The technology exists for patients to obtain an accurate INR reading themselves, but can clinicians support it?
In all of preventive medicine there is little to rival the risk reduction of anticoagulation in atrial fibrillation. In those with non-valvular AF, whose stroke risk is 5 times greater than someone of a similar age, gender and comorbidity, oral anticoagulation can reduce the risk by 70%. With the advent of the Non-vitamin K Oral AntiCoagulants (NOACs) not requiring the monitoring burden of warfarin many have been freed from the clinic environment.
In my clinical practice I am finding many people are choosing the convenience of the NOAC over the traditional care mainstay of warfarin
But what of those with valvular AF? In those with mitral stenosis of rheumatic origin or metallic valves the stroke risk of AF is known to be seventeen times higher than the matched individuals. Once again we have fantastic stroke risk reduction with oral anticoagulants. These patients are essentially mandated to anticoagulation therapy and the only evidence based oral therapy is warfarin.
So does this group of patient need to attend clinic?
The evidence based answer is a resounding “no”
The evidence to support self-monitoring and self-care for warfarin is substantial and with the ease of use of point of care kit for assessment of capillary blood INR we should also be liberating these individuals from the clinic environment.
The mantra of the modern NHS is self-care and yet in this area we find that in most clinical commissioning groups (CCGs) there is no facility for patient to be supported in warfarin self-monitoring.
Is this because there is no national advice?
Again the answer to this is a resounding “no”
When the National Institute for Health and Social Care Excellence (NICE) reviewed the use of point of care coagulometers in Diagnostic Guidance 14 (NICE DG14) it clearly saw the value of self-testing in those with AF who require anticoagulation in the long term. This was not only those with valvular AF but this should be an option for all on warfarin therapy who would like to improve their care through a higher level of involvement in their care.
This followed their previous advice on commissioning of anticoagulation services (Commissioning anticoagulation in Adults ) which specifically commented on the need to ensure that both clinic and self-care options should be commissioned in health communities
The technology exists to ensure patients can obtain an accurate INR; then this information can be easily inputted in to the computer aid decision software and the patient supported in dose manipulation if needed
So where does the issue develop that people with AF who are mandated to warfarin through their cardiac anatomy or who choose to use the well-established therapy?
The answer unfortunately is at the whim of the clinic if they choose to offer support if the patient was to choose to obtain their own coagulometer.
Unless you live on the Isle of White where liberated commissioners have liberated the patients in to a new paradigm of good control and independence:- First CCG to launch digital self-monitoring service for warfarin patients
More about this writer:
Dr Matthew Fay is a General Practioner at The Willows Medical Practice Queensbury (part of the Westcliffe Group) he established a GPwSI cardiology service in Bradford which now provides services across the district. He was a member of the NICE AF Guideline Development Group and is a Trustee of AF Association and ThrombosisUK.
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