Chronic Care Management Differences in Anticoagulant Clinics

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This research study published in BioMed Central Health Services Research compared the patient outcomes between Dutch Anticoagulant Clinic (AC) regions taking into account the variations in chronic care management (CCM) in order to explore whether these CCM elements could improve the quality of oral anticoagulant therapy. The data were subjected to regression analysis to identify to what extent the differences in patient outcomes are associated with chronic care management activities.


The Chronic Care Model (CCM) of Wagner was used to identify the elements of chronic care management. The CCM captures six components which all conceive elements on practice level to structure chronic care such as software applications for decision support or education for self-management support. The CCM elements that were included in this questionnaire were selected and made measurable based on the literature and the expert opinion of about twenty professionals working in the thrombosis field.

The characteristics of the chronic care management identified with the questionnaire were described by five components of the CCM namely: health care organization (i.e. the organizations’ focus on chronic care for instance by incident reporting system); self-management support (i.e. supporting patients to manage their condition for instance by self-management education); delivery system design (i.e. the organization of providing care such as other roles/teams); decision support (i.e. integration of evidence-based clinical guidelines into practice for example by a reminder system) and clinical information system (i.e. systems that support the information exchange).

The identified chronic care management elements applied by the Anticoagulant Clinic regions were hypothesized to improve the chronic care management and as a consequence the patient outcomes as suggested by the CCM. Although the sixth component of the CCM – community resources and policies – was relevant for chronic care management (e.g. legislation to allow self-management), this was not taken into account in this study because the variation in this element differs on another level than the level of analysis of this study, i.e. the Anticoagulant Clinic regions

**Data Analysis:**
The associations between the use of CCM and quality of care were studied in two different ways; the combination of descriptive analysis and regression analysis were used to perform this study. The variation in patient outcomes and the elements of chronic care management were studied with descriptive analyses. The regression analyses were controlled for the type of reagent (the use of Innovin versus other reagents) since previous research showed that use of Innovin may systematically give different results on the measured INR.

Other than studying the use of each separate element of the CCM and its association with quality of care, a scale was also constructed to represent the use of all elements of the CCM. The components of Wagner were included as a score in the construct when its use was more than 0 on the scale, indicating that it was used more than average by the AC region. The ensuing scale represented the number of CCM components which were used more by a thrombosis clinic than by other thrombosis clinics. It can be interpreted as a count of the relative use of the CCM components: the higher the score, the more CCM components are used.

The differences in chronic care management between the AC regions, categorized to components of the CCM, are shown in this dataset. All ACs reported having a quality manager and almost all a client board which is mandatory in the Netherlands. Differences are shown in the component ‘health care organization’ considering quality improvement system and patient orientation. In addition, more than half of the ACs has been accredited more than once which implies consistency of their quality of care.

The component ‘delivery system design’ showed that 7 of the 59 thrombosis clinics reported participating in regional multidisciplinary meetings. The ratio of specialized nurses versus doctors – measured in full-time equivalent – showed a mean ratio of 8.7. This implies that the average number of full-time equivalents (FTE’s) of the specialized nurses is 8.7 times higher than the number of FTE’s of the doctors. Especially the number of specialized nurses differed; ranging from 0 specialized nurses (which is the case for 9 ACs) to 15 specialized nurses working at the AC.

Furthermore, the component ‘decision support’ was applied in most AC regions (n = 57) by using a software system which proposes dosage advice that could give the doctors a direction. Formal agreements between the hospital and the ACs are less frequently reported; 34 of the ACs had formal agreements with at least one hospital in their region.

In addition, the characteristics of the component ‘clinical information system’ showed that 44 of the ACs always contact the physician about an INR above 8.0 (which is advised by the Dutch National Network of ACs), 11 of the ACs use a web-based dosage system, less than half of the ACs are always informed about interacting drugs by the pharmacist.

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John Snow Labs; BioMed Central Health Services Research;

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BioMed Central / BioMed Central Health Services Research / PubMed Central / U.S. National Institutes of Health's National Library of Medicine (NIH/NLM).


Anticoagulant Therapy, Anticoagulation Clinics, Anticoagulation Guidelines, Warfarin Dosage, Anticoagulation Dosage, Novel Anticoagulants, Anticoagulant Study, Anticoagulation Outcomes, JAMA Studies, Long-term Oral Anticoagulation Therapy

Other Titles

Chronic Care Anticoagulant Therapy Management, Differences in Anticoagulation Clinic Chronic Care Management, Anticoagulation Guidelines in Chronic Care Management, Warfarin Dosage in Anticoagulant Chronic Care Management

Chronic_Care_Management_ElementsDescription of the components of the Chronic Care Management used in different Dutch Anticoagulant Clinic (AC) regions.string-
OutcomesDescription of the outcomes observed after using the different components of the Chronic Care Managementstringrequired : 1
NotesDescription of the details of the outcome such as frequency, elements involved in the CCM and/or scale used to measure the outcome.string-
Sample_SizeThe number of participants or sample population in this study.integerlevel : Ratio
MeanShows the mean, median or average values in terms of the outcomes in the use of the CCM.numberlevel : Ratio
Standard_DeviationShows the measure that is used to quantify the amount of variation or dispersion in the use of the CCM.numberlevel : Ratio
Quality manager58
AccreditationMore than once32
Quality improvement systemNone1
Quality improvement systemBoth48
Software used for dosage advice57
Health Care OrganizationClient board56
Quality improvement systemNone1
Specialized nurses versus doctors8.711.3