To the Editor: The recent article by Lowthian and colleagues raises some important concerns regarding current management of warfarin therapy in Australia, especially the provision of quality warfarin education.1 While the study focused on the uncertainty surrounding who is responsible for this task, additional barriers to providing warfarin education include limited access to suitable resources and a tendency to rely on a single verbal counselling session and/or the supply of written material, often just before discharge from hospital.2

As Lowthian et al note, it is plausible that warfarin education was provided to the patients interviewed; it may simply have been inadequate to meet their needs or delivered at the wrong time or place. It is not always feasible for health care providers to reliably provide the necessary education in busy health care settings (eg, general practitioners when prescribing warfarin, pharmacists when supplying it). The authors note a potential role for practice nurses in providing this education; we would also like to highlight the role of accredited pharmacists, who can visit patients in their homes and provide targeted medication-related education. An annual Home Medicines Review can be provided for patients taking high-risk medications such as warfarin.3

Under the Fourth Community Pharmacy Agreement Research and Development Program, the Pharmacy Guild of Australia has funded two projects that are attempting to meet the education needs of patients taking warfarin. One project is trialling a comprehensive postdischarge service involving a series of follow-up home visits by trained accredited pharmacists, to provide not only warfarin education but also point-of-care international normalised ratio monitoring, in liaison with the patients’ GPs.

The other project is piloting a process whereby community pharmacists can identify potential candidates for patient self-monitoring of warfarin and, with GP collaboration, organise suitable training, with ongoing support from the pharmacist and GP. Patient self-monitoring, although not widely practised in Australia, has been shown to provide the best clinical outcomes for suitable candidates.4

An important component of these two projects is a website, launched in late 2008, containing a range of free, downloadable educational resources for both consumers taking warfarin and health care professionals responsible for its management (http://www.anticoagulation.com.au).

Education is crucial in achieving optimal health outcomes for patients taking warfarin, and health care professionals should cooperate to ensure their patients are well educated. This should involve regular reinforcement of consistent messages, and can also involve better use of existing services and educational tools.

In reply: Bereznicki and colleagues have reinforced the importance of patient education in optimising warfarin safety, while highlighting the need for role clarification in its provision.

We applaud the Pharmacy Guild of Australia’s sponsorship of research projects trialling different models of service delivery, such as the coordination of postdischarge warfarin home care by pharmacists and support of patient self-monitoring programs, where appropriate. The success of such care models will be enhanced by a collaborative partnership between the patient and all members of the warfarin care team.1

In addition, appraisal of patient suitability for programs such as patient self-monitoring requires systematic and regular evaluation of cognitive function, compliance and health literacy, to reduce the likelihood of adverse events.2-4 Likewise, ongoing education with resources tailored to individual patients’ capabilities will optimise patient safety.5

To the Editor: Lowthian and colleagues ask who is responsible for the care of patients treated with warfarin therapy.1 In Melbourne, it seems that this devolves mainly upon the pathology laboratory, whereas in other states, general practitioners manage care for their own patients, in my own experience.

Where management of warfarin dosing, based on the international normalised ratio (INR) result, is performed by the laboratory, this is done as a courtesy to GPs. This practice possibly evolved from competition between private laboratories and, as such, may have been intended to induce other pathology requests to the service provider.

Larger metropolitan private pathology services may have sufficient pathologists with haematology training to provide warfarin dosing to patients, but this may not always apply in smaller laboratories. In some laboratories, warfarin dosing may be provided to patients by scientific staff. Although warfarin therapy can sometimes be challenging, its difficulties are not usually insurmountable.

Problems for pathologists arise because they are expected to give a warfarin dose by telephone to a patient they do not know and have never seen. The patient’s phone number may be not supplied or incomplete, and the call may not be answered. If answered, a brief history of previous INR results, dosages and test intervals may or may not be elicited from a person who may have poor English, who may be the patient, a relative, friend or neighbour; or a message may have to be left. If the message is received, it may not be acted on, depending on memory, understanding or level of compliance. If the message is not received, the patient and the patient’s GP may be unreasonably irate, even though multiple attempts to contact the patient may have been made. It is not hard to understand why some GPs prefer to pass this often frustrating and time-consuming aspect of treatment to pathologists — who may also be pressed for time.

Problems are further compounded if warfarin dosing devolves to pathology laboratory scientists, which may be required by their employer. Scientists would be, in effect, performing drug dosing without medical training or medical registration and may be exposing themselves to litigation risk, without carrying medical indemnity.

In other Australian states, it seems that GPs do provide treatment and dosing of warfarin for their own patients. In my view, this is the safest and most satisfactory outcome for patients, pathologists and scientists. With the projected advent of point-of-care testing with reliable INR results2 and new anticoagulant alternatives1 that would enable easier management of anticoagulant therapy by GPs, this whole issue could potentially be resolved.