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Van Beek A, Moeyaert M, Ragheb B, Price E, MacEwan JP, Ahmed N, Ansell J. Outcomes of Warfarin Home INR Monitoring vs Office-Based Monitoring: a Retrospective Claims-Based Analysis. J Gen Intern Med 2024; 39:1127-1134. [PMID: 38100006 PMCID: PMC11116318 DOI: 10.1007/s11606-023-08348-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/03/2023] [Accepted: 07/21/2023] [Indexed: 05/25/2024]
Abstract
BACKGROUND Home INR testing (patient self-testing) is feasible and effective for warfarin patients but little is known about real-world differences in outcomes for patients using PST versus laboratory-based INR monitoring. OBJECTIVE To compare the safety/efficacy of patient self-testing of real-world warfarin therapy versus office/lab-based monitoring of therapy. DESIGN/SETTING/PARTICIPANTS/EXPOSURE A retrospective claims-based analysis of warfarin patients enrolled in the MarketScan® Commercial Claims and Encounters and Medicare databases between January 1, 2013, and March 30, 2020. Stratification was based on INR testing method: patient self-testing versus testing at physicians' offices/local laboratory. The probability of adverse events in each cohort was determined after adjusting for demographic and baseline clinical characteristics using a repeated measures analysis. MAIN MEASURES Rates of all adverse events: deep venous thrombosis, pulmonary embolism, bleeding, and stroke. A secondary outcome of interest was emergency department visits. KEY RESULTS A total of 37,837 patients were included in the analysis: 1592 patients in the patient self-testing group and 36,245 in the office-based therapy group. After adjusting for demographic and baseline clinical characteristics, patients in the office-based group had statistically significantly higher rates of all adverse events (incidence rate ratio [IRR]=2.07, 95% CI [1.82, 2.36]), and specific adverse events including thromboembolism (IRR=4.38, 95% CI [3.29, 5.84]), major bleed (IRR=1.45, 95% CI [1.28, 1.64]), and stroke (IRR=1.30, 95% CI [1.05, 1.61]) than patients in the patient self-testing group. Office-based patients also had a statistically significant higher rate of emergency department visits than patient self-testing patients (IRR = 1.65, 95% CI [1.47, 1.84]). CONCLUSIONS/RELEVANCE This analysis of real-world claims data shows lower rates of stroke, thromboembolism, and major bleeding, as well as fewer emergency department visits, with patient self-testing compared to office-based/lab INR monitoring. Our finding that PST is safe and effective among current users suggests that more patients may benefit from its use.
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Affiliation(s)
| | - Mariola Moeyaert
- University at Albany - State University of New York, Albany, NY, USA
| | - Bishoy Ragheb
- VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - Erika Price
- San Francisco VA Health Care System, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Jack Ansell
- Hofstra Northwell Zucker School of Medicine, Hempstead, NY, USA.
- , Long Branch, NJ, USA.
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2
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Magon A, Arrigoni C, Durante A, Falchi C, Dellafiore F, Stievano A, Caruso R. Barriers to self-monitoring implementation in the oral anticoagulated population: A qualitative study. Int J Nurs Pract 2023; 29:e13095. [PMID: 35971277 DOI: 10.1111/ijn.13095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/31/2022] [Accepted: 07/25/2022] [Indexed: 02/04/2023]
Abstract
AIM This study aimed to explore and understand the barriers perceived by Italian nurses to adopting self-monitoring for managing oral anticoagulation in real-life settings. BACKGROUND Barriers to self-monitoring implementation for managing oral anticoagulation have been poorly described. DESIGN The study had a qualitative descriptive and exploratory design with a hybrid approach. METHODS A literature review was conducted to identify a priori barriers (deductive approach), while a small and semi-structured focus group discussion was performed to explore the contextual barriers experienced by Italian nurses (inductive approach). A classic content analysis technique was adopted. Data were collected in 2019. FINDINGS Two main categories were identified. Organizational barriers referred to the lack of inter-professional collaboration and health-care system strategies to provide clinical pathways for self-monitoring. Individual barriers encompassed professional characteristics (e.g. university background, professional knowledge, continuum education and accountability/responsibility) and patient characteristics (e.g. patient health literacy and knowledge, engagement/empowerment and educational programmes). Finally, unwarranted clinical variation in oral anticoagulation management arose as a barrier determined by organizational and individual elements. CONCLUSIONS The results of this study pointed out an urgent public health issue in addressing barriers influencing self-monitoring practice and in sustaining care models that might enhance the quality improvement of self-monitoring for managing oral anticoagulation.
