Specifying an anticoagulation therapy service

Service components

The key components of an effective anticoagulation therapy service are:

• ensuring appropriate referral and management of patients with atrial fibrillation (AF) who require anticoagulation therapy
• effective management of patients who require anticoagulation for other reasons
• developing a high-quality anticoagulation therapy service.

Appropriate referral and management of patients with AF who require anticoagulation therapy

This commissioning guide does not describe the diagnosis of patients with AF. However, it is clearly an important step towards directing appropriate patients to anticoagulation therapy services. Local organisations might wish to develop protocols for diagnosing patients with AF, based on the NICE clinical guideline CG36 on AF.

Key priorities for implementation, as outlined in the NICE clinical guideline CG36 on AF, include:

• “in patients with newly diagnosed AF for whom antithrombotic therapy is indicated (see section 1.8.6), such treatment should be initiated with minimal delay after the appropriate management of comorbidities”
• “the stroke risk stratification algorithm should be used in patients with AF to assess their risk of stroke and thromboembolism, and appropriate thromboprophylaxis given”.

Ensuring that appropriate patients with AF are referred for anticoagulation therapy is important both in terms of reducing the risk of stroke, but also in managing service demand.

Management of patients who require anticoagulation therapy for other reasons

NICE has not issued guidance on the management of patients who require anticoagulation therapy for other reasons, such as those who have experienced an episode of thromboembolism.

Advice on managing these patients can be obtained from NHS Evidence Health Information Resources and also from the Clinical Knowledge Summaries service, which has produced guidelines for the management of patients with deep vein thrombosis.

Developing a high-quality anticoagulation therapy service

Information on the detailed requirements of an anticoagulation service is available from the national enhanced service specification for anticoagulation monitoring within the General Medical Services contract.

Commissioners may wish to consider that an anticoagulation therapy service can be delivered in a number of different ways, and that mixed models of provision may be required across a local health economy. Examples include:

• full service provision in secondary care
• full service provision in primary care
• shared provision between primary and secondary care
• domiciliary provision
• patient self-management.

Services may be managed by a range of healthcare professionals including nurses, pharmacists and general practitioners.

Local stakeholders, including service users, should be involved in determining what is needed from an anticoagulation therapy service in order to meet local needs. The service specification needs to consider:

• the expected number of patients
• ease of access
• location of the service
• information and audit requirements, including IT support and infrastructure
• required competences of, and training for, staff responsible for providing anticoagulant care
• planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway or equitable waiting times locally for those services currently outside 18 weeks
• service monitoring criteria.

Useful sources of information may include:

• Implementation advice for NICE clinical guideline CG36 on atrial fibrillation
• NICE National Costing Report for further information on costs associated with implementing the NICE clinical guideline CG36 on AF
• National Library for Health
• British Committee for Standards in Haematology (BCSH)
• 'Delivering the 18 week patient pathway: 18 week commissioning pathways'