Fitzmaurice DA et al. 1996 "Evaluation of computerized decision support for oral anticoagulation management based in primary care."

Fitzmaurice DA, Hobbs FDR, Murray ET, et al. Evaluation of computerized decision support for oral anticoagulation management based in primary care. Br J Gen Pract 1996;46(410):533-535.
"Background. Increasing indications for oral anticoagulation has led to pressure on general practices to undertake therapeutic monitoring. Computerized decision support (DSS) has been shown to be effective in hospitals for improving clinical management. Its usefulness in primary care has previously not been investigated.
Aim. To test the effectiveness of using DSS for oral anticoagulation monitoring in primary care by measuring the proportions of patients adequately controlled, defined as within the appropriate therapeutic range of International Normalised Ratio (INR).
Method. All patients receiving warfarin from two Birmingham inner city general practices were invited to attend a practice-based anticoagulation clinic. In practice A
all patients were managed using DSS. In practice B patients were randomized to receive dosing advice either through DSS or through the local hospital laboratory. Clinical outcomes, adverse events and patient acceptability were recorded.
Results. Forty-nine patients were seen in total. There were significant improvements in INR control from 23% to 86% (P>O.OO1) in the practice where all patients received dosing through DSS. In the practice where patients were randomized to either DSS or hospital dosing, logistic regression showed a significant trend for improvement in intervention patients which was not apparent in the hospital-dosed patients (P<0.001). Mean recall times were significantly extended in patients who were dosed by the practice DSS through the full 12 months (24 days to 36 days) (P=0.033). Adverse events were comparable between hospital and practice-dosed patients, although a number of esoteric events occurred. Patient satisfaction with the practice clinics was high.
Conclusion. Computerized DSS enables the safe and effective transfer of anticoagulation management from hospital to primary care and may result in improved patient outcome in terms of the level of control, frequency of review and general acceptability."

To "test the effectiveness of using DSS for oral anticoagulation monitoring in primary care."

Type Clinic
Primary care
Small and/or medium
Other Information
The study took place at two inner-city locations in Birmingham, England, United Kingdom.
Type of Health IT
Decision support system
Type of Health IT Functions
"At the initial visit, back-data and relevant medical histories were collected and a venous blood sample taken for INR estimation. At follow-up visits, haemorrhagic or thrombotic episodes and any changes in other therapy were noted, compliance checked and venous blood taken for INR estimation. Clinics were run by practice nurses, although a doctor was always available. Blood samples were sent to the local hospital laboratory for testing and results were faxed back to the practice the same afternoon. INR results were recorded on patient-held records. Patients whose warfarin dose was determined using DSS in the practice had their cards posted with dose instructions the same evening. Hospital-dosed patients had their cards posted after a decision by a consultant haematologist; copies were sent to the practice."
Workflow-Related Findings
"Intervention patients showed an improvement in INR control compared with the pre-study, with [the first group's] rise (from 23% to 89%) achieving significance."
"Control patients were consistently under-anticoagulated compared with intervention patients."
The time between appointments increased and the number of appointments decreased for patients in the intervention group.
Study Design
Pre-postintervention (no control group)
Study Participants
Forty-nine patients took part in this study.