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Affiliation(s)
- Arianna Magon
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Cristina Arrigoni
- Department of Public Health, Experimental and Forensic Medicine, Section of Hygiene, University of Pavia, Pavia, Italy
| | - Angela Durante
- Nursing department, GRUPAC, Universidad de la Rioja, Logroño, Spain
| | - Chiara Falchi
- Medical Ward, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Federica Dellafiore
- Department of Public Health, Experimental and Forensic Medicine, Section of Hygiene, University of Pavia, Pavia, Italy
| | | | - Rosario Caruso
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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3
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Chan J, Michaelsen K, Estergreen JK, Sabath DE, Gollakota S. Micro-mechanical blood clot testing using smartphones. Nat Commun 2022; 13:831. [PMID: 35149711 PMCID: PMC8837659 DOI: 10.1038/s41467-022-28499-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 01/26/2022] [Indexed: 11/09/2022] Open
Abstract
Frequent prothrombin time (PT) and international normalized ratio (INR) testing is critical for millions of people on lifelong anticoagulation with warfarin. Currently, testing is performed in hospital laboratories or with expensive point-of-care devices limiting the ability to test frequently and affordably. We report a proof-of-concept PT/INR testing system that uses the vibration motor and camera on smartphones to track micro-mechanical movements of a copper particle. The smartphone system computed the PT/INR with inter-class correlation coefficients of 0.963 and 0.966, compared to a clinical-grade coagulation analyzer for 140 plasma samples and demonstrated similar results for 80 whole blood samples using a single drop of blood (10 μl). When tested with 79 blood samples with coagulopathic conditions, the smartphone system demonstrated a correlation of 0.974 for both PT/INR. Given the ubiquity of smartphones in the global setting, this proof-of-concept technology may provide affordable and effective PT and INR testing in low-resource environments. Therapy with anticoagulants requires frequent monitoring. Here the authors describe a proof-of-concept study of a simple and affordable blood clot test that uses a smartphone’s vibration motor and camera to track micro-movements in a single drop of blood.
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Affiliation(s)
- Justin Chan
- Paul G. Allen School of Computer Science and Engineering, University of Washington, Seattle, WA, USA.
| | - Kelly Michaelsen
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA.
| | - Joanne K Estergreen
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA, USA
| | - Daniel E Sabath
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA, USA
| | - Shyamnath Gollakota
- Paul G. Allen School of Computer Science and Engineering, University of Washington, Seattle, WA, USA.
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4
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Williams NX, Carroll B, Noyce SG, Hobbie HA, Joh DY, Rogers JG, Franklin AD. Fully printed prothrombin time sensor for point-of-care testing. Biosens Bioelectron 2020; 172:112770. [PMID: 33157410 DOI: 10.1016/j.bios.2020.112770] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/25/2020] [Indexed: 01/14/2023]
Abstract
With an increasing number of patients relying on blood thinners to treat medical conditions, there is a rising need for rapid, low-cost, portable testing of blood coagulation time or prothrombin time (PT). Current methods for measuring PT require regular visits to outpatient clinics, which is cumbersome and time-consuming, decreasing patient quality of life. In this work, we developed a handheld point-of-care test (POCT) to measure PT using electrical transduction. Low-cost PT sensors were fully printed using an aerosol jet printer and conductive inks of Ag nanoparticles, Ag nanowires, and carbon nanotubes. Using benchtop control electronics to test this impedance-based biosensor, it was found that the capacitive nature of blood obscures the clotting response at frequencies below 10 kHz, leading to an optimized operating frequency of 15 kHz. When printed on polyimide, the PT sensor exhibited no variation in the measured clotting time, even when flexed to a 35 mm bend radius. In addition, consistent PT measurements for both chicken and human blood illustrate the versatility of these printed biosensors under disparate operating conditions, where chicken blood clots within 30 min and anticoagulated human blood clots within 20-100 s. Finally, a low-cost, handheld POCT was developed to measure PT for human blood, yielding 70% lower noise compared to measurement with a commercial potentiostat. This POCT with printed PT sensors has the potential to dramatically improve the quality of life for patients on blood thinners and, in the long term, could be incorporated into a fully flexible and wearable sensing platform.
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Affiliation(s)
- Nicholas X Williams
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Brittani Carroll
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Steven G Noyce
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Hansel Alex Hobbie
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Daniel Y Joh
- Department of Biomedical Engineering, Duke University, Durham, NC, 27708, USA
| | - Joseph G Rogers
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, NC, 27708, USA
| | - Aaron D Franklin
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA; Department of Chemistry, Duke University, Durham, NC, 27708, USA.
