When patients do it better than doctors: self management with warfarin
Doctors and health professionals are often reluctant to put the ball in the court of the patient because that patients will not be able to cope with the responsibility. Last week a Cochrane review update was published about self-monitoring and self-management of warfarin therapy and challenges this concept. Warfarin is an anticoagulant (“blood-thinner”) and is used in several situations, including atrial fibrillation, pulmonary embolism, deep vein thrombosis and patients who have mechanical heart valves. In the latter case, warfarin therapy is for life. The major risk or side-effect of warfarin is bleeding, which can be life-threatening and so in order to check that the blood is not to thin, the “thickness” of the blood is checked regularly by the INR blood test, and the warfarin dose is adjusted accordingly.
Warfarin is a common drug in both primary care and hospitals and there are huge costs associated with INR testing in healthcare settings. The introduction of portable monitors (point-of-care devices) for the management of patients on warfarin allows self-testing at home. Patients who self-test can either adjust their medication according to a pre-determined dose-INR schedule (self-management) or they can call a clinic to be told the appropriate dose adjustment (self-monitoring).
The systematic review included 18 randomised controlled trials with nearly 5000 patients. The risk of death or a clot-related (thromboembolic) event was reduced by 36% and 50% respectively. Importantly, the benefit of self-management alone persisted, whereas, the benefit of self-monitoring was not statistically significant. In other words, it is not enough to let patients just measure their reading; the benefit comes when they are responsible for a treatment change based on that reading. The same paradigm of “self-management” versus “self-monitoring” needs to be tested in other conditions such as hypertension and diabetes in order to improve outcomes and to empower patients.