A call to action: Warfarin patient self-management

Abstract

Warfarin patient self-management (PSM), whereby the patient assumes responsibility for international normalized ratio (INR) testing and adjusting warfarin dosage in collaboration with a provider once competence has been demonstrated, has been endorsed since the 1990s.¹ In the September 2023 issue of JACCP, Wilson et al. reported the results of the first of two qualitative studies describing provider perceptions of warfarin PSM and in this issue reported a second qualitative study of patient opinions and experiences with warfarin PSM in the US healthcare system.^{2, 3} As the authors point out, vitamin K antagonist (VKA) PSM is more common in Europe than the United States, comprising about 1%–2% of patients prescribed a VKA.^{4, 5} Despite the fact that warfarin PSM has been recommended by the American College of Chest Physicians (CHEST) and the American Society of Hematology (ASH) and found to reduce the risk of thromboembolism and all-cause mortality without increasing bleeding events, it is adoption as a standard of care has been woefully slow in the United States.^6-8 Warfarin PSM has also been found to be cost-effective.⁹ As anticoagulation providers have been asked to assume more responsibility for managing the appropriate selection, education, and monitoring of the growing number of patients prescribed direct-acting oral anticoagulants, the adoption of PSM as a routine practice for warfarin would be welcomed. The work of Wilson et al. reports that patients are willing to perform PSM.³ In today's model of services, easy access to the electronic health record and telehealth appointments support their findings that patients believe self-testing may offer a way to feel supported in their care while maintaining their close relationship with the healthcare team that in-person visits provided. Providers had many more barriers to offering PSM, namely the lack of a structured program to identify appropriate candidates, methods to measure patient competence, and lack of clarity as to how to fit it into their workflow.² Compared to other countries where provider reimbursement models and patient costs for items such as monitors and test strips are not barriers, there are currently inadequate payment mechanisms for anticoagulation provider services outside of the Veteran's Affairs system. Patients are left to pay for testing equipment and hope that insurance offers reimbursement. There are still real barriers—despite the demonstration of both the need and benefit of PSM.

What can be done now? First, we need a standard model of patient education, documentation of competence, and structured follow-up. In fact, Fleming et al. recently reported on the results of their program at the University of Utah Health Thrombosis Service.¹⁰ They demonstrated similar or improved warfarin INR control with a 68% reduction in anticoagulation pharmacist workload which is a “win–win” for patients and providers. What could nudge more providers to implement such programs? First, one or more professional associations, such as the American College of Clinical Pharmacy (ACCP), American Society of Health-System Pharmacists (ASHP), and/or Anticoagulation Forum, should develop a model curriculum that identifies appropriate patients to switch to PSM, easily accessible patient and provider education tools, implementation strategies, and metrics to assess performance. Other organizations, such as ASH or CHEST, could endorse. Next, implementation analyses could be performed to examine the impact on hospitalizations, thromboembolism, and bleeding. While this has already been done in individual trials, having resulted from the endorsed model curriculum across different health systems would cement these practices as a standard of care. Should the data show reduced bleeding, the Joint Commission could add this practice as a National Patient Safety Goal. Additional work, such as that done by Wilson et al. documenting patient preferences for this type of care model, along with outcomes data and professional association endorsements, has the potential to improve reimbursement models. Wilson et al. are to be commended for bringing this model back to the spotlight. Now, it is up to us to keep up the momentum.

The author declares no conflict of interest.