Nurse-led primary care clinics with computerized decision support and near-patient testing improved the proportion of time spent in the therapeutic INR range compared to hospital care (P=0.008).
RCT (n=367)
Randomized
Yes
Does a nurse-led primary care clinic with computerized decision support and near-patient testing improve therapeutic control of INR in patients on oral anticoagulation compared to routine hospital management?
A nurse-led primary care anticoagulation clinic using computerized decision support and near-patient testing provides INR control at least as good as routine hospital follow-up, with significantly improved time in therapeutic range.
p-value: p=0.008
BACKGROUND: There is increased pressure on primary care physicians to monitor oral anticoagulation. OBJECTIVE: To test the null hypothesis that oral anticoagulation care can be provided at least as well in primary care through a nurse-led clinic, involving near-patient testing and computerized decision support software, compared with routine hospital management based on a variety of clinical outcome measures. METHODS: A randomized, controlled trial in 12 primary care practices in Birmingham, England (9 intervention and 3 control). Two control populations were used: patients individually randomly allocated as controls in the intervention practices (intrapractice controls) and all patients in control practices (interpractice controls). Intervention practices' patients were randomized 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 intervention patients, 102 intrapractice control patients, and 143 interpractice control patients). Standard measures of control of the international normalized ratio (point prevalence) showed no significant difference between the intervention and control groups. Data on proportion of time spent in the international normalized ratio range showed significant improvement for patients in 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 and near-patient testing. Care given by this model is at least as good as routine hospital follow-up. The model is generalizable to primary health care centers operating in developed health care systems.
Fitzmaurice et al. (2000) conducted an RCT in Patients requiring oral anticoagulation (n=367). Nurse-led primary care clinic with near-patient testing and computerized decision support vs. Routine hospital management was evaluated on Therapeutic control of the international normalized ratio (p=0.008). Nurse-led primary care clinics with computerized decision support and near-patient testing improved the proportion of time spent in the therapeutic INR range compared to hospital care (P=0.008).