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5
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Tripathi MM, Egawa S, Wirth AG, Tshikudi DM, Van Cott EM, Nadkarni SK. Clinical evaluation of whole blood prothrombin time (PT) and international normalized ratio (INR) using a Laser Speckle Rheology sensor. Sci Rep 2017; 7:9169. [PMID: 28835607 PMCID: PMC5569083 DOI: 10.1038/s41598-017-08693-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 07/12/2017] [Indexed: 11/22/2022] Open
Abstract
Prothrombin time (PT) and the associated international normalized ratio (INR) are routinely tested to assess the risk of bleeding or thrombosis and to monitor response to anticoagulant therapy in patients. To measure PT/INR, conventional coagulation testing (CCT) is performed, which is time-consuming and requires the separation of cellular components from whole blood. Here, we report on a portable and battery-operated optical sensor that can rapidly quantify PT/INR within seconds by measuring alterations in the viscoelastic properties of a drop of whole blood following activation of coagulation with thromboplastin. In this study, PT/INR values were measured in 60 patients using the optical sensor and compared with the corresponding CCT values. Our results report a close correlation and high concordance between PT/INR measured using the two approaches. These findings confirm the accuracy of our optical sensing approach for rapid PT/INR testing in whole blood and highlight the potential for use at the point-of-care or for patient self-testing.
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Affiliation(s)
- Markandey M Tripathi
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Satoru Egawa
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Department of Precision Engineering, University of Tokyo, Tokyo, Japan
| | - Alexandra G Wirth
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Diane M Tshikudi
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Elizabeth M Van Cott
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Seemantini K Nadkarni
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
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6
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Lee JC, Horner KE, Krummel ML, McDanel DL. Clinical and Financial Outcomes Evaluation of Multimodal Pharmacist Warfarin Management of a Statewide Urban and Rural Population. J Pharm Pract 2017; 31:150-156. [PMID: 28441899 DOI: 10.1177/0897190017703506] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the efficacy, safety, and indirect financial outcomes of pharmacist face-to-face warfarin management with telephone-based distance management utilizing local laboratories or patient self-testing (PST). METHODS A retrospective analysis of a clinic population of 336 patients on established warfarin therapy distributed statewide in rural and urban settings over a 6-month period was conducted. Participants were stratified into face-to-face management, telephone-based management utilizing local laboratory testing, and telephone-based management utilizing PST. RESULTS The primary outcome of international normalized ratio (INR) time in therapeutic range (TTR) for face-to-face management was significantly greater than distance management utilizing local laboratory testing (69.0% vs 60.5%, P = .0032). No difference was observed between face-to-face management and PST (69.0% vs 68.0%, P = .25). No significant difference in bleeding or thromboses was observed. Although increased clinician time was utilized during face-to-face encounters compared to telephone encounters (8.7-minute face-to-face, 5.5-minute local laboratory, and 5.4-minute PST), face-to-face encounters tended to be billable at lower levels, whereas telephone-based encounters were billable at higher levels. CONCLUSION A multimodal approach to pharmacist warfarin management of a patient population distributed statewide in rural and urban locations is effective despite TTR differences associated with INR testing used in distance management. PST may improve warfarin treatment outcomes and adherence in distance management, particularly when the use of alternative oral anticoagulants is inappropriate. Although time and billing differences between face-to-face and distance management exist, clinical and safety outcomes remain acceptable despite encounter complexity and support reimbursement of pharmacist anticoagulation management in all settings.
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Affiliation(s)
- James C Lee
- 1 Department of Pharmacy Practice/Ambulatory Pharmacy Services, University of Illinois Hospital & Health Sciences System, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Kathleen E Horner
- 2 Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Michelle L Krummel
- 2 Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Deanna L McDanel
- 2 Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Iowa City, IA, USA.,3 Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, IA, USA
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7
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Grogan A, Coughlan M, Prizeman G, O'Connell N, O'Mahony N, Quinn K, McKee G. The patients' perspective of international normalized ratio self-testing, remote communication of test results and confidence to move to self-management. J Clin Nurs 2017; 26:4379-4389. [PMID: 28231618 DOI: 10.1111/jocn.13767] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2017] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To elicit the perceptions of patients, who self-tested their international normalized ratio and communicated their results via a text or phone messaging system, to determine their satisfaction with the education and support that they received and to establish their confidence to move to self-management. BACKGROUND Self-testing of international normalized ratio has been shown to be reliable and is fast becoming common practice. As innovations are introduced to point of care testing, more research is needed to elicit patients' perceptions of the self-testing process. DESIGN This three site study used a cross-sectional prospective descriptive survey. METHODS Three hundred and thirty patients who were prescribed warfarin and using international normalized ratio self-testing were invited to take part in the study. The anonymous survey examined patient profile, patients' usage, issues, perceptions, confidence and satisfaction with using the self-testing system and their preparedness for self-management of warfarin dosage. RESULTS The response rate was 57% (n = 178). Patients' confidence in self-testing was high (90%). Patients expressed a high level of satisfaction with the support received, but expressed the need for more information on support groups, side effects of warfarin, dietary information and how to dispose of needles. When asked if they felt confident to adjust their own warfarin levels 73% agreed. Chi-squared tests for independence revealed that none of the patient profile factors examined influenced this confidence. The patients cited the greatest advantages of the service were reduced burden, more autonomy, convenience and ease of use. The main disadvantages cited were cost and communication issues. CONCLUSION Patients were satisfied with self-testing. The majority felt they were ready to move to self-management. RELEVANCE TO CLINICAL PRACTICE The introduction of innovations to remote point of care testing, such as warfarin self-testing, needs to have support at least equal to that provided in a hospital setting.
