Where does patient self-management of oral anticoagulation fit within the current models of service provision?

Therapeutic management of oral anticoagulation is not straightforward. The British Committee for Standards in Haematology produced updated evidence-based guidelines in 1998 for therapeutic management, which encourage clinicians to aim for a target International Normalized Ratio (INR), with specific targets and ranges stated for individual conditions [1]. However, there remain concerns over where and how warfarin monitoring should be undertaken [2,3]. Historically, oral anticoagulation has been underutilized as a thromboprophylactic agent for patients with atrial fibrillation, whilst without screening programs, it is possible that approximately 60% of patients with atrial fibrillation remain unidentified [3,4]. It is clear, therefore, that the number of patients receiving warfarin therapy will continue to rise above the currently estimated 1 million [5,6]. Traditionally, patients receiving oral anticoagulant therapy attended a hospital out-patient clinic where INR estimation was undertaken using either capillary or venous citrated blood samples, with the result being available either immediately or at a later stage. Whilst the clinic has traditionally been led by a consultant hematologist, alternative arrangements have utilized cardiologists, surgeons, specialist nurses [7], laboratory staff and pharmacists [8]. Based on UK data, patients should expect to be within their own therapeutic range at least 65% of the time. This is the standard to which any alternative models have to compare [6]. Where INR results are available with the patient present, dosing recommendations are made and the patient given a date for the next appointment (up to 12 weeks in a stable patient [1]). When there is a delay in the INR estimation, patients receive dosing and recall advice through the post via patient-held records, or