Self-management of INR improves quality of life and reduces day-to-day stress for warfarin users. With proper training, patients can perform the checks safely and effectively at home, which also saves healthcare resources.
Guidelines recommend offering self-management of INR to long-term warfarin users who are motivated and capable (1). In a qualitative study published in this edition of the Journal of the Norwegian Medical Association, Dahle-Andersen et al. explore patients' experiences with INR self-management. Several study participants described positive experiences, with reduced daily stress and a sense of empowerment after starting INR self-management.
The introduction of direct oral anticoagulants (DOACs) in 2008 has led to a considerable decline in warfarin use. Today, only around 15 % of those requiring anticoagulation therapy use warfarin. These are primarily patients with mechanical heart valves, severe kidney failure, antiphospholipid syndrome, as well as children, pregnant women and nursing mothers. A total of 22,500 patients were using warfarin in 2022, and there are strong indications that this figure will remain stable (1).
Given the current challenges in the sustainability of health services, it is essential to explore ways to optimise resources (2). It therefore makes good economic sense to relieve the health service of INR testing, as patients themselves can perform these tests safely and probably more effectively with proper training, as several studies suggest (1).
It therefore makes good economic sense to relieve the health service of INR testing, as patients themselves can perform these tests safely and probably more effectively
Self-management of INR is one of several options within remote patient monitoring and treatment. Home-based services are likely to expand in the future and currently include the use of equipment such as insulin pumps, glucose monitors, oxygen therapy and respiratory support. Remote monitoring is administered by the regional units for medical aids within the specialist health service, and the equipment is loaned out for as long as necessary. The medical aids arrangement entails transferring expertise from the hospital setting and requires extensive training of the patient – and sometimes their family – to monitor and manage chronic conditions at home. Other similar examples where expertise is transferred from the hospital setting include patient-led monitoring of rheumatic diseases and various forms of 'hospital at home' (3,4). Patients are often highly motivated for such treatment, but it can also require significant effort from caregivers. For healthcare personnel, assessing a patient's ability to manage this type of follow-up can be challenging (4).
In Dahle-Andersen et al.'s study, some of the patients described the increased responsibility for their own health as challenging. The authors also discuss whether self-management of INR might lead to reduced contact with healthcare services and less personalised care. Several patients failed to carry out all the necessary checks, while other studies have shown that patients may underreport poor INR regulation out of fear of losing access to the service. The authors propose a solution involving a refresher course in the specialist health service. Good collaboration routines and regular follow-up with the patient's general practitioner (GP) are probably just as important. GPs are aware that not all patients attend the recommended check-ups. INR testing at the doctor's office tends to be carried out as consultations, providing a valuable opportunity for patients to address other concerns or health issues that may require follow-up. Reduced contact with the health service could also make it harder to detect frailty and cognitive decline in older patients, both of which can impact their ability to follow through with treatment and self-management safely.
Improving follow-up and establishing good routines for regular GP contact could therefore be an important area for enhancing care for patients using warfarin and self-managing their INR
INR self-management appears to be a good and sustainable option for long-term users of warfarin who have the motivation and resources to carry it out. However, a long-term doctor-patient relationship has benefits such as continuity and trust, which are important for detecting changes in the patient's health. Improving follow-up and establishing good routines for regular GP contact could therefore be an important area for enhancing care for patients using warfarin and self-managing their INR. Equally important is the need to monitor other aspects of the patients' health in a lifelong perspective, ensuring that self-management of INR remains both safe and effective in the long term.