
15. Williams JR. A cost-saving method for monitoring oral warfarin anticoagulant therapy. Cardiovasc Econ. 1997;9-10. Referenced in Giles TD, Roffidal L. Results of the Prothrombin Office-Testing Benefit Evaluation (PROBE). CVR&R. 2002;23:33.
16. CoaguChek S system package insert. Indianapolis, IN. Roche Diagnostics Corporation, 2002.
17. The concept of Systematic Anticoagulation Management was developed by the Premier Innovation Institute.
Point-of-care PT/INR testing: A better choice for your patients and your practice
Michael Samoszuk, MD
Dr. Michael Samoszuk currently holds the position of Chief Medical Officer with Roche Diagnostics Corporation, maker of CoaguChek® products. The views expressed herein are based upon his professional judgment and do not necessarily reflect the views of Roche Diagnostics Corporation.
Oral anticoagulant therapy with warfarin is generally used for the prevention and treatment of strokes related to atrial fibrillation, DVT and other vascular conditions. Under many conditions, the therapy can be highly effective.1,2
The management of that therapy, however, can be highly ineffective.
For example, one study reported that less than half of all patients on oral warfarin treatment are in their therapeutic range – which means the rest are at greater risk for serious complications, including bleeding and strokes.1,3
There are several reasons why therapy management can be problematic: a narrow therapeutic dosing range; the influence of medication, diet and liver function; and inefficient office workflow models that make it hard to manage warfarin patients cost-effectively.4,5,6 Those challenges help explain why only one out of four patients with indications for warfarin therapy actually receive the treatment.4,7,8,9
There is a solution, however – one that can benefit both patients and a physician practice.
A systematic focus on patient care
Systematic anticoagulation management (SAM) at the point of care shifts the focus in warfarin therapy from a very labor-intensive administrative process to personalized patient care.
Multiple studies have shown that a systematic approach to anticoagulation management, focused at the point of care, may increase the time patients are in range and reduce the risk of adverse events.5,10,11
In particular, they’ve shown that point-of-care PT/INR testing and anticoagulation management can be more cost-effective than traditional medical care. By putting patient, physician and test results in the same place at the same time, they facilitate timely and proper patient evaluation and education.2,4
Immediate access to results for better quality of care
Point-of-care anticoagulation management combines testing accuracy comparable to that of outside laboratories with the convenience of immediate access to test results.13,14 Thus, treatment decisions can be made and discussed with patients while they are still in the office (see Figure 1).
By establishing systematic anticoagulation management at the point of care, healthcare professionals have an ideal framework to:
Studies have shown that point-of-care PT/INR testing enhances the quality of care – enabling faster and more consistent clinical turnaround time for warfarin dose adjustment and closer monitoring of patients on anticoagulation therapy.1,4,5
Improved patient satisfaction and compliance
Patients say they like the convenience of point-of-care testing, too. Results from the Prothrombin Office-Testing Benefit Evaluation (PROBE) study indicate that patients prefer fingerstick PT/INR tests with a portable monitor over venous lab draws.1,15
img src='http://www.physiciansofficeresource.com/images-article/figure10.JPG''width=400 height=300'>
That preference doesn’t have to come at the expense of accuracy. Extensive evaluation of the accuracy of the CoaguChek S portable, office-based monitor to test PT/INR, for example, indicates that the results are essentially equivalent to what would be expected from a central laboratory.1,13,14,16
Perhaps most importantly, office-based PT/INR testing can provide a greater degree of satisfaction to physicians, nurses, and patients than conventional lab-based testing – and “satisfaction” may be the most critical component in determining patient adherence to therapy and, therefore, outcomes.1
Greater efficiency for better office economics
Conventional lab-based care of anticoagulated patients can involve significant direct and indirect costs – often including extensive chart activity and follow-up phone contact with the laboratory and the patient.
There can also be additional medical costs and liability concerns if the office or clinic does not track patients accurately and perform timely follow-up.
Therefore, making anticoagulation patient evaluation and treatment easier and more efficient is important from both a financial and a practical standpoint.
Establishing systematic anticoagulation management at the point of care can have a significant impact on office efficiency because it can help eliminate the extra time-consuming steps involved in traditional lab-based care. For example, it may reduce or even potentially eliminate late-night calls to the emergency room to verify results, as well as other inconvenient, labor-intensive administrative tasks.
