Self-monitoring and self-management of oral anticoagulation.
BACKGROUND
The introduction of portable monitors (point-of-care devices) for the management of patients on oral anticoagulation allows self-testing by the patient at home. Patients who self-test can either adjust their medication according to a pre-determined dose-INR schedule (self-management) or they can call a clinic to be told the appropriate dose adjustment (self-monitoring). Several trials of self-monitoring of oral anticoagulant therapy suggest this may be equal to or better than standard monitoring.


OBJECTIVE
To evaluate the effects of self-monitoring or self-management of oral anticoagulant therapy compared to standard monitoring.


METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 4), MEDLINE, EMBASE and CINAHL (to November 2007). We checked bibliographies and contacted manufacturers and authors of relevant studies. No language restrictions were applied.


METHODS
Outcomes analysed were thromboembolic events, mortality, major haemorrhage, minor haemorrhage, tests in therapeutic range, frequency of testing, and feasibility of self-monitoring and self-management.


METHODS
The review authors independently extracted data. We used a fixed-effect model with the Mantzel-Haenzel method to calculate the pooled risk ratio (RR) and Peto's method to verify the results for uncommon outcomes. We examined heterogeneity amongst studies with the Chi(2) and I(2) statistics.


RESULTS
We identified 18 randomized trials (4723 participants). Pooled estimates showed significant reductions in both thromboembolic events (RR 0.50, 95% CI 0.36 to 0.69) and all-cause mortality (RR 0.64, 95% CI 0.46 to 0.89). This reduction in mortality remained significant after the removal of low-quality studies (RR 0.65, 95% CI 0.46 to 0.90). Trials of self-management alone showed significant reductions in thromboembolic events (RR 0.47, 95% CI 0.31 to 0.70) and all-cause mortality (RR 0.55, 95% CI 0.36 to 0.84); self-monitoring did not (thrombotic events RR 0.57, 95% CI 0.32 to 1.00; mortality RR 0.84, 95% CI 0.50 to 1.41). Self-monitoring significantly reduced major haemorrhages (RR 0.56, 95% CI 0.35 to 0.91) whilst self-management did not (RR 1.12, 95% CI 0.78 to 1.61). Twelve trials reported improvements in the percentage of mean INR measurements in the therapeutic range. No heterogeneity was identified in any of these comparisons.


CONCLUSIONS
Compared to standard monitoring, patients who self-monitor or self-manage can improve the quality of their oral anticoagulation therapy. The number of thromboembolic events and mortality were decreased without increases in harms. However, self-monitoring or self-management were not feasible for up to half of the patients requiring anticoagulant therapy. Reasons included patient refusal, exclusion by their general practitioner, and inability to complete training.
Garcia-Alamino
Josep M
JM
Department of Primary Health Care, University of Oxford, Old Road Campus, Old Road, Headington, Oxford, UK, OX3 7LF.
Ward
Alison M
AM
Alonso-Coello
Pablo
P
Perera
Rafael
R
Bankhead
Clare
C
Fitzmaurice
David
D
Heneghan
Carl J
CJ
D000284:Administration, Oral; D000328:Adult; D000925:Anticoagulants / Q000008:administration & dosage*; D002423:Cause of Death; D002648:Child; D006470:Hemorrhage / Q000401:mortality / Q000517:prevention & control; D006801:Humans; D019934:International Normalized Ratio; D019095:Point-of-Care Systems; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012648:Self Care / Q000379:methods*; D013923:Thromboembolism / Q000401:mortality / Q000517:prevention & control*
D000925:Anticoagulants