Inquiring minds need to know why .........

[lance]

There have been not a few threads discussing the mismanagement of ACT by professionals, highly educated, well trained individuals whose IQ is far from the bottom of the barrel. Individuals who have sworn an oath to do no harm.

Why then are some of them so lacking in the basic fundamentals of warfarin management? I would really like to learn how this happens. Heaven knows it's not rocket science.

Any ideas or suggestions? These rumours had to start somewhere.

 

[Karlynn]

As far as I know, there is no requirement for medical people to certify, or re-certify themselves as knowledgeable warfarin managers. Any doctor can "manage" warfarin patients.

Management has changed over the last 10 - 15 years in particular. I think some medical people figure that once they learn about a drug, then that's all they need to know and don't bother to seek out further information. For me, one of the tell-tale signs (but not fool proof) about how much a manager is in the past is if they refer to needing to test your PT, and not use the term INR in conjunction with that term. The INR has been around since about 1990. I had my surgery in '91. I don't recall exactly when I started being told my PT and INR #'s, but it was probably 3 or 4 years after my surgery. Then eventually I was just told my INR. Any office that still uses PT #'s (usually in the double digits such as 20-30) to manage warfarin lets you know they haven't' done much, if any reading on the drug in 15 years or use current dosing charts and algorithms .

It's pretty ridiculous when you have a Cleveland Clinic cardiac care nurse tell someone they can no longer use a regular razor now that they're on Coumadin.

 

[ALCapshaw2]

There have been not a few threads discussing the mismanagement of ACT by professionals, highly educated, well trained individuals whose IQ is far from the bottom of the barrel. Individuals who have sworn an oath to do no harm.

Why then are some of them so lacking in the basic fundamentals of warfarin management? I would really like to learn how this happens. Heaven knows it's not rocket science.

Any ideas or suggestions? These rumours had to start somewhere.

Before 1990?, the standard for measurement was ProThombin sp? Time. The problem with that was that there was considerable variation in the Chemical Reagents used in that measurement and therefore a lot of variation in the results.

Around 1990 a new method of testing was developed that measured what was called the International Normalized Ratio (I hope I remembered the right word for the 'N'). It measured the Ratio of the Clotting Time to a standard sample. This still has some variation for other reasons, but the variation is WAY LESS than in the 'old days'.

That's as much as I remember from the Booklet that came with my 5 year old Protime monitor.

'AL Capshaw'

 

[Nancy]

I think it's boring, does not provide a lot of compensation, can be a BIG PITA for some patients who have trouble with getting regualted and need to be micromanaged, plus it's not as interesting as other medical things, and you have to use a mathematical formula to do it right, necessitating that you have to look up what level the person was at last time you had to do a calculation.

In a nutshell, it's more trouble than it's worth, for "busy" doctors.

Oh, Joe was also told when he had his first heart surgery in the 70s that he should grow a beard, to minimize shaving, that's why he had one.

 

[lance]

Millions of ACT patients ....................

Millions of ACT patients ....................

are prescribed this drug which is declared to be "safe" and yet many problems develop from its use.

I hate to think that physicians just bury their mistakes or send them to chronic care facilities for life and remain uninformed as to the cause. Maybe every ACT recipient should be forced to deal with the skilled personnel in a hospital with an appropriat level of expertise to deal with potential problems.

There is no doubt that home testing is a giant step forward in patient care and in Canada we're still in the dark ages regarding their use.

Also I wonder what part drug companies play in this scenario. Mechanical valves guarantee them a consumer for life--patients can't change their mind and opt out. Maybe they undersell the risks to the medical community. Maybe risks are kept under wraps so as to not deter future consumers.

If it's a PITA to monitor this drug, then why not refer the patients elsewhere? No one can be an expert in everything and doctors are busy.

 

[Marty]

Lance, You shouldn't have any problem- the world experts in ACT hang out at McMaster U. in Hamilton!

 

[lance]

You're absolutely right, I haven't

You're absolutely right, I haven't

Lance, You shouldn't have any problem- the world experts in ACT hang out at McMaster U. in Hamilton!

That's right Marty, I don't have any problems with ACT as I am far and away from anywhere those persons hang out and intend to keep it that way.

In 2004 when I inquired of them about obtaining a home testing unit they had no idea what I was asking about and weren't remotely interested in the subject. That's one of the reasons I feel Canada is in the dark ages regarding ACT. They might be the world's best experts but evidently they have limited knowledge of the world around them. Last Tuesday I was in the emerge and of course ACT came up. That doctor was absolutely amazed that I home tested, and that my slightly elevated INR had already been addressed. He was speechless and asked how I managed to draw my own venous blood without help because I told him my INR was checked that morning.

For a lark perhaps I should contact Hamilton General again and inquire about home testing.

 

[Nancy]

I think it ends up being a courtesy to patients more than anything else. It definitely is not a big money maker for most doctors.

 

[ALCapshaw2]

My Anti-Coagulation Clinic serves 140 to 180 patients per day with 4 CRNP's (Certified Registered Nurse Practicioneers). Technicians check the wrist band, prepare and stick the finger, and place the sample / slide into the portable processing machine. The CRNP checks the result, compares it to the past history on a computer and makes a recommendation for dosing and schedules the next visit. They seem to do a Good Job and I've never had a major disagreement over dosing. We often 'negotiate' the exact dose (+/- 1 mg/wk) and reach a quick concensus.

