Now more than ever people need to be offered greater choice and control over their care whilst PCTs/CCGs need also identify cost savings and productivity opportunities wherever possible.
In view of the clear benefits to patients in terms of greater choice, empowerment, freedom and improved outcomes, combined with the potential to reduce costs through savings from anticoagulation monitoring and potentially reducing the number of patients prescribed more costly new oral anticoagulants (NOACs)1, there are a number of exemplar sites now offering support for self-monitoring.
County Durham and Darlington Foundation Trust
The County Durham and Darlington Foundation Trust (CDDFT) has recently completed a telehealth pilot, which included the trial of International Normalised Ratio (INR) self-monitoring by patients using Roche’s CoaguChek meter. The basis for the scheme was a series of pre-arranged automated telephone calls so that patients could provide their INR data to the Trust. This was tied to a software package that links to GP records. This enables the clinicians to access patient INR records 7 days per week.
CDDFT serves around 600,000 people in County Durham, Darlington, North Yorkshire, the Tees valley and south Tyneside. Local Clinical Commissioning Groups (CCGs) commission the Trust to provide anti-coagulation services for patients in the area. It has a total of 2648 registered warfarin patients across a variety of locations: hospital outpatient clinics, community satellite clinics and in patients’ own homes, of which over 200 people were included in the pilot scheme.
The telehealth pilot was put in place as part of CDDFT’s drive to increase efficiency and capacity without compromising on care quality. It was also recognised that normal clinic-based services had an impact on the users’ lifestyle choices and that a telehealth system could provide an opportunity to address all of these issues. Consequently, an appropriate INR care pathway was developed based on the views of patients, clinicians and the Trust’s chief pharmacist.
The results showed a 20% improvement in time in therapeutic range (TTR) for 70% of self-monitoring patients in the pilot – a great improvement when compared to clinic-based patients, in which 49% of patients improved their TTR by 2%. Extrapolated to a national level, it is believed that this could prevent 400 to 500 strokes each year. All of the patients in the pilot said that they would recommend the scheme to others and cited additional benefits when compared to in-clinic INR monitoring:
- Less disruption to their working lives and attendant loss of pay or paid holiday;
- Less money spent on travel and parking; and
- The ability to continue testing whilst away from home or on holiday.
According to the Trust, in-clinic monitoring required each patient to attend the clinic on average 18 times per year. For self-monitoring patients, this was reduced by 16, to just two visits per patient per year, thereby achieving the Trust’s stated aim of increased efficiency whilst actually improving care quality.
The service is now fully up and running. 287 patients are self-monitoring making this the largest scheme of its kind in the country. The Trust is continuing to recruit warfarin patients to the scheme. Furthermore, the National Institute for Health and Care Excellence has cited this scheme as a best practice example of what can be achieved with INR self-monitoring in the context of managing warfarin patients with atrial fibrillation and heart valve disease.
County Durham and Darlington NHS Foundation Trust.
Case Study: County Durham and Darlington Foundation Trust enhance self-managed care by introducing digital health for patients on warfarin. 2016.
County Durham and Darlington NHS Foundation Trust. County Durham and Darlington NHS Foundation Trust INR telehealth pilot. Economic considerations for INR telehealth and current service models. 2015.
Isle of Wight CCG Pilot
The Isle of Wight Clinical Commissioning Group (CCG) is the first to introduce a pilot scheme to provide International Normalised Ratio (INR) self-testing for patients on long-term warfarin treatment. The scheme, which started in January 2016, is an initial pilot programme offered to 100 patients in the Sandown area. If successful, it will be expanded further to other parts of the island.
The scheme allows patients to check their INR levels using Roche’s CoaguChek meter. To participate, patients need only a landline, mobile phone or internet access in order to send and receive data. The patient transmits the data to the clinic, which calculates and relays the patient’s recommended dose of warfarin via a dosing software package. The package links into and automatically updates the patient’s records.
The new service is expected to alleviate pressure on both clinics and general practices which are experiencing high demand from warfarin users on the Island. INRstar, the dosing software, is also expected to free up administrative resources within service providers as less time is required to input data.
Patients will have the benefit of reduced numbers of visits to clinics, so less time is required away from work and travel and parking costs are reduced. They will also have the ability to monitor whilst on holiday or away from home, allowing greater freedom to live their lives.
Dr Peter Randall, Clinical Lead for the home testing pilot, said: “All warfarin clinics on the island are experiencing a high volume of patients accessing the service, so enabling patients to self-test will alleviate pressure on General Practices. The reduction in patients attending the clinics will allow more time to be spent with more complex patients, increasing the level of care for all.”
The scheme is part of a care pathway initiative on the Isle of Wight called “My Life is a Full Life” which involves an integrated service across different care providers aimed at improving patients’ quality of care. The service also supports the latest National Institute for Health and Care Excellence (NICE) guidance on self-testing for patients on long-term anticoagulation therapy.
“The evidence shows that greater use of self-monitoring offers clinical and patient benefit and, over time, is likely to result in reductions in heart attacks and strokes caused by blood clots,” says Professor Carole Longson, NICE Health Technology Evaluation Centre Director.
