Comparison of oral anticoagulant control by a nurse-practitioner using a computer decision-support system with that by clinicians

Vadher, Bipin; Patterson, David; Leaning, M.S.

doi:10.1111/j.1365-2257.1997.tb00008.x

Cited by 41 publications

(24 citation statements)

References 7 publications

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“…More extensive use of computer-based algorithms for does adjustment of anticoagulants could help avoid systemic underanticoagulation. [42][43][44][45][46] We found that the relative risk of thromboembolic events increased significantly when the international normalized ratio exceeded 5. This reflects the curvilinear association between ratio levels and risk of thromboemboli that we identified in 7 of 16 studies included in our analysis.…”

Section: Discussionmentioning

confidence: 99%

Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: a systematic review and meta-analysis

Oake¹,

Jennings²,

Forster³

et al. 2008

Canadian Medical Association Journal

148

124

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O ral anticoagulant therapy is essential for the treatment and prevention of many thromboembolic disorders. Since anticoagulants can cause serious adverse events, 1-3 physicians monitor the international normalized ratios of patients taking these drugs to ensure that their ratios fall within a target range.An international normalized ratio of 2-3 is the most common target range. Results of previous studies revealed an increased risk of bleeding among patients whose ratios exceeded 4, an increased risk of stroke among patients whose ratios were 1.5-2 and a decreased risk of stroke at a ratio of 2.4. 4,5 However, the evidence supporting the range of 2-3 has some deficiencies. We sought to determine whether the risk of hemorrhagic and thromboembolic events is minimized at an international normalized ratio of 2-3 among patients taking anticoagulants. In addition, it has been observed that patients spend more time with a ratio below 2 than above 3.6,7 The impact of such systematic underanticoagulation on patient outcomes is unknown. We sought to determine the effect of under-or overanticoagulation on the risk of thromboemboli and hemorrhage. Methods Data sourcesWe searched MEDLINE (1966MEDLINE ( -2006 for potentially pertinent studies. We then modified our strategy to include EMBASE (1980EMBASE ( -2006, the Cochrane Central Register of Controlled Trials (1980Trials ( -2006 and CINAHL (1982CINAHL ( -2006 databases. We manually searched references in the Science Citation Index. Our search strategy is outlined in Appendix 1 (available at www.cmaj.ca/cgi/content/full/179/3/235/DC2). Study selection

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Section: Discussionmentioning

confidence: 99%

Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: a systematic review and meta-analysis

Oake¹,

Jennings²,

Forster³

et al. 2008

Canadian Medical Association Journal

148

124

View full text Add to dashboard Cite

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“…20 This study was not powered to detect equivalence. The study compared Both triage studies assessed the impact of CDSS in terms of performance measures and patient outcomes.…”

Section: Cdss (4 Rcts 1 Its 19744 Participants)mentioning

confidence: 97%

“…18,23 In three RCTs, the targeted behaviour was anticoagulation management. 18,20,24 Characteristics of these studies are given in Table 4 and the results are reported in Table 5.…”

Section: Cdss (4 Rcts 1 Its 19744 Participants)mentioning

confidence: 99%

Effects of computerized decision support systems on nursing performance and patient outcomes: a systematic review

Randell

Mitchell

Dowding

et al. 2007

J Health Serv Res Policy

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Objective To examine the effect of computerised decision support systems (CDSS) on nursing performance and patient outcomes.Data sources 15 databases including Medline and CINAHL were searched up to May 2006, together with reference lists of included studies and relevant reviews.Review methods Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies that assessed the effects of CDSS use by nurses in a clinical setting on measurable professional and/or patient outcomes were included.

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“…The variation from the dose suggested by the software was 35%, which is higher than the 25% found by Vadher et al when they studied nurses using CDSS. 8 However, it is less than the 43% gap found when doctors' decisions were compared with that suggested by the CDSS.…”

Section: Discussionmentioning

confidence: 95%

“…Where comparison has been made between nurses using computerised decision support and junior doctors using clinical judgement, the nurses achieved better control for patients with an INR target ratio of 2-3, and as good control as the doctors when target INR is 3-4.5. 8 A primary care organisation (PCO) recognised the potential benefits of a practice-based anticoagulation service and implemented it across 13 practices, deciding that practice nurses would be the appropriate professional group to deliver the service. They put on a training course comprising the relevant biomedicine: how anticoagulants work, the patients who need it and for how long, interactions and safety issues.…”

Section: Refereed Papersmentioning

confidence: 99%

Lessons from the implementation of a near patient anticoagulant monitoring service in primary care

Lusignan

Singleton²,

Wells³

2004

Journal of Innovation in Health Informatics

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Objective To evaluate the implementation of a primary care, nurse-led, near patient anticoagulant monitoring service. Design Action research workshops, supported by questionnaires and clinical audit, to define the strengths and weaknesses of the service and the effectiveness of the computerised decision support system used to set the dosage of anticoagulant and time interval to the next appointment. Setting 13 general practices that implemented anticoagulant monitoring in a primary care organisation in south east England. Participants 18 practice nurses, 72% of whom had over 20 years' clinical experience; the universitybased investigators and managers from the primary care organisation. Main outcome measure The nurses felt that the patients preferred the practice-based service, finding it more personal and accessible. However, circumstances arose where the nurse's intuition had to override the software's advice. The nurses found it stressful when they were unclear whether their decision making represented acceptable variation or dangerous practice. An audit tool was developed to measure the extent to which there was variation from the software's recommendation, and patterns of variation emerged. Most evident was that nurses responded to uncertainty by practising cautiously, shortening the interval until the next visit and slightly reducing the recommended dose of warfarin. Conclusions The group, by sharing their experiences through a structured series of workshops, developed an understanding of when it might be appropriate to vary from the decision support software's recommendations and how this could be audited. The technological solution modelled on hospital practice proved hard to implement in primary care.Keywords (MeSH terms): anticoagulants, computerassisted, decision making, family practice, medical informatics, medical informatics applications, warfarin S de Lusignan, A Singleton and S Wells 28 Near patient testing allows monitoring to be provided outside the hospital setting. Traditionally patients had to travel to the local hospital for testing, where junior doctors adjusted their warfarin dose without the benefit of CDSS. 6,7 The combination of near patient testing and CDSS allows warfarin testing to take place in local clinics or in patients' homes, with the service provided by nurses or other non-medical staff. Where comparison has been made between nurses using computerised decision support and junior doctors using clinical judgement, the nurses achieved better control for patients with an INR target ratio of 2-3, and as good control as the doctors when target INR is 3-4.5. 8 A primary care organisation (PCO) recognised the potential benefits of a practice-based anticoagulation service and implemented it across 13 practices, deciding that practice nurses would be the appropriate professional group to deliver the service. They put on a training course comprising the relevant biomedicine: how anticoagulants work, the patients who need it and for how long, interactions and safety issues. The p...

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Comparison of oral anticoagulant control by a nurse-practitioner using a computer decision-support system with that by clinicians

Cited by 41 publications

References 7 publications

Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: a systematic review and meta-analysis

Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: a systematic review and meta-analysis

Effects of computerized decision support systems on nursing performance and patient outcomes: a systematic review

Lessons from the implementation of a near patient anticoagulant monitoring service in primary care

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