More on Self-Management

[Guest]

J Clin Pathol. 2007 Jan 26; [Epub ahead of print]

Patient self management of oral anticoagulation in routine care in the UK

McCahon D, Murray ET, Jowett S, Sandhar HS, Holder R, Hussain S, O'donoghue B, Fitzmaurice D.
Department of Primary Care and General Practice,University of Birmingham, United Kingdom.

BACKGROUND: Self management of anticoagulation: a randomised trial (SMART) was the first large scale UK trial to assess clinical and cost effectiveness of PSM of oral anticoagulation therapy compared to routine care. SMART demonstrated that whilst PSM was as clinically effective as routine care, it was not as cost effective. SMART adds to the growing body of trial data to support PSM however there are no data on clinical effectiveness and cost of PSM in routine care. Objective: To evaluate clinical effectiveness of PSM compared to routine care outside trial conditions. METHODS: A retrospective multi centred matched control study. 63 PSM patients from primary care in the West Midlands were matched by age and International Normalised Ratio (INR) target with controls. INR results were collected for the period 01/07/03 - 30/06/04. The primary outcome measure was INR control. RESULTS: 38 PSM and 40 control patients were recruited. INR percentage time in range was 70% PSM v 64% control. 60% PSM were having a regular clinical review, 45% were performing an Internal Quality Control (IQC) and 82% External Quality Assurance (EQA) on a regular basis. CONCLUSION: PSM outside trial conditions is as clinically effective as routine UK care.

 

[catwoman]

And the interpretation is ...

PSM works just as well as routine management in the U.K., but isn't as cost effective.

Health care in the States is far different from that in the U.K.

Al: Have you seen any studies in the United States on PSM vs. routine management?

 

[jeffp]

Routine management here in the US will not be as good as that in Europe. Here routine management is viewed as being done by the physician with the usual lab draw. In Europe, ACT management is very much more done in anticoagulation clinics and often with finger-stick testing and occasional lab draw for comparison. There have been some studies in the US comparing the two and routine physician management maintains the patient within range 50-60% of the time while PSM tends to be in the 85-90% range. I can dig out the relevant articles if anyone wants them (I have them on a CD somewhere from when I was completing my thesis).
As to the cost effectiveness, its not all that clear cut. The cost of the unit and test strips amortized over time is less than cost of the lab testing + office visit + the cost of the care for the differential rate of complication care (also depends on the other risk factors involved with each patient). A big factor is that the frequency of the testing schedules of both are different and that accounts for part of the difference of the time within range. Also, in the US there is no system for physician payment for phone dose adjusting and such, so there is little incentive to do this on the part of the physicians. (Medicare attempted to get into this, but the logistics are such that it's not being done much at all.)

 

[catwoman]

Jeff:

I agree with you.
We've seen horror stories here about doctors' attempting to manage their patients' INR and dosages.
Anticoagulation management isn't something that all doctors would like to do, and it's certainly not something that most are able to do.

 

[Marty]

I had a German doctor tell me patient self testing did not help if they had to call in and he had to manage their dose. Only complete patient self management, self dosing did him any good.

 

[Ross]

I had a German doctor tell me patient self testing did not help if they had to call in and he had to manage their dose. Only complete patient self management, self dosing did him any good.

I can honestly see why especially with the physicians that we contend with everyday. It makes sense, at least to me.