An evaluation of patient self-testing competency of prothrombin time for managing anticoagulation: pre-randomization results of VA Cooperative Study #481–The Home INR Study (THINRS)

Abstract

Prior studies suggest patient self-testing (PST) of prothrombin time (PT) can improve the quality of anticoagulation (AC) and reduce complications (e.g., bleeding and thromboembolic events). "The Home INR Study" (THINRS) compared AC management with frequent PST using a home monitoring device to high-quality AC management (HQACM) with clinic-based monitoring on major health outcomes. A key clinical and policy question is whether and which patients can successfully use such devices. We report the results of Part 1 of THINRS in which patients and caregivers were evaluated for their ability to perform PST. Study-eligible patients (n = 3643) were trained to use the home monitoring device and evaluated after 2-4 weeks for PST competency. Information about demographics, medical history, warfarin use, medications, plus measures of numeracy, literacy, cognition, dexterity, and satisfaction with AC were collected. Approximately 80% (2931 of 3643) of patients trained on PST demonstrated competency; of these, 8% (238) required caregiver assistance. Testers who were not competent to perform PST had higher numbers of practice attempts, higher cuvette wastage, and were less able to perform a fingerstick or obtain blood for the cuvette in a timely fashion. Factors associated with failure to pass PST training included increased age, previous stroke history, poor cognition, and poor manual dexterity. A majority of patients were able to perform PST. Successful home monitoring of PT with a PST device required adequate levels of cognition and manual dexterity. Training a caregiver modestly increased the proportion of patients who can perform PST.

Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data

“…Self-monitoring patients deemed not com petent had higher numbers of practice attempts and higher cuvette wastage, and were less able to effi ciently do a fi ngerstick procedure. 40 Factors associated with unsuccessful self-monitoring include refusal by patients, exclusion by their family practitioner, failure to pass training, old age, poor cognition, and poor manual dexterity. 6,20,40 One trial excluded people unable to attend training, 19 and in another trial 20 of an unselected population, young patients were more likely to successfully self-monitor oral anticoagulatoin.…”

Telephone-based anticoagulation management in the homebound setting: a retrospective observational study

“…Homebound patients who need chronic anticoagulation would likely not be able to attend anticoagulation clinics, and most of them are not candidates for self-testing at home 14. To our knowledge, there are no clear guidelines on how to manage this population in a safe and efficient way.…”

Factors determining patients' intentions to use point-of-care testing medical devices for self-monitoring: the case of international normalized ratio self-testing

“…In addition, patients’ limited physical and cognitive abilities, low manual dexterity, older age, literacy, and income, as well as negative attitudes towards the technology, which might include inconvenience, usability, design, and safety issues, can also prove to be barriers in the acceptance of the technology 1,10,11. Moving the focus away from the individual patient, there is evidence of reluctance on the part of some clinicians/GPs for incorporating INR self-testing as part of the service they deliver due to a lack of resources 12,13.…”