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Affiliation(s)
| | - Michael Coughlan
- School of Nursing and Midwifery, Trinity College Dublin, Dublin 2, Ireland
| | - Geraldine Prizeman
- Trinity Centre for Practice and Healthcare Innovation, School of Nursing and Midwifery, Trinity College Dublin, Dublin 2, Ireland
| | | | | | - Katherine Quinn
- Anticoagulation Service, Tallaght Hospital, Dublin 24, Ireland
| | - Gabrielle McKee
- School of Nursing and Midwifery, Trinity College Dublin, Dublin 2, Ireland
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8
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Nogueira F, Signorelli F, Levy RA. Antiphospholipid Syndrome On Cloud (APSOnCloud): web-based monitoring of oral anticoagulation. Lupus 2017; 26:179-185. [PMID: 27436335 DOI: 10.1177/0961203316658558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Antiphospholipid Syndrome (APS) is an autoimmune disease characterized by recurrent thromboses and fetal losses with the presence of antiphospholipid antibodies. The main treatment to prevent recurrent thrombotic events is oral anticoagulation with vitamin K antagonist (VKA), which requires frequent monitoring and dosage adjustments. Outpatient anticoagulation monitoring has its limitations, such as patients spending long hours between the testing procedure and waiting for the results to be adjusted. To optimize this adjustment and to improve APS patients-doctors relationship, we developed a website to help monitor APS patients, called Antiphospholipid Syndrome On Cloud or APSOnCloud. To test it, since March 2014 to March 2016, we registered 20 patients with APS that have inserted 132 international normalized ratio (INR) values. Sixty two percent were out of range and it took on average 7 hours for the doctor in charge to adjust these values. The mean time in therapeutic range was 58.1%. Our preliminary experience in monitoring VKA oral anticoagulation on APSOnCloud suggests that patients with APS might benefit from this web-based monitoring.
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Affiliation(s)
- F Nogueira
- 1 Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - F Signorelli
- 2 Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,3 Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - R A Levy
- 1 Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
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9
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Kuljis J, Money AG, Perry M, Barnett J, Young T. Technology-assisted self-testing and management of oral anticoagulation therapy: a qualitative patient-focused study. Scand J Caring Sci 2016; 31:603-617. [PMID: 27500499 DOI: 10.1111/scs.12374] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 07/03/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Oral anticoagulation therapy requires regular blood testing to ensure therapeutic levels are maintained and excessive bleeding/clotting is avoided. Technology-assisted self-testing and management is seen as one of the key areas in which quality of care can be improved whilst reducing costs. Nevertheless, levels of patient engagement in self-testing and management remain low. To date, little research emphasis has been placed on understanding the patients' perspectives for low engagement. The typical approach adopted by healthcare providers is to provide patient education programmes, with the expectation that individual patients will change their behaviour and adopt new self-care strategies. However, if levels of patient engagement are to be increased, healthcare providers must also develop a better understanding of how their clinical service provision is perceived by patients and make adaptations. OBJECTIVE To explore patient views, needs and expectations of an anticoagulation service and the self-testing and management services provided. METHODS Interviews were conducted with 17 patients who currently engage in international normalised ratio (INR) self-testing and management. Thematic coding and analysis were carried out on the interview transcripts. RESULTS Four high-level themes emerged from interviews: (i) role of clinic, (ii) motivations for self-testing, (iii) managing INR and (iv) trust. The clinic was seen as adding value in terms of specifying testing frequency, dosage profiles and calibrating equipment. Prompt communication from clinic to patient was also valued, although more personalised/real-time communication would help avoid feelings of isolation. Patients felt more in control as self-tester/managers and often took decisions about treatment adjustments themselves. However, some also manipulated their own test results to avoid 'unnecessary' interventions. CONCLUSIONS AND RECOMMENDATIONS More personalised/real-time communication, pragmatic and collaborative patient-clinician partnerships and recognition of expert patient knowledge and expertise are needed if increased levels of engagement with self-testing and management service provision is to be realised.
