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Oral anticoagulation with warfarin DES for 2017/18 - Wales

Details of the directed enhanced service (DES) for oral anticoagulation with warfarin.

INR testing (Photo: Dr P Marazzi/Science Photo Library)
INR testing (Photo: Dr P Marazzi/Science Photo Library)

Payment information

There are three levels of re-imbursement.

  • Slow loading warfain – £120 for the first treatment quarter to cover the initial counselling of the patient. This will be a one-off payment unless there is a gap in warfarin treatment of more than one month.
  • Warfarin monitoring –£150 per annum per patient (£37.50 per quarter) for the provision of INR monitoring and dosing service. The local health board will fund external quality assurance, point of care coordinator support, lancets and strips, POCT machines and POCT machine training, Dosing software and associated training.
  • Non-monitoring/dosing practices – £10 per patient for practices not providing a testing and dosing service to cover the cost of work involved in communicating with the warfarin service provider

Housebound patients – Arrangements for testing and communication of dosing for housebound patients will be covered by a separate locally agreed policy

NB. The deliver of NOAC treatment will be supported through a local enhanced service.

Service outline

The new 2017/18 DES for Wales will fund:

Training – Practices must ensure all staff involved in providing any aspect of care under the enhanced service have the necessary skills and training.

Developing and maintaining a register – Practices must maintain an up to date register of all patients in receipt of anticoagulation therapy. The register should include an indication of the local of monitoring using the following READ codes

  • Anticoagulation monitoring – secondary care 66QC
  • Anticoagulation monitoring – primary care 66QD
  • Self monitoring of INR – 66QE

A call and recall system – Practices should ensure that for patients managed in primary care they have a systematic call and recall system in place, including clear arrangements for home-based assessment of housebound patients and care home residents.

Initial assessment – This should document stroke and bleeding risk assessment, a full blood count, urea and electrolytes, liver function tests, coagulation screen and INR

Risk and benefit discussion - Discussion with the patient about the risk and benefits of treatment using accredited decision aids such as Keele University's Decision Support resource or the NICE patient decision aid.

Patient education - All patients and/or their carers should receive appropriate information relating to prevention and management of potential complications. Patients should be issues with the information (yellow) booklet.

Patients initiated on a NOAC should be provided with written information and monitoring booklet such as the European Heath Rhythm Association Arial Fibrillation Oral Anticoagulation Card.

Patients should be advised to carry an alert card with them at all times.

Initiation of warfarin therapy in line with a recommended slow loading schedule.

Monitoring – INR testing should be frequent for the firs few weeks or months then normally every 1-2 months in people with AF. Self-monitoring is an option.

Dosing – Practices should use computer dosing software systems – the choice of a system should be agreed with the health board. Computer dosing should be interpreted and actioned by non-administrative professionals who are trained and competent to manage warfarin therapy.

Review – At initial diagnosis and at least annually an appropriate review of the patients’ health and medication should be undertaken. See full DES below for more details on what this should involve.

Record keeping – Maintain records of the performance and result of the service provided, including significant event analysis for every bleeding episode requiring hospital admission and deaths caused or related to anti-coagulation therapy.

Audit – Annual audit of the care of patients using an agreed proforma.

Risk management – to have in place a risk management strategy.

Regular service review - annually

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