Review: self testing and self management increase the benefits and reduce the harms of anticoagulant therapy

摘要

Patient self management is an integral part of the care of people with chronic health problems such as thromboembolic disorders.' The systematic review by Heneghan ef al evaluated self monitoring in patients receiving oral anticoagulation across a range of disease entities and concluded that both self testing alone and self management (self testing and self dosage) are more effective and safer than standard management by healthcare professionals. Patient self management can facilitate outpatient treatment, decrease the use of health professionals for interpretation and dose adjustment, and lead to substantial cost savings. However, several caveats should be noted. Firstly, Heneghan ef al reported that 62% of patients were unable or unwilling to engage in self management, suggesting that this approach is not appropriate for all patients. Further information is needed to identify individual and health system factors that influence the acceptability and use of patient self management, as well as implications for patient education, training, and resource use. Secondly, the review focused on physiological complications, with little information provided on other important outcomes such as quality of life, caregiver outcomes, and more process oriented outcomes such as autonomy, empowerment, and decision making. Thirdly, a full economic analysis comparing the 2 approaches is needed. Fourthly, most patients were relatively young (mean age < 66 y in all but 2 trials). Given that use of oral anticoagulation therapy increases with age, further information is needed about the effectiveness and acceptability of self management in older people and specific subgroups that would benefit most. Finally, the studies were limited to primary care and outpatient anticoagulation clinics; applicability to home care or community settings, where nurses provide monitoring, is unknown.Nevertheless, the findings of Heneghan ef al suggest that patient self monitoring is a safe, effective, and convenient alternative for management of oral anticoagulation. Achieving the benefits of this model of care will depend on the balance between increased convenience, the ability of patients to perform self management, the availability of healthcare resources, and the potential for cost savings.