Recommendations for patients undertaking self management of oral anticoagulation

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D A Fitzmaurice, senior lecturera (d.a.fitzmaurice@bham.ac.uk),
S J Machin, professorb the British Society of Haematology Task Force for Haemostasis and Thrombosis.

^a Department of Primary Care and General Practice, Medical School, University of Birmingham, Birmingham B15 2TT
^b Department of Haematology, University College London Hospital, London WC1E 6DB

Correspondence to: D A Fitzmaurice

Accepted 18 June 2001

This paper aims to provide guidance for clinicians, based on the evidence available regarding the clinical effectiveness and health economics of the self management of oral anticoagulation therapy by patients. The paper focuses on self management, in which patients measure their own international normalised ratio and interpret the result themselves, as opposed to self testing, in which patients measure their own international normalised ratio but have to contact a health professional for interpretation of the results. The need to provide guidance and recommendations has been driven by patients' demand for self management at primary and secondary care levels. This demand has been fuelled partly by a national media advertising campaign promoting self management by patients using a particular near patient device (CoaguChek, Roche Diagnostics, Mannheim) to test their international normalised ratios. This paper follows on from evidence based guidelines for the therapeutic management of warfarin that were published by the British Committee for Standards in Haematology.1

Summary points

Data on clinical utility and cost effectiveness to support routine adoption of self management of oral anticoagulation by patients are limited

Patients undertaking self management must be trained by a competent healthcare professional and must remain in contact with a named clinician

The device used for self management must have been evaluated and found acceptable

Quality control of the delivery device and its use is essential

The scale of the problem

The expansion of clinical indications for warfarin, 2 3 particularly non-rheumatic atrial fibrillation, 4 5 has raised concerns about how warfarin monitoring should be undertaken. 6 7 The importance of this issue for all healthcare systems with ageing populations can be estimated from data showing that only one third of patients with identified atrial fibrillation receive anticoagulation.8 In the absence of screening programmes, probably 60% of patients with atrial fibrillation remain unidentified.7 On the basis …