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Three Part Question

In patients on [anti-coagulant therapy] is follow up with a [ general practioner ] as good as [ in-hospital anti-coagulation clinics] ?

Clinical Scenario

A 34 year old lady was admitted with leg pain and diagnosed to have lower limb DVT.She was started on LMWH initially and warfarinised prior to discharge.Should she be monitored in the hospital clinics or at her GP surgery?

Search Strategy

MEDLINE FROM 1950 TODATE USING INTERFACE DIALOG DATASTAR
"(ANTICOAGULANTS#.W..DE.) AND (FAMILY-PRACTICE#.DE.) AND (OUTPATIENT-CLINICS-HOSPITAL#.DE.)"
On further searches in PUBMED, COCHRANE
& OVID NO FURTHER RELEVANT ARTICLES WERE FOUND.

Search Outcome

11 papers found of which only 4 answered the three part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Holm T, Lassen JF, Husted SE, Christensen P, Heickendorff L 2002 DENAMRK	A total of 207 GPs, including their enlisted patients on OAT, were invited, and 61.4% accepted participation. They were randomized into an intervention group [group-INT: 64 GPs and 453 patients (170 patients on OAT throughout the study period, i.e. full follow-up)], and a control group [group-CON: 63 GPs and 422 patients (173 with full follow-up)]. The remaining 80 GPs served as a nonresponder group (group-NON) of 485 patients (184 with full follow-up).	prospective, randomized, controlled trial	Time spent within therapeutic INR interval (TI)	The groups did not differ significantly with regard to age, sex, OAT indication, anticoagulant drug used, or the therapeutic control at baseline. In a comparison based on intention-to-treat principles, the therapeutic control increased statistical significance amongst patients with full follow-up in group-INT compared with group-CON (median time within TI: group INT = 86.6% vs. 80.5%, P = 0.007
Holm T et al, 2002 DENAMRK	124 OAT patients (59.7% males. Median age 70.0: 25-75 percentile: 62.0-76.0)2500 g	Prospective observational study	time spent within therapeutic INR interval (TI)	We identified 124 OAT patients, and found a significant increase in the QOAT from 65.0% before to 69.1% after referral of the patients to the GPs (P<.0001). In 75 patients with full follow-up, the QOAT increased from 67.5% before to 69.7% after the alteration (P<.0001)	Small scale study
Diptarup Mukhopadhyay et al 2002 Wales	Patients on anticoagulation needing INR check. 50 were selected from Anticoagulation clinics. 50 referred from GP for INR check	Audit Retrospective	Therapeutic INR	No statistically significant difference between the 2 groups at the 95% confidence interval	Small scale study Retrospective
Jill P Pell et al 1993 Scotland	Three year record of patients anticoagulated in Local GP practice and nearby District Gen. Hospital. There were 32 from Gp practice and 123 from the Hospital clinic	Retrospective data analysis	Therapeutic	52% of GP thrombotests lay within normal range compared to 45% of hospital results

Comment(s)

Three out of the four papers suggested that quality of anticoagulation in the general practice was good as the hospital clinics.One of them found GP practice doing a better job.

Clinical Bottom Line

We can conclude that maintaining target INR can be done safely in the primary care setting

References

1. Holm T, A randomized controlled trial of shared care versus routine care for patients receiving oral anticoagulant therapy J Intern Med 2002 Oct;252(4):322-31.
2. Holm T, Deutch S, Lassen JF, Jastrup B, Husted SE, Heickendorff L. Prospective evaluation of the quality of oral anticoagulation management in an outpatient clinic and in general practices Thromb Res. 2002 Jan 15;105(2):103-8.
3. Mukhopadhyay D, Gokulkrishnan L, Jones P, Mohanaruban K. Audit of anticoagulation control: a comparison between the performance of a hospital anticoagulation clinic and the general practice Clin Med 2002 Mar-Apr;2(2):169
4. Pell JP, McIver B, Stuart P, Malone DN, Alcock J. Comparison of anticoagulant control among patients attending general practice and a hospital anticoagulant clinic Br J Gen Pract . 1993 Apr;43(369):152-4.