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June 23/30, 1999

Patient Self-management of Oral Anticoagulation

Author Affiliations

Margaret A.WinkerMD, Deputy EditorIndividualAuthorPhil B.FontanarosaMD, Interim CoeditorIndividualAuthor

JAMA. 1999;281(24):2283-2284. doi:10-1001/pubs.JAMA-ISSN-0098-7484-281-24-jbk0623

To the Editor: The interesting study by Dr Sawicki1 provides further evidence of the potential value of patient self-management in oral anticoagulation. However, several peculiarities of the study design make the results difficult to extrapolate to patients currently receiving optimal care.

The intervention group, in addition to self-assessment of their prothrombin time and international normalized ratio (INR), had extensive weekly teaching sessions that included topics and issues that could clearly affect future coagulation control (effect of diet, medications). More important, they were instructed in a model of care regarding how to increase or decrease the anticoagulant dosages to achieve target INR values. The algorithm they were taught is not available to the reader. At our ambulatory center, we have been able to see considerable improvement in achieving target INR values by standardizing all physicians' adjustments in dosages with a standard of care algorithm. Was the same model of change in dosage used by the family physicians who were adjusting the anticoagulants for the control group? If not, this confounder makes the results nearly uninterpretable. If used, the algorithm should be provided for review of practicing physicians. Could differing clinical care explain the significant effect seen between centers?