Who is responsible for the care of patients treated with warfarin therapy?

Abstract

Objective: To identify potential weaknesses in the system of managing warfarin therapy. Design, participants and setting: A structured interview‐based study of 40 community‐dwelling patients taking warfarin and with an international normalised ratio ≥ 6.0 and 36 of their treating doctors (35 general practitioners and 1 specialist), conducted between July and November 2007. Patients all received services from and were recruited sequentially by a large, private metropolitan pathology provider in Melbourne. Main outcome measures: Patients’ demographic, clinical, cognitive and psychosocial characteristics, warfarin knowledge, medication complexity and adherence; and doctors’ experience with, approach to and involvement in warfarin management, and their perception of responsibility for warfarin management and patient education. Results: Interviews revealed multiple difficulties, including cognitive dysfunction, possible depression, and medication non‐adherence, in 30 of 40 patients. Of 36 doctors interviewed, 12 were unaware of these difficulties in their patients. Five doctors considered they had sole responsibility for their patients’ anticoagulation, while 15 confirmed a mutual relationship with the pathology service, and 16 deferred total responsibility to the pathology provider. Only 14/36 doctors reported conducting patient education at commencement of warfarin therapy, with the other 22 stating this was the responsibility of the initiating specialist, pathology service or dispensing pharmacist. Conclusions: There is a need for improved role clarification in coordinating warfarin management. We propose exploring the possibility of a Warfarin Suitability Score to assist better recognition of patients in whom treatment may be problematic, along with a model of care using practice nurses with GPs to facilitate optimal patient care.

Warfarin management after discharge from hospital: a qualitative analysis

“…It has identified some perceived benefits and disadvantages of the current systems in terms of education practices, communication at the hospital–community interface and the role of home‐delivered services in ensuring timely follow‐up and promoting continuity of care. Previous qualitative studies exploring anticoagulation management, although not specifically during the post‐discharge period, have identified similar themes 22–26 …”

Legal and professional implications of shared care: a case study in oral anticoagulation stroke prevention therapy

“…The need to clarify roles in the system of delivering warfarin therapy has been highlighted previously [34]. Although, we could find no case law considering the legal liability of teams working across different geographical sites, the court has held that the way that a team of hospital doctors worked together produced a negligent level of care and in that case, the team leader was found to be negligent in having inadequately trained his team [35].…”

Who is responsible for the care of patients treated with warfarin therapy?

“…T o the Editor: The recent article by Lowthian and colleagues raises some important concerns regarding current management of warfarin therapy in Australia, especially the provision of quality warfarin education 1 . While the study focused on the uncertainty surrounding who is responsible for this task, additional barriers to providing warfarin education include limited access to suitable resources and a tendency to rely on a single verbal counselling session and/or the supply of written material, often just before discharge from hospital 2 …”