The Centre for Evidence-Based Medicine has made a strong contribution to the field of oral anticoagulation for over a decade now. We have published primary studies, qualitative pieces and systematic reviews on the topic. Examples include the optimal loading dose to commence patients on warfarin and the role of self-monitoring and self-management of oral anticoagulation.
Perhaps the latter is the body or work with the greatest impact. The project began in 2006 and was led by Carl Heneghan. The first study of the work, a systematic review and meta-analysis of self-monitoring of oral anticoagulation published in the Lancet, has (to date) been cited over 400 times according to Google scholar. This was followed up with a systematic review and meta-analysis of individual patient data, which concluded that self-monitoring and self-management of oral anticoagulation is a safe option suitable for patients of all ages. In 2014, NICE published guidance that supported the use of self-monitoring tests for people on long-term anticoagulation therapy.
This week we published a pair of papers in the British Journal of General Practice following a cohort of patients as they self-monitored their oral anticoagulation therapy outside of trial conditions in the “real world”. In the first paper, we examined whether any demographic, psychological and behavioural characteristics of cohort members were associated with high levels of anticoagulation control. Factors studied included general wellbeing, conscientiousness, medical adherence, depression, anxiety, illness perception, treatment self-regulation, self-efficacy and planned behaviour. In the second, we conducted a series of qualitative interviews to learn more about the barriers and facilitators to successful self-monitoring.
We found that, despite sometimes ad-hoc training and assistance, it was possible to achieve the high levels of anticoagulation control observed in clinical trials of self-monitoring, and that discontinuation rates were much lower than anticipated. Unlike clinical trials participants, UK patients purchase their own monitors and, in some areas, negotiate to obtain health service support to self-monitor. Halving one’s risk of thrombosis by spending several hundred pounds has obvious implications in terms of equity. It did mean, however, that cohort members were often well educated, determined and committed to successfully self-monitoring. If access to anticoagulation self-monitoring schemes is broadened in the future, the existing training schemes and support systems may have to be strengthened.
You can read the methods and full findings of this research – led by Alison Ward – here and here. By using a mixed methods approach we have gained a valuable insight into how anticoagulation self-monitoring works in the “real world” and how best to support these patients.