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Affiliation(s)
- Jasna Kuljis
- Department of Computer Science, Brunel University, London, UK
| | - Arthur G Money
- Department of Computer Science, Brunel University, London, UK
| | - Mark Perry
- Department of Computer Science, Brunel University, London, UK
| | - Julie Barnett
- Department of Psychology, University of Bath, Bath, UK
| | - Terry Young
- Department of Computer Science, Brunel University, London, UK
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10
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Money AG, Barnett J, Kuljis J, Duffin D. Patient perceptions and expectations of an anticoagulation service: a quantitative comparison study of clinic-based testers and patient self-testers. Scand J Caring Sci 2015; 29:662-78. [PMID: 25684404 PMCID: PMC4964929 DOI: 10.1111/scs.12195] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 10/17/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Government initiatives see the provision of technology-assisted self-care as one of the key areas in which there is capacity for improving quality of care whilst reducing costs. However, levels of patient engagement in self-testing and management (STM) remain low. Little emphasis has been placed on understanding the patients' perspectives of the reasons for this limited engagement. Typically, patient engagement in STM is achieved via the provision of patient education programmes, which aim to enable patients to make the changes necessary to become competent self-carers. However, placing the onus to change on the individual patient is unrealistic. If levels of patient engagement are to be improved, patient needs and expectations of clinical services must be better understood and service provision must be adapted accordingly. OBJECTIVE Explore patient perceptions and expectations of clinical service provision and their views of having and making choices about care. METHODS Participants [N = 191, 103 patient self-tester managers (PSTMs) and 87 clinic-based testers (CBTs)] completed the SERVQUAL and ChQ instruments to capture perspectives on service quality and choice, respectively. A comparative statistical analysis explored the similarities and differences between PSTMs' and CBTs' responses. RESULTS Clinic-based testers' perceptions of service quality were significantly more positive than PSTMs', as were their expectations of the 'tangible' aspects of service delivery. PSTMs' expectations of service quality were significantly higher than their perceptions. PSTMs attributed significantly more value to making choices compared with CBTs. CONCLUSIONS AND RECOMMENDATIONS To close the gap between PSTMs expectations and perceptions of service quality and better cater for their choice preferences, service providers may benefit from taking into account the following practice considerations: maintain frequent, timely, personalised and direct interactions with PSTMs; prioritise investment in resources to facilitate patient/practitioner interaction over tangible facilities; ensure that PSTMs are given the opportunity to make choices about their care.
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Affiliation(s)
- Arthur G. Money
- Department of Computer ScienceBrunel University LondonUxbridge, LondonUK, UB8 3PH
| | - Julie Barnett
- Department of Computer ScienceBrunel University LondonUxbridge, LondonUK, UB8 3PH
| | - Jasna Kuljis
- Department of Computer ScienceBrunel University LondonUxbridge, LondonUK, UB8 3PH
| | - Debbie Duffin
- Haemostasis and Thrombosis UnitNottingham University Hospitals NHS TrustQueen's Medical Centre CampusDerby RoadNottinghamNG7 2UH
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11
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Gallagher J, Mc Carthy S, Woods N, Ryan F, O' Shea S, Byrne S. Economic evaluation of a randomized controlled trial of pharmacist-supervized patient self-testing of warfarin therapy. J Clin Pharm Ther 2014; 40:14-9. [DOI: 10.1111/jcpt.12215] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 09/10/2014] [Indexed: 12/19/2022]
Affiliation(s)
- J. Gallagher
- Clinical Pharmacy Research Group; School of Pharmacy; University College Cork; Cork Ireland
| | - S. Mc Carthy
- Clinical Pharmacy Research Group; School of Pharmacy; University College Cork; Cork Ireland
| | - N. Woods
- Centre for Policy Studies; University College Cork; Cork Ireland
| | - F. Ryan
- McGee Pharma International; Dublin UK
| | - S. O' Shea
- Department of Haematology; Cork University Hospital; Cork UK
| | - S. Byrne
- Clinical Pharmacy Research Group; School of Pharmacy; University College Cork; Cork Ireland
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12
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Anticoagulation early after mechanical valve replacement: improved management with patient self-testing. J Thorac Cardiovasc Surg 2012; 146:599-604. [PMID: 22921821 DOI: 10.1016/j.jtcvs.2012.03.088] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 03/15/2012] [Accepted: 03/28/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Self-testing to determine the international normalized ratio improves management with warfarin and reduces the risks of adverse events. Self-testing usually begins several weeks after hospital dismissal after valve replacement. We aimed to compare the in-hospital initiation of international normalized ratio self-testing with usual care in mechanical heart valve recipients. METHODS A total of 200 adult mechanical heart valve recipients were randomly assigned to in-hospital international normalized ratio self-testing instruction or usual care. Instruction for self-testing patients began on the fourth postoperative day. The patients were followed up for 3 months to compare the number of international normalized ratio tests, percentage of time in the therapeutic range, and adverse events. RESULTS The baseline characteristics were similar between the 2 groups. During the first 3 postoperative months, the usual-care group underwent an average of 10 international normalized ratio tests, and the self-testing group completed 14 international normalized ratio tests. The mean ± SD percentage of international normalized ratio tests within the therapeutic range was 45% ± 22% for the usual-care group and 52% ± 22% for the self-testing group (P = .05). Within 90 days after dismissal, transient ischemic attack occurred in 1 patient in the usual-care group and 2 patients in the self-testing group. Bleeding complications occurred in 3 patients in the usual-care group and 5 patients in the self-testing group. CONCLUSIONS Management of anticoagulation with warfarin after mechanical valve replacement is improved with self-testing, even during the early postoperative phase when international normalized ratio testing is performed frequently. Although the incidence of adverse events was similar in the 2 groups, better control of the international normalized ratio would be expected to improve outcome in large populations of patients.
