Síntesis de miconazol y econazol

Anticoagulation clinics may take the form of hospital outpatient clinics or specialised community-based clinics. In general, anticoagulation clinics can be defined as “a specialised program of patient management focused predominantly, if not exclusively, on managing oral anticoagulation.”205 _{Anticoagulation clinics are}

regarded as a more systematic and coordinated model of care than traditional office- based management.12 _{They incorporate patient education, systematic INR testing,}

tracking and follow-up, and good communication with the patient regarding results and dosage decisions.12 _{They also have the advantage of having the INR result}

available whilst the patient is present, allowing for immediate dosage advice and additional education where necessary.

An anticoagulation clinic program is often directed by a single physician who assumes no responsibility for the primary care of the patients under their management, while the actual management is usually conducted by registered nurses or pharmacists, who become responsible for making dosage changes, scheduling future tests and providing education.202, 205 _{The health professional}

assuming responsibility for the anticoagulation management then becomes an expert in the area and subsequently is able to offer an improved quality of care.202

Both anticoagulant nurses and pharmacists have been found to be at least as safe and effective as physicians in managing anticoagulated patients.206-210

Anticoagulation clinics have been shown to be an effective way of improving the quality of anticoagulation management compared to usual care.201, 202, 211-214 _Studies

consistently find clinically important differences in the TTRs achieved by anticoagulation clinics when compared to usual models of care.201, 213-216 _{They also}

find that anticoagulation clinics achieve significantly lower rates of adverse clinical events in terms of both major haemorrhage and thrombotic events than are achieved with traditional care models.209, 214, 216, 217

Despite the improved outcomes that can be expected with clinic-based care, a considerable time commitment can still be required from the patient. Traditionally, patients had a venous sample drawn on arrival to the clinic and waited until the result was available before having their consultation. One study estimated that the time involved in attending an anticoagulation clinic could range from 42 minutes to 3.5 hours.218 _{The increasing availability and adoption of POC testing devices has}

reduced the time involved in attending clinics and will continue to improve anticoagulation clinics’ abilities to provide timely dose adjustments and education.

In a systematic review of 67 studies, involving over 50,000 patients, management by anticoagulation clinics was compared to usual community care.56 _{It was found that}

time spent within the therapeutic range was generally lower in patients from community-based studies than in those from anticoagulation clinics, with mean TTRs of 50.0% (95% CI: 45.1-55.0%) and 65.6% (95% CI: 63.7-67.7%) respectively.56 _{It was concluded that patients managed by community practices}

showed significantly worse anticoagulation control than those managed by anticoagulation clinics.56

Other systematic reviews have supported the suggestion that anticoagulation clinics offer improved control of therapy when compared to usual care.219, 220

Anticoagulation clinics were found to be superior to usual care by Dolan et al., resulting in improvements in time in range of 11.3% (95% CI: 0.1-21.7%).219

Similarly, Cios et al. found that usual care resulted in a time in range that was 13.0% (95% CI: 7.9-18.0%) less than that achieved by specialist clinics.220

Another, more recent, systematic review identified three randomised controlled trials and eight cohort studies for review.221 _{It was concluded that evidence for the}

safety and efficacy of anticoagulation clinics is limited but overall suggests that care provided by such clinics may lead to improvements in time in therapeutic range.221

The analyses suggest that face to face interactions, computer-based monitoring systems for appointments, specialised staff, and the provision of written instructions have an important role to play in the improved care offered by anticoagulation clinics.221

2.4.2.1 Computer-assisted dosage support

While anticoagulation clinics alone have been shown to improve anticoagulation control, superior INR control is achieved by experienced personnel in anticoagulation clinics who utilise computer-assisted dosage adjustment

methods.222 _{Computer-based dose adjustment programs typically calculate whether}

a dose adjustment is necessary from a pre-defined table of rules for the therapeutic range.12 _{If the computer recommends a dose adjustment, it then uses the current}

INR and the target INR to calculate the new dose.12 _{It is also able to calculate the}

time to the next test by taking into consideration the current INR, the interval which has passed since the last test, the number of previous dose changes, and the number of previous INR results in range.12

Numerous studies support the use of computer-based dosing algorithms over manual dosing methods.223-227 _{They found that computer-based dosing gave better}

INR control, as measured by improvements in the TTR, when compared to manual dose adjustments made by expert medical staff.223-227 _{Increases in TTR as great as}

12% were seen through the use of computer-based dosing.227 _{Other benefits}

reported include fewer extreme low results and fewer extreme high INRs,226 _{and a}

reduction in adverse clinical events.227 _{Computer-based dosing methods have also}

been shown to be at least as effective as physicians for the initiation of warfarin therapy, as well as for the long term management.228, 229

These positive findings in support of computer-based dosing algorithms have resulted in their widespread use in anticoagulation clinic situations and their inclusion in clinical practice guidelines.230