A well trusted source of bad information

[Guest]

Last Friday there was a guy being discharged from our hospital on warfarin. The information sheets that they give the patient were on his chart so I decided to read the warfarin one. It something like the following... this medication have have to be stopped days or weeks before surgery or a test.

Where did this come from? Did a new graduate working in a small hospital in Pueblo, Colorado write it? NOOOOOOOOOoooooo. It came from Thomson Healthcare, the publishers of the Physician's Desk Reference (PDR) and Micromedex - the main source of information on-line for pharmacists in the world. What chance does the average valver on the street have convincing their doctor to continue warfarin when such a "trusted" source pushes such bull .... ?

 

[catwoman]

Unfortunately, you can't believe everything you read.

It's a sad situation when a medical publisher is dispersing info like this.

 

[Nancy]

Are you going to follow up on this problem with the hospital and the reference source?

Good grief, isn't this just about as bad as it gets??? Imagine a hospital passing out such crap.

How can anyone be sure that things that are done to them are correct?

The reference source should be ashamed, and should send out an addendum.

 

[Karlynn]

How disheartening! Days or even weeks - can't be too many weeks or you'd never live long enough to make it into surgery.

 

[Guest]

I'm going to try to get it changed. I think that I'll be about as successful as pushing a chain.

 

[Karlynn]

Kind of like - where did my doctor come up with the higher end INR with a below normal hematocrit. Apparently she read or heard or was educated on that somewhere!

 

[jeffp]

You live and you learn. Before I had my valve replacement and had a life of coumadin to foward to, I routinely had patients scheduled for minor surgery and would take them off anticoagulants for 3 days prior and 2 days after surgery. It was the way I was trained and is still the standard hospital protocol. I've done tons of reading since my surgery (4 wks ago) since I've got the spare time now; and can say that things will change once I get back to work. No way would I go off the coumadin for a low risk procedure, and I would insist on bridging before anything major. I think the patients deserve to same consideration.

 

[PJmomrunner]

I'm going to try to get it changed. I think that I'll be about as successful as pushing a chain.

Hi Al:

I won't even guess whether you might agree with these guidelines (although I do presume you have seen them). I am posting this link to the National Guidelines Clearinghouse because they post guidelines for lots of interesting medical things and it's so easily accessible. You might find it a good starting point anyway...

http://www.guidelines.gov/summary/summary.aspx?doc_id=4576&nbr=3366&string=surgery+AND+coumadin

P. J.

 

[Nancy]

Thank you, thank you, thank you, Jeff. I hope you will educate your colleagues as well.

While you have the time, also do a search on Lovenox on this site. There are some issues with Lovenox bridging in patients who either have compromised kidneys or whose surgery has the potential to cause kidney function problems, Lovenox can accumulate in these patients and cause life-threatening bleeding. My husband had this problem after gallbladder surgery, when he used Lovenox bridging and had a TOTAL bleedout. He came very close to dying. There is another man who had a similar problem after gallbladder surgery.

Al Lodwick has mentioned that these kinds of patients need to have kidney function monitored.

I know my husband will NEVER have Lovenox bridging again, only in-hospital Heparin.

Do a search on gallbladder and you might pull up the posts re: the above.

 

[Karlynn]

Hi Al:

I won't even guess whether you might agree with these guidelines (although I do presume you have seen them). I am posting this link to the National Guidelines Clearinghouse because they post guidelines for lots of interesting medical things and it's so easily accessible. You might find it a good starting point anyway...

http://www.guidelines.gov/summary/summary.aspx?doc_id=4576&nbr=3366&string=surgery+AND+coumadin

P. J.

I just glanced through it for now, but the following caught my eye right away:

<<Patients should be encouraged and empowered to play an active role in the self-management of their treatment. Self-management is best initiated and sustained through active involvement of patients and family members with their multidisciplinary health care team. This educational partnership should be encouraged to decrease potential risks and improve understanding of the importance of patient adherence to their treatment regimen. >>

Amen

I'm becoming more and more a staunch believer of warfarin-dependant people being treated the same as insulin-dependant people. Give them the knowledge and the tools and let them take an active roll in the testing and dosing. Can you imagine if an insulin-dependant person had to go to a lab twice a day for a blood test, then contact the doctor each time to see what the dose of insulin should be? To assume that all warfarin-dependant people don't have the capability to handle their testing and dosing is saying people are just too dumb and diabetics shouldn't be given the responsibility they have for their own treatment. Many physicians and insurance companies still take this point of view.

There are obviously people who need much more assistance and can't handle the responsibility. Or would just rather have others take care of it. But to assume that no one can, is taking up a lot of time, money and energy for everyone involved. Not to mention scaring people away from Coumadin who think they'd rather have repeated surgeries in order to avoid the "horrific" change in lifestyle.