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13
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Bauman ME, Mack G, Bruce AK, Bauman ML, Nolan K, Massicotte MP. Natural Health Product Utilization in Warfarinized Children; Prevalence and Knowledge. J Pharm Technol 2012. [DOI: 10.1177/875512251202800303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background:The need for long-term thromboprophylaxis in children using warfarin therapy is increasing. Natural health products (NHPs) are administered to children by parents who perceive them to be useful and acceptable adjuncts or alternatives to conventional therapies. Interactions of NHPs with prescribed therapies may result in serious adverse events. NHP usage is underevaluated in children and there are no studies evaluating NHP usage in warfarinized children.Objectives:To explore NHP use in warfarinized children and their siblings to determine the prevalence, varieties, and reasons for NHP usage, as well as the potential effect on warfarinization (eg, time in therapeutic range [TTR]).Methods:This is a 3-phase cross-sectional cohort study that includes the (1) prevalence (2) NHP education and knowledge assessment, and (3) the follow-up NHP utilization phase.Results:Forty-six percent of warfarinized children consumed NHPs, with time in therapeutic range of 74%. The mean score for baseline knowledge of NHPs and warfarin following the education phase was 67%. Follow-up NHP use was 30%, and increased consistency of utilization with TTR was 83% (p < 0.05), consistent with education provided.Conclusions:The consistent prevalence rates over time of NHP usage in warfarinized children indicate the need for future studies. Education remains vital to combat the potential risks of NHP-warfarin interaction, encouraging patient disclosure and consistency.
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Affiliation(s)
- Mary E Bauman
- MARY E BAUMAN MN NP, Nurse Practitioner, Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Gordon Mack
- GORDON MACK MD, Fellow, Stollery Children's Hospital
| | - Aisha K Bruce
- AISHA K BRUCE MD FRCPC, Staff Physician, Stollery Children's Hospital
| | - Michelle L Bauman
- MICHELLE L BAUMAN BScN, Research Student, Stollery Children's Hospital
| | - Kyle Nolan
- KYLE NOLAN BA, Research Student, Stollery Children's Hospital
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Two monitoring methods of oral anticoagulant therapy in patients with mechanical heart valve prothesis: a meta-analysis. J Thromb Thrombolysis 2011; 33:38-47. [DOI: 10.1007/s11239-011-0626-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Hua TD, Vormfelde SV, Abu Abed M, Schneider-Rudt H, Sobotta P, Friede T, Chenot JF. Practice nursed-based, individual and video-assisted patient education in oral anticoagulation--protocol of a cluster-randomized controlled trial. BMC FAMILY PRACTICE 2011; 12:17. [PMID: 21477372 PMCID: PMC3089775 DOI: 10.1186/1471-2296-12-17] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 04/10/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Managing oral anticoagulant treatment (OAT) is a challenge for patients and primary care providers. It requires a high level of patient knowledge and adherence. Studies have shown that insufficient adherence and a low level of patient knowledge about OAT are primary causes for complications. This trial is the first to evaluate the long-term effects of a complex practice nurse-based patient education program in comparison to a patient brochure only. METHODS AND DESIGN This trial will be a cluster-randomized controlled trial in 22 general practices (GPs) recruiting 360 patients with OAT. GPs will be randomized into an intervention group or a control group. A baseline questionnaire will assess pre-existing knowledge about OAT. The patients in the intervention group will be educated by a complex education program which consists of a video, a brochure and individual training by a practice nurse. The video gives information about OAT, nutrition, and instructions about how to manage critical situations. The brochure repeats the content of the video. After 4 to 6 weeks, the intervention will be recapitulated. The control group will receive the brochure only. After 6 months, questionnaires will be used in both groups to assess patient knowledge about OAT as well as patients' subjective feelings of safety. Separately, we will evaluate patient records, looking for documented complications and the time spent in the therapeutic range. DISCUSSION This trial will start in January 2011. This trial will evaluate the long-term effectiveness of a video-assisted education program on patients with OAT in comparison to a patient information brochure. Most previous studies have evaluated knowledge directly after an educational intervention. Our trial will look for long-term differences in basic knowledge of OAT. We expect that our complex patient education program effectively increases long-term basic knowledge about OAT. Although the population of our study is too small to observe differences in adverse effects, we expect to discover differences in secondary outcomes, such as the time spent in the therapeutic range. TRIAL REGISTRATION Deutsches Register Klinischer Studien (German Clinical Trials Register): DRKS00000586Universal Trial Number (UTN U1111-1118-3464).
