Anticoagulation Clinics in North America: Operational Insights

ABSTRACT Background: Although anticoagulation management services have been established since the early 1970s, and reports have consistently confirmed their delivery of high-quality care, little is known about how existing services operate. Objective: To describe the key operational characteristics of anticoagulation management services in North America. Methods: A survey was sent by regular mail to a random sample of anticoagulation management services in the United States (n = 250) and to all Canadian clinics (n = 15). Demographic characteristics, processes of patient care, and quality assurance measures were assessed. Results: Overall, 228 of the 265 clinics were eligible for inclusion and could be reached by mail; of these, 118 (52%) responded to the survey. The clinics were staffed by pharmacists (68% of the clinics [n = 80]), nurses (38% [n = 45]), clerical personnel (26% [n = 31]), physicians (19% [n = 22]), nurse practitioners (10% [n = 12]), and physician assistants (3% [n = 4]). Most of the clinics were operating at maximum capacity, with a median of 300 appointments per month (equally split between in-person and telephone appointments). Referrals originated primarily from physicians, and 47 (40%) of the 118 clinics accepted referrals only for specific indications. The majority of the clinics used algorithms to systematically assess and manage patients (87% [103/118]) and computer systems to document patient care (86% [101/118]). Warfarin dosing algorithms were used by 82% (84/103) of the clinics, and the same proportion (82% [97/118]) performed quality assurance checks. In the event of an adverse outcome, liability was reported to be shared among the referring physician and clinic staff for 48% (57/118) of respondents, whereas 37% (44/118) reported that clinic staff alone would be accountable. Conclusions: To the authors’ knowledge, this is the first survey describing the operational characteristics of anticoagulation management services. Clinic operations were generally consistent with those outlined in consensus guidelines. By providing insight into the daily operations of these services, this study allows recommendations of mechanisms to enhance clinic efficiency. RESUME Contexte : Bien que les services de gestion de l’anticoagulation existent depuis le debut des annees 1970 et que des rapports aient invariablement confirme que ces cliniques dispensent des soins de haute qualite, nous en connaissons tres peu sur le mode de fonctionnement de ces services. Objectif : Decrire les principales caracteristiques du fonctionnement des services de gestion de l’anticoagulation en Amerique du Nord. Methodologie : Nous avons envoye une enquete par courrier a un echantillon aleatoire de services de gestion de l’anticoagulation aux Etats-Unis (n = 250) et a toutes les cliniques d’anticoagulation du Canada (n = 15). L’enquete evaluait les caracteristiques demographiques, le processus de soins aux patients et les mesures d’assurance de la qualite. Resultats : En general, 228 des 265 cliniques satisfaisaient aux criteres de selection de l’enquete et etaient joignables par courrier; sur ce nombre, 118 (52 %) ont repondu a l’enquete. L’effectif des cliniques se compose de pharmaciens (68 % des cliniques [n = 80]), de personnel infirmier (38 % [n = 45]), d’employes de bureau (26 % [n = 31]), de medecins (19 % [n = 22]), d’infirmieres et d’infirmiers praticiens (10 % [n = 12]), et d’adjoints au medecin (3 % [n = 4]). La plupart des cliniques fonctionnent a capacite maximale dont la mediane se situe a 300 consultations par mois (parts egales de consultations en personne et par telephone). Les patients sont principalement aiguilles a la clinique par des medecins, et 47 (40 %) des 118 cliniques n’acceptent que les requetes concernant des indications precises. La plupart des cliniques utilisent des algorithmes pour systematiquement evaluer et gerer les patients (87 % [103/118]) et des systemes informatiques pour consigner les soins dispenses aux patients (86 % [101/118]). Une proportion semblable de cliniques utilisent des algorithmes pour calculer la dose de warfarine (82 % [84/103]) et effectuent des controles de qualite (82 % [97/118]). En cas d’un resultat clinique indesirable, 48 % des sondes (57/118) ont declare que la responsabilite serait partagee entre le medecin traitant et le personnel de la clinique alors que 37 % des sondes (44/118) ont repondu que seul le personnel de la clinique serait responsable. Conclusions : A la connaissance des auteurs, c’est la premiere fois qu’une enquete evalue les caracteristiques de fonctionnement des services de gestion de l’anticoagulation. Le fonctionnement des cliniques respecte generalement celui decrit sommairement dans les lignes directrices consensuelles. En nous aidant a mieux comprendre le fonctionnement quotidien de ces services, cette enquete nous permet d’emettre des recommandations de mecanismes visant a accroitre l’efficacite des cliniques.

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