Bereznicki Luke Ryan Elliot, Jackson Shane Leigh, Peterson Gregory Mark
Unit for Medication Outcomes Research and Education, School of Pharmacy, University of Tasmania, Hobart 7001, Australia.
J Med Internet Res. 2013 Jul 12;15(7):e138. doi: 10.2196/jmir.2255.
Point-of-care international normalized ratio (INR) monitoring devices simplify warfarin management by allowing selected patients to monitor their own therapy in their homes. Patient self-testing (PST) has been shown to improve the clinical outcomes of warfarin therapy compared to usual care.
To compare management of warfarin therapy using PST combined with online supervision by physicians via a custom system with usual warfarin management, which involved laboratory testing and physician dosing.
Interested patients were recruited via community pharmacies to participate in a warfarin PST training program. Participants were required to have a long-term indication for warfarin, have been taking warfarin for at least 6 months, and have Internet access in their home. The training involved two sessions covering theoretical aspects of warfarin therapy, use of the CoaguChek XS, and the study website. Following training, patients monitored their INR once weekly for up to 3 months. Patients and physicians utilized a secure website to communicate INR values, dosage recommendations, and clinical incidents. Physicians provided a 6-12 month history of INR results for comparison with study results. The percentage of time spent within the therapeutic INR range (TTR) was the primary outcome, with participants acting as their own historical controls. The percentage of INR tests in range and participant satisfaction were secondary outcomes.
Sixteen patients completed training requirements. The mean age of participants was 69.8 (SD 10.1) years. TTR improved significantly from 66.4% to 78.4% during PST (P=.01), and the number of tests within the target range also improved significantly (from 66.0% at prior to the study to 75.9% during PST; P=.04). Patients and physicians expressed a high degree of satisfaction with the monitoring strategy and online system.
PST supported by an online system for supervision was associated with improved INR control compared to usual care in a small group of elderly patients. Further research is warranted to investigate the clinical outcomes and cost-effectiveness of online systems to support patients monitoring medications and chronic conditions in the home.
即时国际标准化比值（INR）监测设备通过允许特定患者在家中自行监测治疗情况，简化了华法林的管理。与常规护理相比，患者自我检测（PST）已被证明可改善华法林治疗的临床结局。
比较使用PST并通过定制系统接受医生在线监督的华法林治疗管理方式与常规华法林管理方式（包括实验室检测和医生给药）。
通过社区药房招募感兴趣的患者参加华法林PST培训项目。参与者必须有长期使用华法林的指征，服用华法林至少6个月，且家中可上网。培训包括两节课，涵盖华法林治疗的理论方面、CoaguChek XS的使用以及研究网站。培训后，患者每周监测一次INR，持续长达3个月。患者和医生利用一个安全的网站交流INR值、剂量建议和临床事件。医生提供INR结果的6至12个月病史以供与研究结果进行比较。处于治疗性INR范围（TTR）内的时间百分比是主要结局，参与者作为自身的历史对照。INR检测在范围内的百分比和参与者满意度是次要结局。
16名患者完成了培训要求。参与者的平均年龄为69.8（标准差10.1）岁。在PST期间，TTR从66.4%显著提高到78.4%（P = 0.01），目标范围内的检测次数也显著增加（从研究前的66.0%增加到PST期间的75.9%；P = 0.04）。患者和医生对监测策略和在线系统表示高度满意。
与一小群老年患者的常规护理相比，由在线系统支持的PST与改善的INR控制相关。有必要进行进一步研究，以调查在线系统支持患者在家中监测药物和慢性病的临床结局和成本效益。