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Affiliation(s)
- Thanh Duc Hua
- Department of General Practice, University Medical Centre Göttingen, Humboldtallee 38, Göttingen, 37073, Germany.
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Affiliation(s)
- Lynn B Oertel
- Anticoagulation Management Service, Massachusetts General Hospital, Boston, MA 02114, USA.
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Kadafour M, Haugh R, Posin M, Kayser SR, Shin J. Survey on warfarin pharmacogenetic testing among anticoagulation providers. Pharmacogenomics 2010; 10:1853-60. [PMID: 19891559 DOI: 10.2217/pgs.09.117] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIMS Our study aimed to assess anticoagulation providers' perception and knowledge of warfarin pharmacogenetic testing, and to identify barriers to using it in their clinical practice. MATERIALS & METHODS An online survey that included 5 perception and 5 knowledge questions about the testing was conducted on anticoagulation providers in North America. Participants were also asked to rank the three most significant barriers to using it. RESULTS The survey response rate was 22%. Over 40% of 448 providers participating in the study were undecided about the testing's potential clinical benefits. On average, providers correctly answered 2 out of 5 knowledge questions. Self confidence in interpreting test results significantly predicted the providers' accuracy of the interpretation. The top three barriers were inadequate literature evidence, testing's impracticality and unproven applicability. CONCLUSION Most of the providers did not respond to the survey. Our study suggests inadequate literature evidence influences providers' perception and their use of the testing. In addition, provider education on warfarin pharmacogenetics may be necessary for testing's widespread use.
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Affiliation(s)
- Maha Kadafour
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, CA 94143-0622, USA
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Public Opinion and Experience of Point-of-Care Testing. POINT OF CARE 2009. [DOI: 10.1097/poc.0b013e3181c4aa1a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ryan F, Byrne S, O'Shea S. Randomized controlled trial of supervised patient self-testing of warfarin therapy using an internet-based expert system. J Thromb Haemost 2009; 7:1284-90. [PMID: 19496921 DOI: 10.1111/j.1538-7836.2009.03497.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Increased frequency of prothrombin time testing, facilitated by patient self-testing (PST) of the International Normalized Ratio (INR) can improve the clinical outcomes of oral anticoagulation therapy (OAT). However, oversight of this type of management is often difficult and time-consuming for healthcare professionals. This study reports the first randomized controlled trial of an automated direct-to-patient expert system, enabling remote and effective management of patients on OAT. METHODS A prospective, randomized controlled cross-over study was performed to test the hypothesis that supervised PST using an internet-based, direct-to-patient expert system could provide improved anticoagulation control as compared with that provided by an anticoagulation management service (AMS). During the 6 months of supervised PST, patients measured their INR at home using a portable meter and entered this result, along with other information, onto the internet web page. Patients received instant feedback from the system as to what dose to take and when the next test was due. During the routine care arm, patients attended the AMS at least every 4-6 weeks and were dosed by the anticoagulation pharmacist or physician. The primary outcome variable was the difference in the time in therapeutic range (TTR) between both arms. RESULTS One hundred and sixty-two patients were enrolled (male 61.6%, mean age 58.7 years), and 132 patients (81.5%) completed both arms. TTR was significantly higher during PST management than during AMS management (median TTR 74% vs 58.6%; z=5.67, P < 0.001). CONCLUSIONS The use of an internet-based, direct-to-patient expert system for the management of PST improves the control of OAT as compared with AMS management.
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Affiliation(s)
- F Ryan
- Pharmaceutical Care Research Group, University College Cork, Cork, Ireland
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Abstract
BACKGROUND Warfarin therapy has been used clinically for over 60 years, yet continues to be problematic because of its narrow therapeutic index and large inter-individual variability in patient response. As a result, warfarin is a leading cause of serious medication-related adverse events, and its efficacy is also suboptimal. OBJECTIVE To review factors that are responsible for variable response to warfarin, including clinical, environmental, and genetic factors, and to explore some possible approaches to improving warfarin therapy. RESULTS Recent efforts have focused on developing dosing algorithms that included genetic information to try to improve warfarin dosing. These dosing algorithms hold promise, but have not been fully validated or tested in rigorous clinical trials. Perhaps equally importantly, adherence to warfarin is a major problem that should be addressed with innovative and cost-effective interventions. CONCLUSION Additional research is needed to further test whether interventions can be used to improve warfarin dosing and outcomes.
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Affiliation(s)
- Stephen E Kimmel
- University of Pennsylvania School of Medicine, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, 717 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021, USA.
