UMASS Memorial Anticoagulation Service Patient Self Testing Program

Pam Burgwinkle NP, CACP ([email protected])

Challenge:
To provide a consistent high quality warfarin management service to a large, diverse and growing population within the confines of a fixed budget.
 
Objectives:
Take advantage of the Medicare national coverage for weekly patient self-testing and implement a management by exception protocol for patients that that meet CMS guidelines and are motivated to actively participate in their warfarin management.

Context:
The University of Massachusetts Memorial Anticoagulation Service provides warfarin management services for nearly 2300 patients. Patients are managed by seven nurses using three primary blood draw techniques including: office visit point of care (POC), outside lab venous draws, and patient self-testing. We use the ISTAT device for our POC office visits and we use both the INRatio2 and Coagucheck monitor for our home testing patients.  Our home testers perform weekly INR’s. Three quarters of our patients are 60 years and older and a quarter is over 80 years old. More men (59.1%) than women (40.9%) are managed in our clinic.

	AF	DVT/PE	MHV	CHF	CVA	OTHER
NON PST	1421	794	187	11	102	3344
PST	248	120	93	0	9	37

Patients or their caregivers using self-testing comprise 22% of our total warfarin population. 95% of our self-testers test weekly with excellent adherence. We use a patient contract to reinforce the importance of communication and strict adherence to our instruction.

Patient Selection & Compliance:
Criteria for enrollment is an insurance approved diagnosis and 3 months of warfarin management. During that 3-month period we evaluate compliance with blood testing and warfarin dosage.

In order to participate, patients must sign a home monitor contract which includes the understanding that they come in with their device at 6 months and then yearly. We watch them perform the test, check the memory and make sure it matches our data and then validate the result with our clinic device or lab draw. We ask them to test in the morning while we are open on the same day each week. The contract also has their target INR range on it and at what value they are to page the provider on call with should they test when the clinic is closed.  

Implementation:
We require a phone number or email address for contact. There needs to be a documented warfarin education session with myself, an RN or we use EMMI program (web based education) for those patients who have email. Our home testers follow the same instructions we give all our patients. They are to notify the clinic with any new meds, new health problems, changes in ETOH or diet.

Bridging:
We see patients face-to-face if they need a peri-op/procedure plan and evaluate for BRIDGE therapy.

We follow the same clinic protocol with our self testers as with our other patients. The difference is the self-testers do not receive a phone call from our staff if their INR is within target range. They are educated to remain on the same dose of warfarin and test on the same day the following week. We find this improves our operational efficiency and supports weekly testing without overwhelming our clinic staff. In addition, we have worked with our IDTF and created an interface with our software so that when our patients call the IDTF with their INR, it is deposited into our software management system. This eliminates phone calls and faxes from the IDTF to our clinic and contributes as well to the efficiency of our program.

Findings to date:

TTR NON PST 08/01/2011-07/31/2013	TTR PST 08/01/2011-07/31/2013
83.8%	84.4%

Weekly self-testers spent less time (2% vs. 3%) with INR tests that exceeded 5.0 or were below 1.5 than patients not participating in weekly home INR monitoring suggesting our patients are at less risk of bleeding or thrombosis with shorter testing frequencies.

Key lessons:
Warfarin will remain a drug for many patients for years to come. Its affordability and ability to monitor adherence is important to the long-term success of our outpatient service. Strategies to improve warfarin control and patient safety include patient self-testing for our population. We offer self-testing as a practical means of patient empowerment while still being under our care. Our high TTR of 84.4% is proof that weekly testing is a standard of care achievable in a real-world patient care setting.  TTR for all patients calculated using 0.2 below and 0.2 above the target range.