Whilst warfarin has proven efficacy in the prevention of stroke, patients taking the drug need their therapy monitored by regular blood tests to prevent the occurrence of thrombotic and haemorrhagic events. This anticoagulation service has traditionally been provided in secondary care anticoagulation clinics. The National Service Framework (NSF) for Older People prioritized reduction in the incidence of stroke 1 which, coupled with the UK's ageing population, has resulted in an estimated 10% yearly increase in the demand for anticoagulation services 2, yet current evidence suggests that not all patients who would benefit from warfarin receive it 3. Despite this unmet need, the pressure on the traditional hospital-based service is already unsustainable. These factors have led to the development and implementation of alternative anticoagulation service delivery models, particularly in primary care.
In this study, anticoagulation service development at Barts and The London Trust was approached from a research perspective. The study consisted of three phases; Exploratory, Preparatory and Intervention. The Exploratory work involved the administration and analysis of a semi-structured patient satisfaction survey at Barts and The London Trust and at Homerton University Hospital to compare patients' satisfaction with anticoagulation services. The survey identified patient groups with lower levels of satisfaction and aspects of the service that patients were less content with. A literature review of developments in anticoagulation service identified alternative models, use of technology and requirements and implications of establishing primary care-based services. Discussions with key stakeholders identified the salient issues, priority-setting, the feasibility of various models and the two alternative service models for implementation and evaluation. Evidence from the Exploratory Phase underpinned the development of the intervention that addressed the issues within current service provision. The preparatory phase further addressed the issues that were highlighted during stakeholder discussions, the essential requirements and practical considerations for implementation of services. These included training, standards of care, protocol development and defining staff roles and responsibilities.
The intervention was tested in a crossover study to compare the two models of domiciliary anticoagulation service for mobility-impaired patients. The first model involved a general phlebotomist obtaining venous samples in the patients' homes, with all other parts of the service being performed by the hospital. In the second model, one-stop testing and dosing in the patients' homes was performed by a trained pharmacist using point-of-care testing and software-assisted warfarin dosing. The domiciliary models were evaluated in terms of patient satisfaction, anticoagulation control and safety. Data showed that anticoagulation control achieved by both domiciliary services was equivalent to that achieved by the traditional hospital-based service. There was a significant improvement in patient satisfaction with the domiciliary services compared to the hospital-based service. Experience gained in the study has been used to refine and implement a new domiciliary service to address a number of pertinent issues, including:

o Lengthy patient waiting times
o Poor access to service

The success of the service development and the robust evaluation is an excellent example of linking research with practice whilst linking academic personnel with clinical practitioners and enhancing multidisciplinary working while improving patient care.

References

1. Department of Health. National Service Framework for Older People Standard five: Stroke. 2001.
2. The Department of Primary Care and General Practice. The University of Birmingham. 2002.
3. Cohen, N., moznino-Sarafian, D., Alon, I., Gorelik, O., Koopfer, M., Chachashvily, S., Shteinshnaider, M., Litvinjuk, V., & Modai, D. Stroke 2000, 31(6):1217-1222