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Eitz T, Schenk S, Fritzsche D, Bairaktaris A, Wagner O, Koertke H, Koerfer R. International normalized ratio self-management lowers the risk of thromboembolic events after prosthetic heart valve replacement. Ann Thorac Surg 2008; 85:949-54; discussion 955. [PMID: 18291177 DOI: 10.1016/j.athoracsur.2007.08.071] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Revised: 08/17/2007] [Accepted: 08/21/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although prosthetic valves are durable and easy to implant, the need for lifetime warfarin-based anticoagulation restricts their exclusive usage. We investigated if anticoagulation self-management improves outcome in a single-center series. METHODS Between 1994 and 1998, 765 patients with prosthetic valve replacements were prospectively enrolled and randomized to receive conventional anticoagulation management by their primary physician (group 1, n = 295) or to pursue anticoagulation self-management (group 2, n = 470). A study head office was implemented to coordinate and monitor anticoagulation protocols, international normalized ratios (INR), and adverse events. Patients were instructed on how to obtain and test their own blood samples and to adjust warfarin dosages according to the measured INR (target range, 2.5 to 4). RESULTS Mean INR values were slightly yet significantly smaller in group 1 than in group 2 (2.8 +/- 0.7 vs 3.0 +/- .6, p < 0.001). Moreover, INR values of patients with conventional INR management were frequently measured outside the INR target range, whereas those with anticoagulation self-management mostly remained within the range (35% vs 21%, p < 0.001). In addition, the scatter of INR values was smaller if self-managed. Freedom from thromboembolism at 3, 12, and 24 months, respectively, was 99%, 95%, and 91% in group 1 compared with 99%, 98%, and 96% in group 2 (p = 0.008). Bleeding events were similar in both groups. Time-related multivariate analysis identified INR self-management and higher INR as independent predictors for better outcome. CONCLUSIONS Anticoagulation self-management can improve INR profiles up to 2 years after prosthetic valve replacement and reduce adverse events. Current indications of prosthetic rather than biologic valve implantations may be extended if the benefit of INR self-management is shown by future studies with longer follow-up.
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Affiliation(s)
- Thomas Eitz
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr Universität Bochum, Bad Oeynhausen, Germany.
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Wirth D. Incorporating patient self-testing into your practice. J Thromb Thrombolysis 2007; 25:12-3. [PMID: 17906912 DOI: 10.1007/s11239-007-0099-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Accepted: 08/30/2007] [Indexed: 10/22/2022]
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Wurster MW. Patient self-testing for management of anticoagulation therapy: challenges. J Thromb Thrombolysis 2007; 25:16-7. [PMID: 17898929 DOI: 10.1007/s11239-007-0097-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Accepted: 08/30/2007] [Indexed: 11/30/2022]
Affiliation(s)
- Mark W Wurster
- OSU Internal Medicine, Ohio State University Medical Center, Columbus, OH 43210, USA.
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Shapiro NL. Patient barriers and solutions for INR self-testing. J Thromb Thrombolysis 2007; 25:14-5. [PMID: 17898931 DOI: 10.1007/s11239-007-0100-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Accepted: 08/30/2007] [Indexed: 12/01/2022]
Affiliation(s)
- Nancy L Shapiro
- Antithrombosis Center, University of Illinois at Chicago College of Pharmacy, Chicago, IL 60612, USA.
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Redman BK. Responsibility for control; ethics of patient preparation for self-management of chronic disease. BIOETHICS 2007; 21:243-50. [PMID: 17845469 DOI: 10.1111/j.1467-8519.2007.00550.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Patient self-management (SM) of chronic disease is an evolving movement, with some forms documented as yielding important outcomes. Potential benefits from proper preparation and maintenance of patient SM skills include quality care tailored to the patient's preferences and life goals, and increase in skills in problem solving, confidence and success, generalizable to other parts of the patient's life. Four central ethical issues can be identified. 1) insufficient patient/family access to preparation that will optimize their competence to SM without harm to themselves, 2) lack of acknowledgement that an ethos of patient empowerment can mask transfer of responsibility beyond patient/family competency to handle that responsibility, 3) prevailing assumptions that preparation for SM cannot result in harm and that its main purpose is to deliver physician instructions, and 4) lack of standards for patient selection, which has the potential to exclude individuals who could benefit from learning to SM. Technology assessment offers one framework through which to examine available data about efficacy of patient SM and to answer the central question of what conditions must be put in place to optimize the benefits of SM while assuring that potential harms are controlled.
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Affiliation(s)
- Barbara K Redman
- College of Nursing, Wayne State University, Cohn Building, Suite 12, 5557 Cass Avenue, Detroit, MI 48202, USA.
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Abstract
The authors consider the advantages and limitations of self-management tools used for treating chronic illness.
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Affiliation(s)
- Harold J DeMonaco
- Decision Support and Quality Management Unit, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
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