The patients' perspective of international normalized ratio self-testing, remote communication of test results and confidence to move to self-management.

AIMS AND OBJECTIVES: To elicit the perceptions of patients, who self-tested their international normalized ratio and communicated their results via a text or phone messaging system, to determine their satisfaction with the education and support that they received and to establish their confidence to move to self-management. BACKGROUND: Self-testing of international normalized ratio has been shown to be reliable and is fast becoming common practice. As innovations are introduced to point of care testing, more research is needed to elicit patients' perceptions of the self-testing process. DESIGN: This three site study used a cross-sectional prospective descriptive survey. METHODS: Three hundred and thirty patients who were prescribed warfarin and using international normalized ratio self-testing were invited to take part in the study. The anonymous survey examined patient profile, patients' usage, issues, perceptions, confidence and satisfaction with using the self-testing system and their preparedness for self-management of warfarin dosage. RESULTS: The response rate was 57% (n = 178). Patients' confidence in self-testing was high (90%). Patients expressed a high level of satisfaction with the support received, but expressed the need for more information on support groups, side effects of warfarin, dietary information and how to dispose of needles. When asked if they felt confident to adjust their own warfarin levels 73% agreed. Chi-squared tests for independence revealed that none of the patient profile factors examined influenced this confidence. The patients cited the greatest advantages of the service were reduced burden, more autonomy, convenience and ease of use. The main disadvantages cited were cost and communication issues. CONCLUSION: Patients were satisfied with self-testing. The majority felt they were ready to move to self-management. RELEVANCE TO CLINICAL PRACTICE: The introduction of innovations to remote point of care testing, such as warfarin self-testing, needs to have support at least equal to that provided in a hospital setting.

Risk factors for nonadherence to warfarin: results from the IN-RANGE study.

BACKGROUND: Warfarin is widely used to prevent stroke and venous thromboembolism despite its narrow therapeutic window. Warfarin nonadherence is a substantial problem, but risk factors have not been well elucidated. METHODS: A prospective cohort study of adults initiating warfarin at two anticoagulation clinics (University and VA-affiliated) was performed to determine factors affecting nonadherence to warfarin. Nonadherence, defined by failure to record a correct pill bottle opening each day, was measured daily via electronic medication event monitoring systems (MEMS) caps. A multivariable explanatory model using logistic regression for longitudinal data was used to identify risk factors for nonadherence. RESULTS: One hundred eleven subjects were followed for a median of 137 days. Warfarin nonadherence was common (4787 of 22,425 or 21% of patient-days observed). Factors independently associated with higher odds of nonadherence included education beyond high school (odds ratio (OR) 1.8 (95%CI 1.2-2.7)), lower Short Form (SF)-36 mental component score (OR 1.4 (1.1-1.6) for each 10 point decrease); and impaired cognition (< or =19 points) on the Cognitive Capacity Screening Examination (CCSE) (OR 2.9 (1.7-4.8)). Compared to currently employed subjects, unemployed (OR 0.6 (0.3-1.2)) and retired (OR 0.5 (0.3-0.8)) subjects had somewhat improved adherence; disabled subjects over age 55 had worse adherence (OR 1.8 (1.1-3.1)) than younger disabled subjects (OR 0.8 (0.4-1.5)). CONCLUSIONS: Poor adherence to warfarin is common and risk factors are related to education level, employment status, mental health functioning, and cognitive impairment. Within the carefully controlled anticoagulation clinic setting, such patient-specific factors may be the basis of future interventions to improve nonadherence.