title: Does distance modify the effect of self-testing in oral anticoagulation?
abstract: OBJECTIVE
  Patient self-testing (PST) improves anticoagulation control and patient satisfaction. It is unknown whether these effects are more pronounced when the patient lives farther from the anticoagulation clinic (ACC). If the benefits of PST are limited to a subset of patients (those living farther from care), selectively providing PST to that subset could enhance cost-effectiveness.
  
  
  METHODS
  This is a secondary analysis of a randomized trial of PST versus usual ACC care, which involved 2922 patients of the Veterans Health Administration (VHA).
  
  
  METHODS
  Our 3 outcomes were the primary composite clinical end point (stroke, major hemorrhage, or death), anticoagulation control (percent time in therapeutic range), and satisfaction with anticoagulation care. We measured the driving distance between the patient's residence and the nearest VHA facility. We divided patients into quartiles by distance and looked for evidence of an interaction between distance and the effect of the intervention on the 3 outcomes.
  
  
  RESULTS
  The median driving distance was 12 miles (interquartile range = 6-21). Patients living in the farthest quartile had higher rates of the primary composite clinical end point in both groups compared with patients living in the nearest quartile. For PST, the hazard ratio (HR) was 1.77 (95% CI, 1.18-2.64), and for usual care, the HR was 1.81 (95% CI, 1.19-2.75). Interaction terms did not suggest that distance to care modified the effect of the intervention on any outcome.
  
  
  CONCLUSIONS
  The benefits of PST were not enhanced among patients living farther from care. Restricting PST to patients living more than a certain distance from the ACC is not likely to improve its cost-effectiveness.
authors.affiliation: Bedford VA Medical Center, 200 Springs Rd, Bedford, MA 01730. E-mail: adam.rose@va.gov.
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Rose
authors.forename: Ciaran S
authors.initials: CS
authors.lastname: Phibbs
authors.forename: Lauren
authors.initials: L
authors.lastname: Uyeda
authors.forename: Pon
authors.initials: P
authors.lastname: Su
authors.forename: Robert
authors.initials: R
authors.lastname: Edson
authors.forename: Mei-Chiung
authors.initials: MC
authors.lastname: Shih
authors.forename: Alan
authors.initials: A
authors.lastname: Jacobson
authors.forename: David B
authors.initials: DB
authors.lastname: Matchar
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage*; D016903:Drug Monitoring; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D055118:Medication Adherence; D017060:Patient Satisfaction; D019095:Point-of-Care Systems; D016032:Randomized Controlled Trials as Topic; D012648:Self Care; D014195:Travel / Q000706:statistics & numerical data*; D014481:United States; D014728:Veterans
chemical_list: D000925:Anticoagulants