Primary care practices and determinants of optimal anticoagulation management in a collaborative care model
Received 23 July 2009; accepted 18 November 2009.
Background
In a collaborative care model (CCM) for managing oral anticoagulant therapy, patients are followed at a pharmacist-managed anticoagulation service and, once stabilized, are transferred to their primary care physician. The objective of this study was to describe physicians' clinical practices and the practice characteristics associated with better international normalized ratio (INR) control in a CCM.
Methods
A telephone questionnaire about their practices was administered to 121 physicians exposed to a CCM. The physicians followed 121 patients for a mean of 14.5 weeks. The percentage of time within the exact INR target range was computed and dichotomized (≥ or < median time within target range). Determinants of better INR control were identified using logistic regression models.
Results
The survey revealed that, after discharge from the pharmacist-managed anticoagulation service, patients are followed mainly by physicians and their secretaries. Physicians do not often consult other health professionals. Few report using technological resources to obtain INR results (39.7%), document medical follow-up (6.6%), or detect drug (32.2%) and food (9.9%) interactions. The median percentage of time within the exact INR target range was 84%. Determinants of better INR control include using computerized support to monitor patients (odds ratio [OR] 9.16, 95% CI 1.77-47.4) and detect drug interactions (OR 3.49, 95% CI 1.71-7.10) and consulting specialists (OR 5.92, 95% CI 1.49-32.48).
Conclusions
Primary care physicians are poorly supported by technological and human resources to monitor patients on oral anticoagulant. Even in a CCM, interprofessional collaboration and better technological support may be associated with optimal INR control.
aBiomedical Science Department, Faculty of Medicine, University of Montreal, Montreal, Canada
bResearch Team in Primary Care, Centre de santé et de services sociaux de Laval, Laval, Canada
cCentre de santé et de services sociaux de Laval, Laval, Canada
dFaculty of Medicine, University of Montreal, Montreal, Canada
eResearch Center, Hôpital Charles LeMoyne, Longueuil, Canada
fCentre hospitalier de l'Université de Montréal–Hôpital Notre-Dame, Montreal, Canada
gDepartment of Medicine, McMaster University, Hamilton, Canada
hFaculty of Pharmacy, University of Montreal, Montreal, Canada
iSanofi Aventis Endowment Research Chair in Ambulatory Pharmaceutical Care, University of Montreal and Centre de santé et de services sociaux de Laval, Laval, Canada
Reprint requests: Lyne Lalonde, PhD, Research Team in Primary Care, Centre de santé et de services sociaux de Laval, Hôpital de la Cité-de-la-Santé, 1755 René-Laennec Blvd, Room D-S080, Laval, Quebec, Canada H7M 3L9.
Institution where the study was conducted: Centre ambulatoire, Centre de santé et de services sociaux de Laval.
An abstract of this study was published in the proceedings of the IXth World Conference on Clinical Pharmacology and Therapeutics (Quebec, Canada, July 2008).
ABSTRACT