Telemedicine and hemostasis-thrombosis centres

ABSTRACT

Nowadays, telemedicine has different clinical applications since it is used in almost all medical specialties. The COVID-19 pandemic has created not only major economic and social upheavals but also has an important impact on public health. In this emergency situation, the use of telemedicine has been rise aiming to mitigate the effects of COVID-19 on human health (1). In Italy, the Hemostasis-Thrombosis Centres (HTCs) belong to the Federation of Centres for the diagnosis of thromboembolic disease and the Surveillance of Anticoagulant therapy (FCSA) and they offer the highest possible quality of assistance to patients treated with Vitamin K Antagonists (VKAs) or Direct Oral Anticoagulants (DOACs). Unlike DOACs, VKAs need a close monitoring through the Prothrombin Time (PT) expressed as International Normalized Ratio (INR). The test result allows doctors at HTCs to prescribe the correct dosage of VKAs to maintain the INR in the therapeutic range. This means that patients have to go to their HTC more often than patients treated with DOACs. Telemedicine has been implemented in the routine clinical practice at HTC many years ago (2) and actually, during the COVID-19 pandemic, this system is of significant aid in the management of this therapy allowing patients to perform the test at home or to self-manage their own therapy. The system is organised as a centralised net-supported program with a server and PC stations in the HTC and workstations in the peripheral districts. Points-of-Care INR allow patients to easy perform the test on capillary blood and to quickly gain the INR result thus reducing the number of controls that patients would perform at the HCT (3). This aspect is of important value during COVID- 19 pandemic since overcrowding should be avoided. In general, self-management and self-testing have similar safety (RR=1.08, 95% CI 0.81-1.45, RR=0.99, 95% CI 0.8-1.23, respectively) than traditional monitoring as reported by the metanalysis of Sharma et al (4). As regard the efficacy, the authors showed a less incidence of thromboembolism when self-management was used (RR=0.51, 95% CI 0.37-0.69) with a trend versus a significant reduction in all-cause mortality (RR=0.68, 95% CI 0.46-1.01) while self-testing allowed to reach a 4.4% (95% CI 1.7-7.18) increase in time in therapeutic range. In accordance with other economic models, the metanalysis also showed that self-monitoring is costeffective. Another advantage of the use of telemedicine in HCT is the patients' satisfaction. In our experience (5) 85% of the patients are satisfied with self-testing at home and the quality of life is improved in 87% of them. The cost of test strips was medium-high for 89% of the patients, and 75% of them stated that it was worth improving their quality of life. Telemedicine is usefull in managing patients on VKAs and, as suggested by the FCSA (6), it is a safe and efficacy system to guarantee an adequate medical assistance not only routinely but especially during pandemic. Finally, telemedicine could be used also for DOACs patients putting in place a system that may allow patients to attach the PDF file of their laboratory tests and to video-call the doctors at HTC.