First CCG to launch digital self-monitoring service for warfarin patients. http://www.isleofwightccg.nhs.uk/default.aspx.locid-02hnew02i.Lang-EN.htm
Great Western Hospital, Swindoni
The Great Western Hospital, Swindon, is a large, modern hospital, which opened in 2002, replacing the Princess Margaret. This article will describe how the anti-coagulation clinic also evolved over time, and became the dynamic service we now deliver today. Prior to 1996 the anticoagulant service at the Princess Margaret Hospital, Swindon, Wiltshire was run by two Consultant Haematologists and rotational junior medical staff.
In October 1996 a business case for one whole time equivalent Nurse specialist/pharmacist was approved and both a nurse and a pharmacist were appointed to jointly run and improve the anticoagulant service.
Our initial job was to reduce the seven week waiting list for patients commencing on oral anticoagulation, and monitor existing anticoagulated patients using a very old dosing software programme for around 500 patients. When the Health of the Nation report was issued in 2001 there was a significant increase in the number of patients with atrial fibrillation (AF) being referred for formal anticoagulation to prevent stroke. At about the same time we were shown a new portable INR tester which could take whole or capillary blood to test INR’s giving the result within a few minutes. After a successful pilot, it was decided that we would use the portable INR tester in our new anticoagulant clinic which proved to be very effective.
The number of anticoagulated patients has increased over the years, and we now have 3,500 patients on our case load. Therefore, when the portable INR tester was introduced for patients who wished to self-test we were proactive, and became the regional training centre for the South West. This increased for a number of years and we were also able to provide training in the use of the INR tester for our community phlebotomist to facilitate INR sampling for patients who had poor venous access and would normally require patient transport to attend the clinic.
We were able to offer a loan scheme as some patients could not afford the meter, which also helped gauge patient suitability. This scheme worked well, which then led onto loaning machines to patients who were going abroad or working away for long periods of time, enabling a remote phone dosing service.
We now have a total of 151 patients (out of a total of 3,500 anticoagulated patients, 4.4%) who self-test. For a number of patients there has been a significant improvement in their
warfarin control, increasing their % time in range from 59% to 77% (looking at the last 24 test results).
Amongst these, patients who self-test are more likely to be taking warfarin for a mechanical valve replacement or following a venous thromboembolic event (VTE.) Of all our self-testing patients, 19% have a mechanical valve replacement (compared to just 5.6% of our total anticoagulant population) and 29% have had a VTE (compared to 18.6%). Patients are less likely to have AF than our general anticoagulated population with 31% of self-testers on warfarin for AF compared to 56.6% of our general anticoagulated population. Patients who are on long-term warfarin will be more likely to invest in a meter.
The patients phone in their INR results to the anticoagulant answering phone. We are then able to post their new dosing advice, but if it is out of range we call back directly. We have a number of patients who have progressed on to self-managing their warfarin. These are all patients who have been on warfarin for a long time and have a very good understanding of the principles of warfarin dose adjustment.
In our clinic’s experience the majority of patients enjoy the convenience of being able to test their INRs at home but also want the reassurance of knowing that they are dosing correctly. Therefore we actively support those patients who want to self-manage, but do not encourage it with all patients. For those who do want to self-manage, we have a process of asking the patient to suggest their own warfarin doses, and gradually, as their experience and knowledge increases, we allow them to self-manage. However, patients always have to send in their INR results and doses every three months to our clinic and each patient is also given INR parameters (for example INRs below 1.5 or above 4.5) outside which they have to phone for advice.
Once a patient has purchased their INR tester, they are encouraged to watch the DVD and practice. If they feel unsure they can call a dedicate care line or the anticoagulation clinic directly. Additionally, an easy step guide was produced in clinic as a compliment to the user’s manual provided with the INR tester.
Patients state that the main benefits of having their own portable INR tester are empowerment and greater quality of life. Many patients have felt they are held hostage to the local surgery if they require frequent INR monitoring and their arms get painful from frequent phlebotomy. There is no need for them to take time off from work or school in the case of children and many patients feel unable to take lengthy holidays as they are unsure of the quality blood testing in other countries. We have many patients in outlying or rural areas; this reduces the amount of time and money spent travelling.
There have been several trials that have shown benefits from self- testing compared to conventional management particularly in maintaining a higher time in therapeutic range, as referenced in Heneghan’s “Systematic Review and Meta-analysis of Individual Patient Data,” published in the Lancet in 2011. Conversely, it has been shown that poor control is a major independent risk factor for reduced long-term survival, particularly after valve replacement. Also this greater control of INR’s reduces costs associated with serious bleeds and thrombosis. Self-testing is not suitable for every patient and ideally this should be agreed between the patient, family or carer and their GP. It is also important that a clear protocol is drawn up which determines a range of issues regarding the testing period, reporting procedures and action.
To conclude, the changes we have made in our service have served as an improvement in our anti-coagulation clinic; we are able to deliver faster results, better outcomes and increased patient satisfaction, and envisage this growing as more patients take control of their own care.
Read more about the benefits of self-monitoring:
BO notes – Suggested hyperlinks to:
Benefits to NHS
The importance of self-monitoring