Long term anticoagulation with Vitamin K antagonists (e.g.
warfarin) has been shown to reduce major thromboembolic
complications in patients with many common chronic conditions,
including atrial fibrillation, history of deep vein thrombosis and
pulmonary embolism, and mechanical heart valves. However, Vitamin K
antagonists have a very narrow therapeutic window requiring
frequent laboratory monitoring to ensure that patients are neither
excessively anti-coagulated, which increases the risk for bleeding,
or under anti-coagulated, which increases the risk for
thromboembolism. Laboratory monitoring consists of measuring the
blood's tendency to clot with a test known as the International
Normalized Ratio (INR), usually performed every 4-6 weeks. Dosage
adjustments are then based on these results. Since management of
long term oral anticoagulation requires frequent testing and dose
adjustment, anticoagulation clinics (ACC) have been developed to
streamline and standardize this care. Typically run by specially
trained nurses or pharmacists, these clinics provide intense
patient education, provide timely follow-up of INR results, use
algorithms for dose adjustments, and are easily accessible to
patients between visits. More recently, portable devices have
become available that are able to accurately measure the INR with a
drop of capillary blood. This means that patients can now test
themselves at home and either call in the result to their provider
who suggests dosage adjustments (known as patient self testing,
PST) or adjust their dose of medication themselves (known as
patient self management, PSM). As a leader in safety and quality,
the Department of Veterans Affairs (VA) is interested in assuring
that veterans on long-term anticoagulation receive state-of-the-art
care that maximizes efficacy and minimizes complications. Towards
that end, this review was commissioned by the VA's Evidence-based
Synthesis Program, in conjunction with the Office of Quality and
Performance. The final key questions are: 1. For management of
long-term outpatient anticoagulation in adults, are specialized
anticoagulation clinics (ACC) more effective and safer than care in
non-specialized clinics (e.g., primary care clinics, physician
offices)? 1a. Which components of a specialized anticoagulation
clinic are associated with effectiveness/safety? 2. Is Patient Self
Testing (PST), either alone or in combination with Patient Self
Management (PSM), more effective and safer than standard care
delivered in either ACCs or non-specialized clinics? 3. What are
the risk factors for serious bleeding in patients on chronic
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