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Evid Based Nurs 9:110 doi:10.1136/ebn.9.4.110
  • Treatment

Review: self testing and self management increase the benefits and reduce the harms of anticoagulant therapy


 
 Q In patients receiving oral anticoagulant therapy, what is the relative effectiveness of self testing and self management compared with standard monitoring?

METHODS

GraphicData sources:

Medline, EMBASE/Excerpta Medica, and CINAHL (up to 2005); Cochrane Central Register of Controlled Trials; Cochrane Library (Issue 2, 2005); UK National Research Register; Trials Central; bibliographies of retrieved studies; manufacturers of home monitors; and experts.

GraphicStudy selection and assessment:

randomised controlled trials (RCTs) that compared self testing (only) or self management (testing and dose adjustment) with management by healthcare professionals (control group) in adults or children receiving oral anticoagulation therapy for any indication. 14 RCTs (n = 3049, mean age 42–75 y) met the selection criteria. Management of the control group was provided by primary care physicians in 8 RCTs and by specialised anticoagulation clinics in 6 RCTs. Duration of the studies ranged from 2 to 24 months. Quality of individual trials was assessed based on randomisation, allocation concealment, blinding of outcome assessors, use of intention to treat analysis, and follow up.

GraphicOutcomes:

thromboembolic events, major bleeding, all cause mortality, proportion of international normalised ratio (INR) measurements within the target range, and frequency of testing.

MAIN RESULTS

Thromboembolic events and major bleeding episodes occurred less frequently in the self testing group than in the control group; groups did not differ for death (table). Thromboembolic events and death occurred less frequently in the self management group than in the control group; groups did not differ for major bleeding (table). The self monitoring group had a higher proportion of INR tests within the target range in 7 of 11 RCTs and a greater proportion of time within the target range in 2 of 7 RCTs. The self monitoring group tested 2–5 times more frequently than the control group, with the ratio increasing in studies with longer duration.

CONCLUSION

In patients receiving oral anticoagulant therapy, self testing and self management increase the benefits and reduce the harms of treatment more than management by healthcare professionals.

A modified version of this abstract appears in ACP Journal Club.

Commentary

  1. Maureen Markle-Reid, RN, PhD
  1. McMaster University
 Hamilton, Ontario, Canada

      Patient self management is an integral part of the care of people with chronic health problems such as thromboembolic disorders.1 The systematic review by Heneghan et al evaluated self monitoring in patients receiving oral anticoagulation across a range of disease entities and concluded that both self testing alone and self management (self testing and self dosage) are more effective and safer than standard management by healthcare professionals. Patient self management can facilitate outpatient treatment, decrease the use of health professionals for interpretation and dose adjustment, and lead to substantial cost savings.

      However, several caveats should be noted. Firstly, Heneghan et al reported that 62% of patients were unable or unwilling to engage in self management, suggesting that this approach is not appropriate for all patients. Further information is needed to identify individual and health system factors that influence the acceptability and use of patient self management, as well as implications for patient education, training, and resource use. Secondly, the review focused on physiological complications, with little information provided on other important outcomes such as quality of life, caregiver outcomes, and more process oriented outcomes such as autonomy, empowerment, and decision making. Thirdly, a full economic analysis comparing the 2 approaches is needed. Fourthly, most patients were relatively young (mean age ⩽66 y in all but 2 trials). Given that use of oral anticoagulation therapy increases with age, further information is needed about the effectiveness and acceptability of self management in older people and specific subgroups that would benefit most. Finally, the studies were limited to primary care and outpatient anticoagulation clinics; applicability to home care or community settings, where nurses provide monitoring, is unknown.

      Nevertheless, the findings of Heneghan et al suggest that patient self monitoring is a safe, effective, and convenient alternative for management of oral anticoagulation. Achieving the benefits of this model of care will depend on the balance between increased convenience, the ability of patients to perform self management, the availability of healthcare resources, and the potential for cost savings.

      References

      Self monitoring v management by healthcare professionals (control) in patients receiving oral anticoagulant therapy*

      
 
 Q In patients receiving oral anticoagulant therapy, what is the relative effectiveness of self testing and self management compared with standard monitoring?

      Footnotes

      • For correspondence: Dr C Heneghan, University of Oxford, Oxford, UK. carl.heneghan{at}dphpc.ox.ac.uk

      • Source of funding: no external funding.

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