Why do I still use the Clinic when I have a Home Tester?

Because the Cuvettes (test slides) are considered DME (Durable Medical Equipment) which is covered under the Home Office of my Company and NO ONE seems to even know (or admit they know) what Anti-Coagulation is whenever I call. It remains a non-covered benefit whereas the Clinic Tests are covered. Go Figure!

I keep a few cuvettes in the refrigerator 'just in case' I sense that I should or need to check my INR.

'AL Capshaw'

 

[Blanche]

Lance:

Some very interesting thoughts here. I would suggest that many of the medical practioners, namely doctors, nurse practioners, physician's assistants, and certified nurses, are so busy with the variety of problems that present in a doctors practice that they just don't see anticoagulation as a concern. To them, it seems simple and straight forward.

Then, there is the army of "Medical assistants" who help in doctor's offices. These are people who have little training but big responsibilities. I found several medical assistants who were in charge of anticoagulation clinics. One woman told me she had been a medical professional for 13 years. Yet, I knew that she had spent the last several years as a receptionist in a cardiologist's office.

I don't think the problems and confusion with anticoagulation is a rumor. There have been too many incidents reported here on this forum to believe that. I think too many of us expect the medical people will care for us and we need do nothing but follow their orders.

People trust and don't see the need to be involved. Sadly, that was the position we took in 1990 when Al had his valve replaced. In the 10 years that followed, we never even heard the term INR. He tested every 4 weeks and did what the "voice on the phone" said to do. In December 2000, the day before he was to get his protime tested, he had the first of three strokes. We were dumbfounded!!! Had we known more, his problem might have been avoided.

Living with a husband who has had three strokes is not a rumor. It is my life.

Blanche

 

[lance]

My Anti-Coagulation Clinic serves 140 to 180 patients per day with 4 CRNP's (Certified Registered Nurse Practicioneers). Technicians check the wrist band, prepare and stick the finger, and place the sample / slide into the portable processing machine. The CRNP checks the result, compares it to the past history on a computer and makes a recommendation for dosing and schedules the next visit. They seem to do a Good Job and I've never had a major disagreement over dosing. We often 'negotiate' the exact dose (+/- 1 mg/wk) and reach a quick concensus.

Why do I still use the Clinic when I have a Home Tester?

Because the Cuvettes (test slides) are considered DME (Durable Medical Equipment) which is covered under the Home Office of my Company and NO ONE seems to even know (or admit they know) what Anti-Coagulation is whenever I call. It remains a non-covered benefit whereas the Clinic Tests are covered. Go Figure!

I keep a few cuvettes in the refrigerator 'just in case' I sense that I should or need to check my INR.

'AL Capshaw'

Hi Al,

You and your professionals certainly have everything under control--good for you and them. I deal with a major hospital in Toronto and I was the 10th patient that was trained to use a home monitor. I have no idea how many patients they monitor--probably a lot both with and without home monitors. As a matter of fact the nurse that prescribes my ACT not only trained me for home monitoring but qualified for her MSn in home monitoring so everything runs famously.

I have to pay for all my supplies too. My private insurance wouldn't cover me because blood draws are covered under Ontario Hospital Insurance Policy (OHIP). There are so many advantages to home testing that I willingly pay myself. Currently I take the test at home, every Monday a.m. e-mail the results to the clinic, and my e-mail is returned with the dose for the following week. They make it very convenient.

Maybe when you contact your insurance instead of refering to anti-coagulation you could say "blood thinners".

I'd sure like to know for sure why so many professionals get it wrong--maybe it's the inherent nature of the drug.

 

[Bina]

Lance, when I approached my private insurance I knew that they covered supplies for diabetics, so I equated my strips with that.
I never mentioned actual blood draws...only testing, and the strips have been paid for, so far.
I'm also well aware that they could change their mind at any time

 

[ALCapshaw2]

Lance wrote: "I'd sure like to know for sure why so many professionals get it wrong--maybe it's the inherent nature of the drug."

Maybe part of it is 'Old School' vs. 'New School'.

The testing and dosing protocols have changed Drastically over the last 15 to 20 years.

I suspect that Bleeding Events (and probably Strokes as well) were much more common before the INR testing method came into being.

In the 'old days' it was common to tell patients to Avoid anything with Vitamin K. NOW the medical establishment has come to realize that there is actually LESS variation when a consistent amount of Vitamin K is consumed and the dose is adjusted accordingly. Simple logic tells us that a small change in Vitamin K consumption (up or down) will have LESS Effect if there is a consistent level consumed than if NONE is consumed. In the latter case, any consumption will be a Dramatic percentage increase.

Another reason is that "Practice makes Perfect". The more patients one sees for AC Management, the better one gets at doing the job. Single Practice Physicians, Nurses, or Pharmacists simply don't see the number and range of patients that are seen by a dedicated AC Clinic. Studies have shown the knowledgable Home Testers do even better than the Clinics, partly because they can and often do test more frequently, thus spotting any needed changes sooner.

'AL Capshaw'