Anticoagulation Patient Self‐Monitoring in the United States: Considerations for Clinical Practice Adoption

Abstract

Systematic management models such as anticoagulation clinics have emerged in order to optimize warfarin effectiveness and to minimize related complications. Most of these models are structured so that patients come to a clinic for in-person testing and evaluation, thus making this model of care difficult to access and time consuming for many patients. The emergence of portable instruments for measuring anticoagulant effect in capillary whole blood made it possible for patients receiving warfarin to self-monitor the effect of their anticoagulant therapy. Self-monitoring empowers patients, offers the advantage of more frequent monitoring, and increases patient convenience by allowing testing at home and avoiding the need for frequent laboratory and clinic visits. Self-monitoring can entail patient self-testing (PST) and/or patient self-management (PSM). Several studies have evaluated and shown the benefit of both PST and PSM models of care when compared with either routine medical care or anticoagulation clinic management of anticoagulation therapy. Self-monitoring (PSM and/or PST) of anticoagulation results in lower thromboembolic events, lower mortality, and no increase in major bleeding when compared with standard care. Despite favorable results and enhanced patient convenience, the adoption of self-monitoring into clinical practice in the United States has been limited, especially in higher risk, disadvantaged populations. Although the emergence of a multitude of novel oral anticoagulants will permit clinicians to better individualize anticoagulant therapy options by choosing the optimum regimen based on individual patient characteristics, it is also expected that traditional agents will continue to play a role in a significant subset of patients. For those patients treated with traditional anticoagulants such as warfarin, future models of care will entail patient-centered management such as PST and PSM. The incorporation of technology (i.e., Web-based expert systems) is expected to further improve the outcomes realized by PST and PSM. Further studies are needed to explore factors that influence the adoption of self-monitoring in the United States and to evaluate the feasibility and implementation in real-life clinical settings.

Quality of vitamin K antagonist control and outcomes in atrial fibrillation patients: a meta-analysis and meta-regression

“…The improved INR control in RCTs and anticoagulation clinics may be the result of increasing the frequency of monitoring, providing more organized care and focusing more on improving poor VKA-drug persistence (as low as 68% at 6-months) [107,108] than typically done in community settings. Unfortunately, not all patients receiving a VKA have access to anticoagulation clinics [109]. In fact, it is estimated that only about one-third of patients receiving a VKA in the US have access to an anticoagulation clinic due to time, distance, economic or other access-to-care issues.…”

“…Finally, people in North America spent significantly less time in the therapeutic range than those in Europe or the UK. This may be a result of North America’s near exclusive use of warfarin, which has been shown in previous analyses to result in as much as a 9% lower TTR compared to other VKAs [6], as well as, North America’s less wide-spread use of proven strategies to increase TTR such as and anticoagulation clinics as noted above [6,8,9,109] and patient self-monitoring [6]. …”

Assessment and evaluation efficacy of a clinical pharmacist-led inpatient warfarin knowledge education program and follow-up at a Chinese tertiary referral teaching hospital

“…It is an effective anticoagulant when dosed appropriately; however, its use requires systematic monitoring and close patient follow-up due to its narrow therapeutic index and several complicated pharmacokinetics and pharmacodynamics profiles. [2] Other factors including diet, alcohol, other medications, illness and adherence can adversely affect the safety and efficacy of warfarin. [3] Until date, a few studies have shown an association between the outcomes of anticoagulation therapy and health literacy, patient education or knowledge of warfarin therapy; however, results are mixed.…”

Comparing Patient and Physician Risk Tolerance for Bleeding Events Associated with Anticoagulants in Atrial Fibrillation—evidence from the United States and Japan

“…In the United States, however, preferences of patients and physicians were not statistically different when all estimates were tested jointly, suggesting that perhaps recent strategies for anticoagulation services and self-monitoring have helped reduce disagreement between patients and physicians because these strategies increase patients' understanding of dosing and their ability to influence their level of anticoagulation [23]. Although our study was not designed to evaluate the impact of specific macroeconomic or societal factors on preferences, we acknowledge that it is possible that social differences and differences in health systems between the two countries could have influenced the observed patterns of preferences among patients and physicians.…”