**stepping down off of soapbox**

Once again, bowing down to Al here with many thanks for his help and expertise. I couldn't be doing it very easily without you.

 

[Guest]

The guidelines look very good. They should since one of the authors was Jill Strykowski. She learned anticoagulation in the same class that I did. We have been friends for the past 8 years.

 

[Valve Nurse]

I agree with Karlynn - why can't INR testing be as readily available as diabetes testing? Every time I go to the pharmacy (which lately is a lot..hmmm?), I look at all of the glucometers and lancets just sitting out for anyone to purchase and get a little ticked.

Has there ever been a concerted movement to make INR tests readily available?

I agree, many patients could do their own testing and adjustment of coumadin with proper training. The reason that it is not done is because the doctors get paid for adjusting the coumadin. Even if it is only a telephone call. so there you go. . . .

 

[jeffp]

I agree, many patients could do their own testing and adjustment of coumadin with proper training. The reason that it is not done is because the doctors get paid for adjusting the coumadin. Even if it is only a telephone call. so there you go. . . .

That's a small part of it. I was doing a lot of web searching for data to give to my GP and the insurance company with regard to my desire to do home testing. Found a real shocker on the cms.gov website. (as Medicare goes - so the rest of the insurance industry goes). They cover the testing machine and strips but it is supplied through the physicians office and the patient gets the strips monthy from them and then they call in the INR weekly for med adjustments if needed. The MD get paid for the initial dispensing and education and training on the machine at the first visit and then one fee every 4 check ins and again for the refill on the test strips. Sounds like a money maker, doesn't. Well the kicker is that he shells out the cost of the machine and then get reimbursed by peicemeal billing out codes G0248,49,50. Checking with my local carriers fee schedule and assuming a machine cost of $2K, break even is at 6 1/2 years! I had to read it twice because it was just too unbelievable. Do a search for transmittal AB-02-180 at the cms web site. Also see http://www.cap.org/apps/docs/cap_today/feature_stories/prothrombin_home_monitoring.html Now I can understand why so few people who are qualified for home testing actually do as lots of them are Medicare covered. Who dreams up this stuff?

 

[Guest]

Medicaid made an announcement about this at our Anticoagulation Forum meeting in Washington DC four years ago. After it took me 1 hour to drive 3 miles on congested streets and streets that went nowhere and getting into a left turn lane only to discover that the stree that I was trying to turn into was closed. I decided that the reason that our laws and regulations are so complicated is that the people who live or work in Washington have to get even with the rest of the country where the streets are laid out (roughly) on North-South grids and you can drive the 8 miles to work in 15 minutes and be disappointed if there is no free parking place within 25 feet of the door.

 

[Karlynn]

I was very shocked when United Health Care forked over 100% of the cost of my machine. Now that we have BC/BS they seem to be favorable to the use. Right now I'm not required to do anything such as getting the supplies monthly or do call-ins of the number. After reading your post, I won't be surprised if that happens.

 

[Ross]

Without going into research mode, is there anyone in particular we can beat on in Washington to try and get some of this lunacy changed?

 

[catwoman]

I agree with Karlynn - why can't INR testing be as readily available as diabetes testing? Every time I go to the pharmacy (which lately is a lot..hmmm?), I look at all of the glucometers and lancets just sitting out for anyone to purchase and get a little ticked.

Has there ever been a concerted movement to make INR tests readily available?

I asked a Wal-Mart pharmacist about requirements for purchasing a glucometer. Rx required if insurance/Medicare is to cover it. Otherwise, none required.
An Rx is required for us to get a PT/INR tester machine.
There's a heckuva lot more diabetics using insulin than there are people who are on warfarin (and able to/amenable to doing their own testing).
I know some diabetics who give themselves insulin but they don't always test. (I've shared a hotel room with a diabetic and never seen her use a glucometer before drawing up a syringe with insulin.)
My mom does test before drawing up a syringe.

 

[jimrh]

There are some issues with Lovenox bridging in patients who either have compromised kidneys or whose surgery has the potential to cause kidney function problems, Lovenox can accumulate in these patients and cause life-threatening bleeding. QUOTE]

I had bleeding with Lovenox. It scared the ... I had a good surgeon for RF Ablation to deal with atrial flutter. They hospitalized me early and bridged with heparin while monitoring my start on sotalol (I also had had several atrial fib conversions). But when the surgery was over, they gave me three days of Lovenox and sent me home. I started peeing blood, so discontinued the Lovenox and decided to take the risk while waiting for the warfarin to kick in.

After reading this post, I will plan to mention this incident to the surgeon when I see him this summer for an annual checkup.