Anticoagulation Management in the Physician Office

By Medical Mutual Insurance Company of Maine

Management of a patient undergoing oral anticoagulation therapy, such as warfarin, requires the physician office to have an established system for test tracking and order management.

Diligence in following established processes is key in avoiding potential impact on patient care due to over or under anticoagulation. Systematic follow-up enhances patient care by decreasing the likelihood of significant complications.

Warfarin has a very narrow therapeutic window. Failure to adequately monitor a patient or provide appropriate dosing could lead to serious, potentially life threatening complications. The patient may become supratherapeutic and have a serious bleeding event or subtherapeutic and be at risk for a clotting episode. An INR result that is outside the therapeutic range and becomes “lost in the shuffle” in a physician’s office can lead to life threatening complications.

Establishing a tracking system is the first step in effectively managing patients who are on warfarin for anticoagulation. A tracking system is implemented to assure that patient testing is completed when ordered, results are received and evaluated and adjustments are made to the patient’s medication regime (if necessary).

In addition to a tracking system, protocols need to be developed to address the process for patients who fail to show for an appointment/lab test. This process should include a review by the medical provider to determine what follow-up is necessary. Establish a process outlining how to manage a patient who cannot be contacted with results or who fails to respond to attempts to contact. If a patient demonstrates repeated non-compliance with the recommended testing and follow-up, schedule an appointment to discuss the importance of close monitoring and the potential risks of non-compliance. Clear, timely documentation in the medical record is essential.

Beyond tracking of test results and appointments, managing the patient’s INR effectively requires a knowledgeable, experienced practitioner to follow established guidelines in dose determination.

Assessment of the patient to determine noncompliance, dietary impact or changes in medications needs to occur. Making warfarin dose adjustments based solely on “experience” or “history” with the patient can lead to challenges if the patient suffers a bad outcome due to anticoagulation management. Using an established algorithm is an objective, systematic way to manage warfarin therapy.

If your patient has multiple providers, establish and clearly document which provider will be responsible for prescribing, monitoring and adjusting the warfarin dose for the patient. For those patients receiving anticoagulation management in your practice, communicate the patient’s status with any other providers involved in their care. If you refer your patient to another provider, assure that information regarding the anticoagulation status is communicated.

Provide patients with clear, understandable educational material. Document patient education and understanding of their responsibilities regarding follow-up and ongoing monitoring as well as the expectation of compliance.

Medical Mutual's "Practice Tips" are offered as reference information only and are not intended to establish practice standards or serve as legal advice. MMIC recommends you obtain a legal opinion from a qualified attorney for any specific application to your practice.