In one workflow process flow analysis, median turnaround time (from initial blood draw to patient notification of test results) was 8 minutes for clinics doing PT/INR testing with a point-of-care device, compared to 498 minutes (8+ hours, with a range of 22 minutes to 23 days) for clinics using outside laboratories.4 In the PROBE study, switching to point-of-care testing significantly reduced the nursing time required for each patient, as well as the workload in medical records.1
Potentially lower costs, higher revenue capture
By streamlining both the data management and the patient care components of warfarin therapy, systematic anticoagulation management may reduce the indirect costs of patient management (see Figure 2).5
In addition, it may actually increase revenue. In one study, for example, managing patients with computerized decision support and an optimized workflow at the point of care enabled a university-affiliated primary care clinic to:
Because systematic anticoagulation management can be more effective than routine care, the costs of care for patients can be reduced as well. One extensive economic analysis estimated that the total cost associated with routine medical care for atrial fibrillation patients on oral warfarin therapy was nearly twice as high as the cost under systematic anticoagulation management, in part due to the costs related to adverse events.2
A closer connection to patients
Adopting systematic anticoagulation management at the point of care allows healthcare professionals to potentially lower their costs for managing patients on oral warfarin therapy, increase their revenue, and improve patient satisfaction
It also can give them the time and information they need to focus on specific patient needs and manage anticoagulant therapy effectively, resulting in fewer adverse events and a higher level of patient care.
References
1.Giles TD, Roffidal L. Results of the Prothrombin Office-Testing Benefit Evaluation (PROBE). CVR&R. 2002;23:27-28, 30, 32-33.
Multicenter, prospective design study with 1951 patients (up to 50 consecutive) to assess patient, physician and physician office staff satisfaction with an office-based finger-stick method of PT testing vs. the usual method of testing in an outside laboratory.
2. Campbell P, Radensky P, Denham C. Economic analysis of systematic anticoagulation management vs. routine medical care for patients on oral warfarin therapy. Disease Management and Clinical Outcomes, 2000;2.
Economic analysis of cost impact of systematic anticoagulation management vs. routine medical care for 1000 atrial fibrillation patients on warfarin therapy.
3. Rosenstock IM. Patient-physician communications and adherence. In: Panky GA, Kalish GH, eds. Outpatient Antimicrobial Therapy. Fort Lee, NJ: Health Care Communications, Inc.; 1989:9-23.
4. Jacobson A, Guilloteau F, Campbell P, Denham C. Comparison of point-of-care testing and standard reference laboratory testing for PT/INR measurements in patients receiving routine warfarin therapy: an engineering work process flow study. Disease Management and Clinical Outcomes, 2000;2.
Comparison of prospective analysis of workflow and operational costs of PT/INR testing and retrospective analysis of the utilization of anticoagulation management strategies for two point of care clinics and two control clinics that used standard reference laboratories.
5. Wurster M, Doran T. Anticoagulation management: A new approach. Disease Management, 2006;4:201-209.
6. Spandorfer JM, Merli GJ. Outpatient anticoagulation issues for the primary care physician. Med Clin North Am. 1996;80:475-491.
7. Bath PMW, Prasad A, Brown MM, et al. Survey of use of anticoagulation in patients with atrial fibrillation. BMJ. 1993;307:1045
8. Kutner M, Nixon F, Silverstone F. Physicians’ attitudes toward oral anticoagulants and antiplatelet agents for stroke prevention in elderly patients with atrial fibrillation. Arch Intern Med. 1991;151:1950-1953.
9. McCrory DC, Matchar DB, Samsa G, et al. Physician attitudes about anticoagulation for nonvalvular atrial fibrillation in the elderly. Arch Int Med. 1995;155:277-281.
10. Ansell JE, Buttaro ML, Thomas OV, et al., and the Anticoagulation Guidelines Task Force. Consensus guidelines for coordinated outpatient oral anticoagulation therapy management. Ann Pharmacother. 1997;31:604-615
11. Singer DF. Anticoagulation for atrial fibrillation: Epidemiology informing a difficult clinical decision. Proc Assoc Am Physicians. 1996:8(1):29-36
12. Jacobson AK. In: Ansell JE et al., eds. Managing Oral Anticoagulation Therapy. 2nd ed. St. Louis, Mo: Facts and Comparisons; 2003:45:1-6.
13. Bussey HI, Chiquette E, Bianco TM, et al. A statistical and clinical evaluation of fingerstick and routine laboratory prothrombin time measurements. Pharmacotherapy. 1997;17(5): 861-866.
14. Kaatz SS, White RH, Hill J, et al. Accuracy of laboratory and portable monitor international normalized ratio determinations. Comparison with a criterion standard. Arch Intern Med. 1995;155:1861-1867.
15. Williams JR. A cost-saving method for monitoring oral warfarin anticoagulant therapy. Cardiovasc Econ. 1997;9-10. Referenced in Giles TD, Roffidal L. Results of the Prothrombin Office-Testing Benefit Evaluation (PROBE). CVR&R. 2002;23:33.
16. CoaguChek S system package insert. Indianapolis, IN. Roche Diagnostics Corporation, 2002.
17. The concept of Systematic Anticoagulation Management was developed by the Premier Innovation Institute.