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Patients on long-term warfarin should have option for INR home monitoring
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If I were a patient on long-term warfarin, I would want an international normalized ratio home monitor.
It would give me independence, and I would not have to waste my time with clinic visits just to have my INRs checked.
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Have breakfast, stick finger and read INR, go to work or play. That’s what I would want, short of preferring to be on a well-established, reversible oral anticoagulant that does not require routine anticoagulation monitoring.
Point-of-care instrument INR testing is reliable, and anticoagulation management through patient self-testing at home is at least as effective and safe as INR testing through a medical practice. The well-done large THINRS trial clearly showed this, and the systematic review performed by Heneghan and colleagues confirms that.
INR home testing even leads to the extra bonus of fewer thromboembolic events.
But even if both methods were “just” equally effective, why deprive a patient of the chance to be able to be more independent through INR home testing?
The published data are convincing: INR home testing is effective and safe and the right thing to do — in appropriately selected and well-trained patients. Of course, some patients are not suitable for self-testing, but the THINRS trial showed that a great many patients (80%) are suitable and trainable. So why do many physicians and anticoagulation clinics not offer it to their patients?
- Reimbursement reasons. Yes, the testing devices and test strips often are paid for by insurers, but INR home testing is unattractive for many health care practice settings because of the often unbillable phone management services or the loss of income from not having patients come to billable clinic visits. Yes, one can bill for the phone management service, but the reimbursement (about $10 per month) often is not worth the effort needed to collect that money. There is, regrettably, not much financial incentive to offer INR home testing to patients.
- Hassle. Getting a patient a device, getting the patient’s INR results phoned into the clinic and managing warfarin over the distance involves some hassle and paperwork, and it requires a good clerical structure to make this a safe management option. Many health care providers perceive the hassle as not worth the effort.
- Control. A number of health care providers are hesitant to give up control and may feel vulnerable to litigation if a bad outcome (bleed or thrombosis) happens to their patient who does INR home monitoring. The present systematic review should aid in dispersing that concern, as it shows that outcomes in appropriately trained patients are not worse than in individuals who receive anticoagulation monitoring care by coming to a clinic for INR testing. I have actually heard the provocative comment that physicians who do not offer their patients INR home testing are liable if a bad outcome occurs, as the present systematic review showed that INR home monitoring is associated with fewer thromboembolic events and should, thus, be the preferred management strategy. I wouldn’t go so far to support this notion, but it reflects that one certainly could view INR home testing in suitable patients as the gold standard of care.
- Lack of awareness and knowledge. There also may be a component of unawareness — among health care professionals, and clearly among patients on warfarin — that INR home testing is available, reliable, safe and effective. Hopefully, the THINRS trial and the present systematic review help increase awareness of this viable monitoring option and disperse the unwarranted concerns that INR home testing devices are not reliable or most patients not suitable for it.
I conclude as I started: If I were a patient on long-term warfarin, I would want an INR home monitor.
I am afraid, though, my physician or anticoagulation pharmacist would say: “Can’t do it; our practice is not set up to do it; too much hassle, too much paperwork, no worthwhile reimbursement.”
I bet if I were to beg and complain enough, they eventually would provide me with the INR home monitoring option — but only as a favor to me as a medical colleague and as an exception to their practice.
I wish, however, that every suitable patient could have the option of having warfarin managed via INR home monitoring. It is safe and effective and, in my mind, the right thing to do to provide good patient service.
Stephan Moll, MD, is an associate professor in the department of medicine and division of hematology-oncology at the University of North Carolina School of Medicine in Chapel Hill, N.C. He also is medical director of the Clot Connect patient education program (www.clotconnect.org).
For more information:
- Heneghan C. Lancet. 2011:doi:10.1016/S0140-6736(11)61294-4.
- Matchar DB. N Engl J Med. 2010;363:1608-1620.
- Patientblog.clotconnect.org/2010/11/01/warfarin-therapy-made-easier
Disclosure: Dr. Moll has received material but not financial research support from International Technidyne Corp.