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ANTICOAGULATION

Delivery of Optimized Anticoagulant Therapy: Consensus Statement from the Anticoagulation Forum

Associate Professor, University of New Mexico School of Medicine; Medical Director, Anticoagulation Clinic, University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, NM

Daniel M Witt, PharmD

Clinical Assistant Professor, School of Pharmacy, University of Colorado; Manager, Clinical Pharmacy Services, Kaiser Permanente Colorado, Denver, CO

Elaine Hylek, MD

Associate Professor, School of Medicine, Boston University; Director, Anticoagulation Clinic, Boston Medical Center, Boston, MA

Ann K Wittkowsky, PharmD CACP FASHP FCCP

Clinical Professor, School of Pharmacy, University of Washington; Director, Anticoagulation Services, University of Washington Medical Center, Seattle, WA

Edith A Nutescu, PharmD FCCP

Clinical Associate Professor of Pharmacy Practice; Director, Antithrombosis Center, College of Pharmacy & Medical Center, The University of Illinois at Chicago, Chicago, IL

Alan Jacobson, MD

Director, Anticoagulation Services; Associate Chief of Staff for Research, Loma Linda Veterans Affairs Medical Center, Loma Linda, CA

Stephan Moll, MD

Associate Professor, School of Medicine, University of North Carolina, Chapel Hill, NC

Geno J Merli, MD FACP

Professor of Medicine, Jefferson Medical College, Thomas Jefferson University; Senior Vice President and Chief Medical Officer, Thomas Jefferson University Hospital, Philadelphia, PA

Mark Crowther, MD MSc FRCPC

Professor and Academic Division Director, Hematology and Thromboembolism, McMaster University; Director of Laboratory Hematology, Hamilton Regional Laboratory Medicine Program; Head of Service, Hematology, St. Joseph's Healthcare, Hamilton, Ontario, Canada

Laura Earl, BSN CACP

Practicing Nurse, University of New Mexico, Albuquerque

Richard C Becker, MD

Professor of Medicine, School of Medicine, Duke University; Director, Duke Cardiovascular Thrombosis Center, Duke Clinical Research Institute, Durham, NC

Lynn Oertel, MS ANP CACP

Clinical Nurse Specialist, Anticoagulation Management Services, Massachusetts General Hospital, Boston, MA

Amir Jaffer, MD

Division Chief of Hospital Medicine, University of Miami, Miami, FL

Jack E Ansell, MD

Chair, Department of Medicine, Lenox Hill Hospital, New York, NY

Reprints: Dr. Garcia, MSC10 5550, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, fax 505/272-0358, DAVGarcia{at}salud.unm.edu

OBJECTIVE: To provide recommendations, policies, and procedures pertaining to the provision of optimized anticoagulation therapy designed to achieve desired clinical endpoints while minimizing the risk of anticoagulant-related adverse outcomes (principally bleeding and thrombosis).

STUDY SELECTION AND DATA EXTRACTION: Due to this document's scope, the medical literature was searched using a variety of strategies. When possible, recommendations are supported by available evidence; however, because this paper deals with processes and systems of care, high-quality evidence (eg, controlled trials) is unavailable. In these cases, recommendations represent the consensus opinion of all authors who constitute the Board of Directors of The Anticoagulation Forum, an organization dedicated to optimizing anticoagulation care. The Board is composed of physicians, pharmacists, and nurses with demonstrated expertise and significant collective experience in the management of patients receiving anticoagulation therapy.

DATA SYNTHESIS: Recommendations for delivering optimized anticoagulation therapy were developed collaboratively by the authors and are summarized in 9 key areas: (I) Qualifications of Personnel, (II) Supervision, (III) Care Management and Coordination, (IV) Documentation, (V) Patient Education, (VI) Patient Selection and Assessment, (VII) Laboratory Monitoring, (VIII) Initiation and Stabilization of Warfarin Therapy, and (IX) Maintenance of Therapy. Recommendations are intended to inform the development of care systems containing elements with demonstrated benefit in improvement of anticoagulation therapy outcomes. Recommendations for delivering optimized anticoagulation therapy are intended to apply to all clinicians involved in the care of outpatients receiving anticoagulation therapy, regardless of the structure and setting in which that care is delivered.

CONCLUSIONS: Anticoagulation therapy, although potentially life-saving, has inherent risks. Whether a patient is managed in a solo practice or a specialized anticoagulation management service, a systematic approach to the key elements outlined herein will reduce the likelihood of adverse events. The need for continued research to validate optimal practices for managing anticoagulation therapy is acknowledged.

Key Words: anticoagulant, antithrombotic, thromboembolism, vitamin K antagonist, warfarin

Published Online, June 17, 2008. www.theannals.com, DOI 10.1345/aph.1L098

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